What is getting in the way of reducing antipsychotic use in older adults with dementia?
Tuesday, September 3rd, 2019
A quarter of Australians with dementia may be taking antipsychotic medication for symptoms that could be better managed through non-pharmacological means. These symptoms – which include aggression, agitation, hallucinations, wandering, verbal outbursts and delusions – are what researchers and health professionals often call “Behaviours and Psychological Symptoms of Dementia” (BPSD), and are experienced by most people with dementia over the course of their condition. However, there is limited evidence that antipsychotics are effective in reducing BPSD; and worse still, that they are associated with an increased risk of falls, hospital admissions, cognitive impairment, and death. This has prompted the creation of national polices to reduce polypharmacy, or overmedication, of older adults.
Putting a HALT to overmedication
Australia has been one country to lead the way in this crackdown. Last year, researchers from the University of New South Wales published a study detailing a targeted reduction of antipsychotic use in residential aged care through a deprescribing intervention and education of health care professionals focused on the non-pharmacological management of BPSD . Of a selected sample of 133 aged care residents, regular antipsychotic use was successfully ceased and maintained for at least one year afterwards for 76 individuals, without any increase in BPSD.
Nurses perceiving worsening aggression as a key driver in represcribing
Last month, the research team published a study that looked more closely at 39 of the individuals for whom antipsychotic medication never ceased or was represcribed after the initial deprescribing . Through questionnaires completed by nursing staff, GP and family, plus careful auditing of the individuals’ medical files, nurses were found to be the main drivers of represcribing, followed by family members and then GPs. Increases in agitation and aggression were the most commonly reported reasons for reinstating antipsychotic medication, despite this not matching objective rating scales that indicated no change in these behaviours. File audits also indicated that GPs did not obtain consent for represcribing in half of the participants, and nor did they start at the lowest possible dose as per legislative guidelines.
The authors recognise that nursing staff who are inexperienced or time poor, or who perhaps work in a facility with organisational issues such as inadequate staffing or poor team cohesion, may find it harder to implement non-pharmacological management of BPSD and thus be more vulnerable to overreliance on medication. The study only comprised a small subset of individuals for whom deprescribing was not successful, and was privy to the usual issues of incomplete file records and questionnaires. However, the findings offer some suggestions for future deprescribing efforts, including further education and support strategies about how to obtain consent and prescribe at low dose, as well as using objective measures to help reappraise perceptions that antipsychotics are needed.