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Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care

Published online by Cambridge University Press:  18 June 2020

Daniel J. Hoyle Open the ORCID record for Daniel J. Hoyle [Opens in a new window] ,
Gregory M. Peterson ,
Ivan K. Bindoff ,
Lisa M. Clinnick ,
Aidan D. Bindoff  and
Juanita L. Breen
Daniel J. Hoyle*
Affiliation:
School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
Gregory M. Peterson
Affiliation:
School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
Ivan K. Bindoff
Affiliation:
School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
Lisa M. Clinnick
Affiliation:
Aged Operations, Ballarat Health Services, Sebastopol, VIC, Australia
Aidan D. Bindoff
Affiliation:
Wicking Dementia Research and Education Centre, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
Juanita L. Breen
Affiliation:
Wicking Dementia Research and Education Centre, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
*
Correspondence should be addressed to: Daniel Hoyle, School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS7001, Australia. Phone: +61 3 6226 1529; Fax: +61 3 6226 2870. Email: [email protected]
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Abstract

Objectives:

To explore the relationships between dose changes to antipsychotic and/or benzodiazepine medications and resident outcomes, including variations in neuropsychiatric symptoms, quality of life (QoL), and social withdrawal, within a multicomponent, interdisciplinary antipsychotic and benzodiazepine dose reduction program.

Design:

Prospective, observational, longitudinal study.

Intervention:

The Reducing Use of Sedatives (RedUSe) project involved 150 Australian Long-Term Care Facilities (LTCFs) incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews.

Setting:

A convenience sample of LTCFs (n = 28) involved in RedUSe between January 2015 and March 2016.

Participants:

Permanent residents (n = 206) of LTCFs involved in RedUSe taking an antipsychotic and/or benzodiazepine daily. Residents were excluded if they had a severe psychiatric condition where antipsychotic therapy should generally be maintained long-term (e.g., bipolar disorder, schizophrenia) or were considered end-stage palliative.

Measurements:

Neuropsychiatric symptoms (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), QoL (Assessment of Quality of Life-4D), and social withdrawal (Multidimensional Observation Scale for Elderly Subjects-withdrawal subscale) were measured at baseline and 4 months where nursing staff completed psychometric tests as proxy raters.

Results:

There was no evidence that psychometric measures were worsened following dose reductions. In fact, dose reduction was associated with small, albeit non-statistically significant, improvements in behavior, particularly less physically non-aggressive behavior with both drug groups (−0.36 points per 10% reduction in antipsychotic dose, −0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behavior with benzodiazepine reduction (−0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with non-statistically significant improvements in QoL and social withdrawal.

Conclusions:

Antipsychotic and benzodiazepine dose reduction in LTCFs was not associated with deterioration in neuropsychiatric symptoms, QoL, or social withdrawal. Trends toward improved agitation with antipsychotic and benzodiazepine dose reduction require further evaluation in larger, prospective, controlled studies.

Keywords

antipsychoticbenzodiazepineneuropsychiatric symptomsquality of lifesocial withdrawallong-term careclinical outcomes
Type
Original Research Article
Information
International Psychogeriatrics , Volume 33 , Special Issue 6: Issue Theme: Diverse Strategies for Improving Seniors’ Well-Being , June 2021 , pp. 587 - 599
Copyright
© International Psychogeriatric Association 2020

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References

Alagiakrishnan, K. and Wiens, C.A. (2004). An approach to drug induced delirium in the elderly. Postgraduate Medical Journal, 80, 388–393. doi: 10.1136/pgmj.2003.017236.CrossRefGoogle ScholarPubMed
Azermai, M., Stichele, R.R.H.V., Van Bortel, L.M. and Elseviers, M.M. (2014). Barriers to antipsychotic discontinuation in nursing homes: an exploratory study. Aging & Mental Health, 18, 346–353. doi: 10.1080/13607863.2013.832732.CrossRefGoogle Scholar
Ballard, C.G., Waite, J. and Birks, J. (2006). Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database of Systematic Reviews, 1, CD00476. Art. No.: CD003476. doi: 10.1002/14651858.CD003476.pub2.Google Scholar
Bates, D., Mächler, M., Bolker, B. and Walker, S. (2015). Fitting linear mixed-effects models using lme4. Journal of Statistical Software, 67, 48. doi: 10.18637/jss.v067.i01.CrossRefGoogle Scholar
Bloch, F. et al. (2011). Psychotropic drugs and falls in the elderly people: updated literature review and meta-analysis. Journal of Aging and Health, 23, 329–346. doi: 10.1177/0898264310381277.CrossRefGoogle ScholarPubMed
Bourgeois, J. et al. (2013). Barriers to discontinuation of chronic benzodiazepine use in nursing home residents: perceptions of general practitioners and nurses. European Geriatric Medicine, 5, 181–187. doi: 10.1016/j.eurger.2013.11.005.CrossRefGoogle Scholar
Bourgeois, J., Elseviers, M.M., Van Bortel, L., Petrovic, M. and Vander Stichele, R.H. (2014). Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study. European Journal of Clinical Pharmacology, 70, 1251–1260. doi: 10.1007/s00228-014-1725-7.CrossRefGoogle ScholarPubMed
Brodaty, H. et al. (2018). Antipsychotic deprescription for older adults in long-term care: the HALT study. Journal of the American Medical Directors Association, 19, 592–600.e597. doi: 10.1016/j.jamda.2018.05.002.CrossRefGoogle Scholar
Cohen-Mansfield, J. (1991). Instruction manual for the Cohen-Mansfield agitation inventory (CMAI) [Online]. Available at: https://www.pdx.edu/ioa/sites/www.pdx.edu.ioa/files/CMAI_Scale%20(1).pdf; last accessed 31 July 2017.Google Scholar
Cox, C.A. et al. (2016). Psychotropic drug prescription and the risk of falls in nursing home residents. Journal of the American Medical Directors Association, 17, 1089–1093. doi: 10.1016/j.jamda.2016.07.004.CrossRefGoogle ScholarPubMed
Defrancesco, M., Marksteiner, J., Fleischhacker, W.W. and Blasko, I. (2015). Use of benzodiazepines in Alzheimer’s disease: a systematic review of literature. International Journal of Neuropsychopharmacology, 18, 1–11. doi: 10.1093/ijnp/pyv055.CrossRefGoogle ScholarPubMed
Diagnostic and Statistical Manual of Mental Disorders . (2013). Neurocognitive Disorders. American Psychiatric Association. Available at: http://dsm.psychiatryonline.org.ezproxy.utas.edu.au/doi/full/10.1176/appi.books.9780890425596.dsm17; last accessed 24 January 2017.Google Scholar
Freeman, S., Spirgiene, L., Martin-Khan, M. and Hirdes, J.P. (2017). Relationship between restraint use, engagement in social activity, and decline in cognitive status among residents newly admitted to long-term care facilities. Geriatrics & Gerontology International, 17, 246–255. doi: 10.1111/ggi.12707.CrossRefGoogle ScholarPubMed
Gilbert, A., Owen, N., Innes, J.M. and Sansom, L. (1993). Trial of an intervention to reduce chronic benzodiazepine use among residents of aged-care accommodation. Australian and New Zealand Journal of Medicine, 23, 343–347. doi: 10.1111/j.1445-5994.1993.tb01433.x.CrossRefGoogle ScholarPubMed
Giles, L.C., Hawthorne, G. and Crotty, M. (2009). Health-related Quality of Life among hospitalized older people awaiting residential aged care. Health and Quality of Life Outcomes, 7, 71–71. doi: 10.1186/1477-7525-7-71.CrossRefGoogle ScholarPubMed
Glass, J., Lanctôt, K.L., Herrmann, N., Sproule, B.A. and Busto, U.E. (2005). Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ, 331, 1169. doi: 10.1136/bmj.38623.768588.47.CrossRefGoogle ScholarPubMed
Gurwitz, J.H., Bonner, A. and Berwick, D.M. (2017). Reducing excessive use of antipsychotic agents in nursing homes. Journal of the American Medical Association, 318, 118–119. doi: 10.1001/jama.2017.7032.CrossRefGoogle ScholarPubMed
Hawthorne, G. and Osborne, R. (2005). Population norms and meaningful differences for the Assessment of Quality of Life (AQoL) measure. Australian and New Zealand Journal of Public Health, 29, 136–142.CrossRefGoogle ScholarPubMed
Hawthorne, G., Richardson, J. and Day, N. (2009). Using the Assessment of Quality of Life (AQoL) Version 1. Melbourne: Centre for Health Program Evaluation.Google Scholar
Hawthorne, G., Richardson, J., Day, N., Osborne, R. and McNeil, H. (2000). Construction and Utility Scaling of the Assessment of Quality of Life (AQoL) Instrument. Melbourne: Centre for Health Program Evaluation.Google Scholar
Helmes, E., Csapo, K.G. and Short, J.A. (1987). Standardization and validation of the Multidimensional Observation Scale for Elderly Subjects (MOSES). Journal of Gerontology, 42, 395–405. doi: 10.1093/geronj/42.4.395.CrossRefGoogle Scholar
Helvik, A.-S., Šaltytė Benth, J., Wu, B., Engedal, K. and Selbæk, G. (2017). Persistent use of psychotropic drugs in nursing home residents in Norway. BioMed Central Geriatrics, 17, 52. doi: 10.1186/s12877-017-0440-5.Google ScholarPubMed
Hoyle, D.J., Bindoff, I.K., Clinnick, L.M., Peterson, G.M. and Westbury, J.L. (2018). Clinical and economic outcomes of interventions to reduce antipsychotic and benzodiazepine use within nursing homes: a systematic review. Drugs and Aging, 35, 123–134. doi: 10.1007/s40266-018-0518-6.CrossRefGoogle ScholarPubMed
International Psychogeriatric Association. (2015). The IPA Complete Guides to Behavioural and Psychological Symptoms of Dementia (BPSD): Specialists Guide. Northfield: International Psychogeriatric Association.Google Scholar
Kiely, D.K., Simon, S.E., Jones, R.N. and Morris, J.N. (2000). The protective effect of social engagement on mortality in long-term care. Journal of the American Geriatrics Society, 48, 1367–1372. doi: 10.1111/j.1532-5415.2000.tb02624.x.CrossRefGoogle ScholarPubMed
Lacey, R.J. et al. (2017). Evidence for strategies that improve recruitment and retention of adults aged 65 years and over in randomised trials and observational studies: a systematic review. Age and Ageing, 46, 895–903. doi: 10.1093/ageing/afx057.CrossRefGoogle ScholarPubMed
Lange, R.T., Hopp, G.A. and Kang, N. (2004). Psychometric properties and factor structure of the Neuropsychiatric Inventory Nursing Home version in an elderly neuropsychiatric population. International Journal of Geriatric Psychiatry, 19, 440–448. doi: 10.1002/gps.1108.CrossRefGoogle Scholar
Lindsey, P.L. (2009). Psychotropic medication use among older adults: what all nurses need to know. Journal of Gerontological Nursing, 35, 28–38. doi: 10.3928/00989134-20090731-01.CrossRefGoogle ScholarPubMed
Marcum, Z.A., Handler, S.M., Wright, R. and Hanlon, J.T. (2010). Interventions to improve suboptimal prescribing in nursing homes: a narrative review. American Journal of Geriatric Pharmacotherapy, 8, 183–200. doi: 10.1016/j.amjopharm.2010.05.004.CrossRefGoogle ScholarPubMed
Maust, D.T. et al. (2015). Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. Journal of the American Medical Association Psychiatry, 72, 438–445. doi: 10.1001/jamapsychiatry.2014.3018.Google ScholarPubMed
McMaster, M., Fielding, E., Lim, D., Moyle, W. and Beattie, E. (2018). A cross-sectional examination of the prevalence of psychotropic medications for people living with dementia in Australian long-term care facilities: issues of concern. International Psychogeriatrics, 30, 1019–1026. doi: 10.1017/S1041610217002447.CrossRefGoogle ScholarPubMed
Morris, S. et al. (2015). Monetary costs of agitation in older adults with Alzheimer’s disease in the UK: prospective cohort study. BMJ Open, 5, e007382. doi: 10.1136/bmjopen-2014-007382.CrossRefGoogle ScholarPubMed
Murman, D.L. et al. (2002). The incremental direct costs associated with behavioral symptoms in AD. Neurology, 59, 1721–1729. doi: 10.1212/01.wnl.0000036904.73393.e4.CrossRefGoogle ScholarPubMed
Osborne, R.H., Hawthorne, G., Lew, E.A. and Gray, L.C. (2003). Quality of life assessment in the community-dwelling elderly: validation of the Assessment of Quality of Life (AQoL) Instrument and comparison with the SF-36. Journal of Clinical Epidemiology, 56, 138–147.CrossRefGoogle ScholarPubMed
Picton, J.D., Marino, A.B. and Nealy, K.L. (2018). Benzodiazepine use and cognitive decline in the elderly. American Journal of Health-System Pharmacy, 75, e6–e12. doi: 10.2146/ajhp160381.CrossRefGoogle ScholarPubMed
R Core Team. (2017). R: A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing. Available at: https://www.R-project.org/.Google Scholar
Saleh, N. et al. (2017). Social engagement and antipsychotic use in addressing the behavioral and psychological symptoms of dementia in long-term care facilities. Canadian Journal of Nursing Research, 49, 144–152. doi: 10.1177/0844562117726253.CrossRefGoogle ScholarPubMed
Sato, S. et al. (2018). Predicting falls from behavioral and psychological symptoms of dementia in older people residing in facilities. Geriatrics & Gerontology International, 18, 1573–1577. doi: 10.1111/ggi.13528.CrossRefGoogle ScholarPubMed
Schneider, L.S., Dagerman, K. and Insel, P.S. (2006). Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. The American Journal of Geriatric Psychiatry, 14, 191–210. doi: 10.1097/01.JGP.0000200589.01396.6d.CrossRefGoogle ScholarPubMed
Schneider, L.S., Dagerman, K.S. and Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. Journal of the American Medical Association, 294, 1934–1943. doi: 10.1001/jama.294.15.1934.CrossRefGoogle ScholarPubMed
Selbaek, G., Kirkevold, O. and Engedal, K. (2007). The prevalence of psychiatric symptoms and behavioural disturbances and the use of psychotropic drugs in Norwegian nursing homes. International Journal of Geriatric Psychiatry, 22, 843–849. doi: 10.1002/gps.1749.CrossRefGoogle ScholarPubMed
Sylliaas, H., Selbaek, G. and Bergland, A. (2012). Do behavioral disturbances predict falls among nursing home residents? Aging Clinical and Experimental Research, 24, 251–256.CrossRefGoogle ScholarPubMed
The Royal Australian & New Zealand College of Psychiatrists. (2016). Professional Practice Guideline 10: antipsychotic medications as a treatment of behavioural and psychological symptoms of dementia [Online]. Available at: https://www.ranzcp.org/Files/Resources/College_Statements/Practice_Guidelines/pg10-pdf.aspx; last accessed 26 April 2018.Google Scholar
The Royal Australian College of General Practitioners. (2015). Prescribing drugs of dependence in general practice, Part B [Online]. Available at: https://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-b; last accessed 31 July 2017.Google Scholar
Thompson Coon, J. et al. (2014). Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: a systematic review. Journal of the American Medical Directors Association, 15, 706–718. doi: 10.1016/j.jamda.2014.06.012.CrossRefGoogle ScholarPubMed
van de Ven-Vakhteeva, J., Bor, H., Wetzels, R.B., Koopmans, R.T. and Zuidema, S.U. (2013). The impact of antipsychotics and neuropsychiatric symptoms on the quality of life of people with dementia living in nursing homes. International Journal of Geriatric Psychiatry, 28, 530–538. doi: 10.1002/gps.3858.CrossRefGoogle ScholarPubMed
van der Spek, K. et al. (2016). Only 10% of the psychotropic drug use for neuropsychiatric symptoms in patients with dementia is fully appropriate: the PROPER I-study. International Psychogeriatrics, 28, 1589–1595. doi: 10.1017/S104161021600082X.CrossRefGoogle ScholarPubMed
van Duinen-van den IJssel, J. et al. (2018). Nursing staff distress associated with neuropsychiatric symptoms in young-onset dementia and late-onset dementia. Journal of the American Medical Directors Association, 19, 627–632. doi: 10.1016/j.jamda.2017.10.004.CrossRefGoogle ScholarPubMed
Van Leeuwen, E. et al. (2018). Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD007726.pub3.CrossRefGoogle ScholarPubMed
Westbury, J., Beld, K., Jackson, S. and Peterson, G. (2010). Review of psychotropic medication in Tasmanian residential aged care facilities. Australasian Journal on Ageing, 29, 72–76. doi: 10.1111/j.1741-6612.2010.00409.x.CrossRefGoogle ScholarPubMed
Westbury, J., Gee, P., Ling, T., Kitsos, A. and Peterson, G. (2019). More action needed: psychotropic prescribing in Australian residential aged care. Australian and New Zealand Journal of Psychiatry, 53, 136–147. doi: 10.1177/0004867418758919.CrossRefGoogle ScholarPubMed
Westbury, J.L. et al. (2018). RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities. Medical Journal of Australia, 208, 398–403. doi: 10.5694/mja17.00857.CrossRefGoogle ScholarPubMed
Whelan, P.J., Walwyn, R., Gaughran, F. and Macdonald, A. (2013). Impact of the demand for ‘proxy assent’ on recruitment to a randomised controlled trial of vaccination testing in care homes. Journal of Medical Ethics, 39, 36–40. doi: 10.1136/medethics-2011-100119.CrossRefGoogle ScholarPubMed
WHO Collaboration Centre for Drug Statistics Methodology. (2013). Guidelines for ATC Classification and DDD Assignment 2014 (17th edn.), Oslo. Available at: http://sifac.it/wp-content/uploads/2013/12/dice1838.pdf.Google Scholar
Wood, S. et al. (2000). The use of the neuropsychiatric inventory in nursing home residents: characterization and measurement. American Journal of Geriatric Psychiatry, 8, 75–83. doi: 10.1097/00019442-200002000-00010.CrossRefGoogle Scholar
Woods, S.W. (2003). Chlorpromazine equivalent doses for the newer atypical antipsychotics. Journal of Clinical Psychiatry, 64, 663–667.CrossRefGoogle ScholarPubMed
Zuidema, S.U. et al. (2011). Assessing neuropsychiatric symptoms in nursing home patients with dementia: reliability and Reliable Change Index of the Neuropsychiatric Inventory and the Cohen-Mansfield Agitation Inventory. International Journal of Geriatric Psychiatry, 26, 127–134. doi: 10.1002/gps.2499.CrossRefGoogle ScholarPubMed
Zuidema, S.U., de Jonghe, J.F.M., Verhey, F.R.J. and Koopmans, R.T.C.M. (2007). Agitation in Dutch institutionalized patients with dementia: factor analysis of the Dutch Version of the Cohen-Mansfield Agitation Inventory. Dementia and Geriatric Cognitive Disorders, 23, 35–41. doi: 10.1159/000096681.CrossRefGoogle ScholarPubMed
Zwijsen, S.A. et al. (2014). Nurses in distress? An explorative study into the relation between distress and individual neuropsychiatric symptoms of people with dementia in nursing homes. International Journal of Geriatric Psychiatry, 29, 384–391. doi: 10.1002/gps.4014.CrossRefGoogle ScholarPubMed