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TORONTO, July 25, 2016 — Australian researchers today presented results from an innovative project where they dramatically reduced the use of antipsychotic medicines to treat the behavioral and psychological symptoms of dementia (BPSD). Results were presented at the Alzheimer's Association International Conference (AAIC) 2016 in Toronto.
The Halting Antipsychotic use in Long Term care (HALT) Project, based in New South Wales, Australia, successfully eliminated regular antipsychotic medication from the treatment plan in 75 percent of study participants after 6 months following initial reduction of antipsychotics (12 month follow up data to come). In this study — which involved 140 residents across 23 care facilities — deprescribing was achieved through training of long-term care facility nurses in non-pharmacological and person-centered approaches to managing BPSD.
"There is broad consensus that using antipsychotics to treat dementia symptoms should be a last resort," said Beth Kallmyer, MSW, Alzheimer's Association vice president of constituent services. "These medicines must be used very carefully because they can blunt behaviors and cause sedation, and they carry serious safety concerns, such as increasing the risk of falls and death."
"There is broad consensus that using antipsychotics to treat dementia symptoms should be a last resort," said Beth Kallmyer, MSW, Alzheimer's Association vice president of constituent services. "These medicines must be used very carefully because they can blunt behaviors and cause sedation, and they carry serious safety concerns, such as increasing the risk of falls and death. Unfortunately, we still see a systematic use of these drugs in residential care facilities in the United States and around the world. With the right type of care strategies in place, difficult-to-manage behaviors are greatly reduced and the need for the drugs is significantly decreased - as was seen in this study."
According to the American Society of Consultant Pharmacists, more than half of nursing facility residents in the U.S. have some form of dementia, many of whom experience behavioral and psychological symptoms. These behaviors, which can pose significant challenges for both residents and nursing facility staff, are often best treated with non-pharmacologic measures such as environmental modifications.
Despite these challenges, more than 25 percent of patients in nursing facilities still receive antipsychotic medications, according to the Centers for Medicare and Medicaid Services (CMS). Evidence documenting the clinical efficacy of antipsychotics for BPSD is variable.
In 2005, the U.S. Food and Drug Administration (FDA) required manufacturers of atypical antipsychotic medications to include a boxed warning that these antipsychotics may increase the risk of death in elderly persons with psychosis related to dementia. This warning was expanded to all antipsychotic drugs in 2008.
Antipsychotic drugs have many legitimate uses, including treatment for psychotic disorders such as schizophrenia, psychotic symptoms such as delusions and hallucinations, and behavioral and psychological symptoms in certain situations.
"Results from the project presented today show there are more effective and appropriate alternatives to managing BPSD, and with well-designed programs to reduce use of antipsychotic medications, cultural barriers can be successfully overcome. We urge prescribers in the U.S. to assess results of this program and understand how they too can continue to work towards more person-centered, non-pharmacological approaches to manage these symptoms," Kallmyer said.
Researchers from the University of New South Wales, based in Sydney, Australia recruited 140 residents from 23 long-term care facilities who were on regular antipsychotic medication, despite not having a primary psychotic illness and without very severe neuropsychiatric symptoms. Concurrently, the project trained facility nurses on how to manage neuropsychiatric symptoms using person-centered, non-pharmacological approaches and performed academic detailing with the residents' primary care physicians. Consenting participants were assessed one month and one week prior to commencement of deprescribing. Protocols for incremental decreases in antipsychotic dose were established on an individual basis by project pharmacists with agreement from the participant's general practitioner. Participants were reassessed 3, 6 and 12 months following initial dose reduction.
Of the 140 residents recruited, 132 commenced deprescribing and 121 have achieved antipsychotic cessation to date. Of these, 75 percent remain off the antipsychotic medication up to 6 months following initial reduction. Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory (CMAI) scores of the first 71 participants assessed 6 months after deprescribing remained stable from baseline to follow-up.
For participants where data were available, more than 60 percent were prescribed the current antipsychotic after admission to long-term care.
"Deprescribing of antipsychotics in long-term care residents with previous BPSD is feasible without reemergence of BPSD; however, challenges still exist regarding sustainability and culture of prescribing in aged care," said Henry Brodaty, MD, DSc, of the Dementia Collaborative Research Centre, University of New South Wales, Sydney, Australia.
Brodaty added, "Often there can be cultural and logistical barriers to moving away from antipsychotics in aged care settings, but we hope the results of this project will serve as a positive example towards a more person-centered approach globally."
The Alzheimer's Association is participating with the Centers for Medicare & Medicaid Services (CMS) in the National Partnership to Improve Dementia Care in Nursing Homes. CMS and its partners are committed to finding new ways to enhance the quality of life for people with dementia, protect them from substandard care and promote goal-directed, person-centered care for every nursing home resident. While the initial focus was on reducing the use of antipsychotic medications, the Partnership's larger mission is to enhance the use of non-pharmacologic approaches and person-centered dementia care practices.
Since the launch of the National Partnership, significant reductions in antipsychotic use in long-stay nursing home residents have been documented. The most recent National Partnership Antipsychotic Medication Use Trend Update reports that in 2011Q4, 23.9 percent of long-stay nursing homes residents were receiving an antipsychotic medication; that number was 17.0 percent in 2015Q4 - a decrease of 28.8 percent. (nhqualitycampaign.org/files/AP_package_20160505.pdf) Recently, CMS established new national goals for reducing the use of antipsychotic drugs in long-stay nursing home residents to 30 percent by the end of 2016.
The Alzheimer's Association International Conference (AAIC) is the world's largest gathering of researchers from around the world focused on Alzheimer's and other dementias. As a part of the Alzheimer's Association's research program, AAIC serves as a catalyst for generating new knowledge about dementia and fostering a vital, collegial research community.
AAIC 2016 home page: www.alz.org/aaic/
AAIC 2016 newsroom: www.alz.org/aaic/press.asp
About the Alzheimer's Association®
The Alzheimer's Association is the leading voluntary health organization in Alzheimer's care, support and research. Our mission is to eliminate Alzheimer's disease through the advancement of research, to provide and enhance care and support for all affected, and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer's. Visit alz.org or call 800.272.3900.