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MAKING residential aged care staff aware of the relative ineffectiveness of antipsychotic medications and benzodiazepines for calming agitated patients was the biggest factor in the success of a national program attempting to reduce inappropriate prescribing.
Lead investigator of the Reducing Use of Sedatives (RedUSe) intervention, Dr Juanita Westbury, senior lecturer in dementia care at the Wicking Dementia Research and Education Centre at the University of Tasmania, said that antipsychotics and benzodiazepines were not particularly effective [for agitation in elderly patients], and could have fatal side effects.
“With antipsychotics, about one in five [people with agitation] will benefit,” Dr Westbury said in an MJA InSight podcast.
While benzodiazepines could work well in calming people initially, she said that they lost their effectiveness in about 2–4 weeks.
“You have to give a little more to get the same effect, but if you try taking benzodiazepines away, often you get a real exacerbation of the original symptoms.”
Dr Westbury said that older people did not metabolise these drugs as effectively as younger people.
“The problem with antipsychotics in older people, especially in those with dementia, is it worsens confusion, it can cause movement disorders and falls,” she said. “Over the past 10 years or so, there has been quite a bit of research linking [antipsychotic] use to higher rates of stroke, higher rates of heart attack and also death.”
The sedating effects of benzodiazepines could increase a resident’s risk of confusion and falls, she said, and the drug also increased the risk of pneumonia.
Writing in the MJA, Dr Westbury and colleagues said that the RedUSe intervention showed that this interdisciplinary program could reduce the over-reliance on psychotropic medications, often used to manage mental and psychological symptoms in aged care residents.
The national program targeted 150 aged-care facilities with 12 157 residents, and comprised a medication audit and feedback, staff education, and interdisciplinary case review at baseline and 3 months, with a final audit at 6 months.
The researchers found that, at 6 months, the proportion of residents prescribed antipsychotics had dropped by 13% (declining from 21.6% [95% confidence interval (CI), 20.4–22.9%] to 18.9% [95% CI, 17.7–20.1]), while 21% fewer residents were regularly prescribed benzodiazepines (declining from 22.2% [95% CI, 21.0–23.5%] to 17.6% [95% CI, 16.5–18.7%]).
Mean drug doses also declined over the study period, with the mean chlorpromazine equivalent dose declining from 22.9 mg/resident/day (95% CI, 19.8–26.0) to 20.2 mg/resident/day (95% CI, 17.5–22.9). The mean diazepam equivalent dose was cut from 1.4 mg/resident/day (95% CI, 1.3–1.5) to 1.1 mg/resident/day (95% CI, 0.9–1.2).
Residents undergoing the full program gained the greatest benefit. The researchers reported that 2195 residents who were regularly prescribed antipsychotics and 2247 residents who were regularly prescribed benzodiazepines at baseline were present for all three audits. Of these, almost 40% had their medications reduced (15%) or ceased (24%) over the 6-month period.
Dr Westbury said that many of the aged care facilities were surprised at the findings of the initial audit.
“A lot of [aged care facilities] don’t really know how much of these medications they are using,” she said. “Often, when we gave them the results, they would be quite surprised and challenge it. But when they thought who was taking it … they realised that their use was probably higher than they thought.”
Associate Professor Ruth Hubbard, Associate Professor in Geriatric Medicine at the University of Queensland, welcomed the findings.
“It is a complex problem that requires a complex intervention, which is what they have employed,” Professor Hubbard said. “There are several domains to the intervention, which is appropriate.”
She said that the results among residents who underwent the entire 6-month intervention suggested that, when delivered consistently, such a program could make a significant difference.
But, she noted, reductions were less significant among the cohort as a whole – with 2-4 percentage point declines – suggesting that residents who were newly admitted continued to be prescribed antipsychotics and benzodiazepines.
“It’s a well designed study with a good sample size and good uptake across lots of different nursing homes, they have applied a well thought-out intervention and have achieved some success in reducing prescribing.”
Professor Sarah Hilmer, Conjoint Professor of Geriatric Pharmacology and the University of Sydney’s School of Medicine, agreed.
“The uptake in 150 nursing homes shows that this is a feasible program. The effect size is not huge – with a reduction of antipsychotic prescribing from 21.6% to 18.9%, there is still a group of people that we are just not reaching. This may be partly because, in a small proportion of people, the drugs may be [used] for a current psychiatric indication,” she said.
“It’s a fabulous step forward. It’s hitting the tip of the iceberg in a sustainable and implementable way, but there is still a lot more work to be done.”
While a full economic analysis has not been possible, data from a clinical impact study suggest that implementation of the RedUSe program could provide annual cost savings of about $3.9 million, primarily due to reduced hospitalisations.
The RedUSe results come ahead of the publication of the findings of another study seeking to tackle the rate of antipsychotic prescribing in aged care facilities.
The Halting Antipsychotic use in Long Term care (HALT) project, also funded by the federal government, and conducted by the Dementia Centre for Research Collaboration (UNSW) looked at a more intensive intervention in a smaller population (23 aged care facilities in Sydney with 136 residents) over 12 months.
Lead investigator Professor Henry Brodaty said that the HALT findings, which will be published in the Journal of the American Medical Directors Association in the coming months, were “quite impressive”.
Professor Brodaty, who is co-Director of the UNSW Centre for Healthy Brain Ageing, said that the upcoming release of the HALT project results, together with the RedUSe findings, were providing some promising leads on the types of strategies needed to tackle the overuse of psychotropic medications in aged care.
“I have been involved in three different studies where person-centred care in nursing homes has demonstrated a reduction in agitation levels in residents and/or improvements in use of medications, essentially a decrease in use of antipsychotics. This is important as antipsychotics can be associated with significant side effects,” he said. “The next issue is: how do we get to make this business as usual? What are the changes that we can introduce to make a difference?”
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I have been managing my mother at home for 2 years with no medication. One needs to know their character and history to understand their and help them manage challenging behaviours. One needs to spend lots of one- on- one time and talk them through their confusion and fears. Relatives and friends need to visit often. I can see a time when edication may be needed later to relieve suffering in those times when they are out of control and talk does not work.
Apart from the measurement of psychotropic drug use, what % of RACF residents were discharged from the RACF due to adverse behaviour towards other residents, eg physical or sexual assault?
Yes, and the feedback I received from many GPs and staff was the same – we dont start these without considerable thought – but what many did admit was that once residents were prescribed these medications they stay on them for extended periods. Much longer than guidelines recommend (3 months with antipsychotics – 2-4 weeks with benzos)
Review happens infrequently and this is what our RedUse project aimed to do …. to review use AND involve nursing staff, GPs and pharmacists when this was done – especially the staff on the ground.
Behavioural symptoms change over time and what may be needed a while ago may not be needed now.
The experts and government can tell us just how to manage the screaming, agitation etc
They have no idea of the effects on other residents etc.
Also the dignity the resident looses etc with this behaviour.
We do not prescribe these Willy nilly.
To CC…as part of the training we promoted non-drug strategies like proper assessment for pain, infections or underlying causes, providing matched activities and personalised care. In feedback from staff most noticed little difference in residents that had been taken off these meds – providing further evidence that these medications don’t work in many people and can successfully be removed. We asked homes to provide feedback about increased need for GPs and hospital admissions – not a single report. Reductions were gradual and monitored – if behaviours re- emerged the medication was restarted.
To anonymous…..In Australian nursing homes residents stay on psychotropic medication for much longer periods than recommended and review occurs infrequently, if at all. When we tracked residents over our 6 month project we found that 40% of residents taking antipsychotics and benzodiazepines had doses ceased outright or reduced – translating to over 1100 residents taking significantly less – more often no sedating medication at all. This is not a minor reduction.
Baseline use of antipsychotics was 22% which, as you rightly point out, reduced to 19% over a 6 month period. This equates to a 13% relative reduction in use. This is an average redcution across all homes as well. Some homes reduced use by more than 60% but some homes had no reduction at all.
To give you some context with other interventions; in the U.S., rates of nursing home antipsychotic use are publicly available and homes are also ranked on antipsychotic use/review using a public 5 star rating. If use is too high homes get financial sanctions and the threat of closure. On-line training on appropriate use is also provided and spot checks routine. Their highly funded national program resulted in a 10% relative reduction (absolute 2.5%) over 2 full years. We acheived a higher relative reduction (13%) in 6 months – AND reduced benzodiazepine use by 21% (or 5% absolute). In the U.S. benzodiazepine use has risen and the rates of use of other sedating medications has increased substantially (e.g anticonvulsant medication use increased by 20%). In RedUSe substitution to other sedating agents did not occur.
If you take the time to read the intervention strategies of RedUSe they involved two audits, 2 hours of staff training and an interdisciplinary review process involving 3 people that is supposed to be mandatory every 3 months in any case (but doesn’t happen) – hardly intensive!
Notably, savings were also recorded from reduction of drug costs, with further cost analysis will be available shortly.
Organisational change is hard – I can tell you that a 13% and 21% relative reduction in primary measures over just 6 months – when previous research has revealed no reduction in routine care – is substantive.
By the way we were also over subscribed by nursings homes wanting to be involved. We received over 320 expressions of interest for 150 places. 75% of those were from for profit homes. For more information on the project please refer to our executive report at: http://www.utas.edu.au/wicking/RedUSe
How do we manage the behaviour.The staffing levels are very poor. At many a time I have requested one to one nursing but it is not affordable. The staff try all simple measures. Eg reading a book , giving herbal tea etc
As above. This is an enormously complex problem and one that either requires imperfect and side effect heavy medication or better but much more expensive therapy and resources.
My brain defines me. When it is gone, I hope that my family do me the dignity of allowing natural death when it occurs and palliating essentially any illness (even reversible ones – why should I be treated for a reversible infection to get me back to an unrecognisable shell of my former self?)
This is ultimately a political issue – how much cost is society willing to bear to get better outcomes? If we have the cash, it’d be nice to see the staffed ‘dementia villages’ that seem to have some success elsewhere with the right suite of support and therapy, and medication reserved for those whose behaviours are beyond our capability to manage otherwise and pose enough of a problem (e.g. injury) to need addressing, only prescribed under the guidance of a specialist with advanced knowledge of the topic and with an appropriate hospital avoidance strategy in place.
they are discouraging use of drugs but make no suggestions how else to manage difficult uncooperative behaviourably disturbed elderly dementia patients in nursing homes at all hours of the night and day with finite staff and resources.
the last thing our public hospital emergency departments need is more and more of these cases being bundled off to hospital in ambulances because nursing home staff cannot control their behaviour.
continuous one on one nursing or physical restraints are not feasible alternatives.
a drop of around 3% with an intensive therapy program for 6 months. can you just see the for profit nursing homes doing this ?. Savings are from drop in hospitalisation i.e. does not affect nursing home profit. Cost of the program ?