Why deprescribing antipsychotics in older people with dementia in long‐term care is not always successful: Insights from the HALT study

Abstract

Introduction Antipsychotic medications are commonly used to manage behavioural and psychological symptoms of dementia despite their side effects and harms. While the Halting Antipsychotic Use in Long‐Term care (HALT) deprescribing trial was successful at reducing antipsychotic use, 19% of participants had their antipsychotics represcribed or never reached a dose of zero. The aim of this study was to investigate the reasons for represcription of antipsychotic medication and factors associated with ongoing antipsychotic use, relating to care staff requests and perceived behavioural changes. Materials and methods Thirty‐nine of 133 HALT participants never ceased their antipsychotic medication or were represcribed a regular or pro re nata (PRN) antipsychotic after initial deprescribing. The views of nursing staff, general practitioner, and family on the circumstances leading up to these outcomes were collected via a questionnaire‐based approach. This information was triangulated with observation and detailed file audit (including progress notes, medical notes, medication charts, incident reports, and hospital discharge summaries). A consensus panel reconstructed the represcribing context. Results Nurses were the most common drivers of represcribing (63.2%), followed by family members (39.5%), GPs (23.7%), specialists (13.2%), and hospital staff (10.5%). There were multiple drivers for antipsychotic use in 46.2% of participants. Increased agitated and aggressive behaviours were the most commonly reported reasons for represcribing even though these changes were not identified over time on objective measures. Consent and dosage practices remained poor despite education. Discussion Nursing staff are the key drivers of deprescribing particularly in response to perceived worsening agitation and aggression among male residents. The train‐the‐trainer model used in the HALT trial may have been insufficient on its own to improve staff competence and confidence in applying nonpharmacological approaches when responding to behaviour change.

Residential Aged Care Pharmacist: An Australian Pilot Trial Exploring the Impact on Quality Use of Medicines Indicators

“…The quality use of medicines in RACH is influenced by numerous factors that contribute to the 'prescribing culture' within the organisation [13,28] These factors include staffing levels, workload and skill mix, managerial expectations and collaboration between visiting health professionals [13,28]. These factors extend beyond the control of interventions targeted at improving clinical appropriateness of medication use for individual residents.…”

“…These factors extend beyond the control of interventions targeted at improving clinical appropriateness of medication use for individual residents. Interventions will likely yield greater success in improving quality use of medicines, and sustaining that improvement, if factors influencing prescribing culture and thereby the quality use of medicines within the organisation are addressed [13]. Additionally, proactive discussion between health care professionals, residents and family members is required to individualise deprescribing processes [15].…”

“…Higher DBI in older adults is associated with adverse outcomes including increased frailty, worsening cognitive and functional impairment, falls, and hospital admissions [8][9][10]. Despite the established risks associated with the use of these medications in the RACH population [11], potentially inappropriate use remains an ongoing challenge [12,13].…”

CanToxoplasma gondiiPave the Road for Dementia?

“…Dementia had been suggested a long time ago to be caused by the excessive constitution of amyloid protein that leads to cell death, synaptic dysfunction, and brain atrophy [ 2 ]. However, pharmacological trials conducted to test this theory have been unsuccessful, and on the contrary, most cases worsen especially in old age [ 3 ]. Interestingly, during the recent decades, interventional epidemiology in neuroscience has been introduced where the possible interaction between the pathogenesis of dementia and various individual/environmental factors is studied, and therefore, different therapeutic protocols will be determined for various patients' subgroups [ 4 ].…”

Impact of interdisciplinary approaches to deprescribing psychotropics on clinical outcomes in older residents of long-term care facilities

“…It is imperative for residents, or their next of kin or significant other to be involved in treatment decisions. However, previous studies have reported that informed consent for antipsychotic use is infrequently documented (Aerts et al, 2019;Westaway et al, 2020). Importantly, the study by Hoyle et al focuses on assessment of outcomes important to residents and family members, such as quality of life, which is a key limitation of existing studies (Hoyle et al, 2018).…”