Abstract
Background Despite warnings of possible serious events, and reports of little benefit, antipsychotic agents are commonly prescribed in residential care for older people with dementia. A residential care provider (RCP) in New Zealand sought to examine and improve prescribing in some of their facilities. Objective To examine changes following a range of interventions implemented by a RCP to improve the prescribing of antipsychotics. Setting Thirteen dementia and psychogeriatric units in New Zealand managed by a RCP. Method An audit (n = 228 residents) was undertaken in thirteen dementia and psychogeriatric units in New Zealand in July–September 2011. A modified Best Practice Advocacy Centre (bpacnz) tool was used to examine antipsychotic prescribing, the administration of “when required” (PRN) antipsychotic doses and antipsychotic-related documentation (e.g. documenting of “target behaviour identified” and “need to monitor for adverse effects”). Prescribing for some central nervous system agents and fractures and fall rates were also examined. Some educational, managerial, environmental, recreational and resident-specific interventions were implemented post-audit. The audit (n = 233) was repeated in July–September 2013. Main outcome measures: (1) Number of residents prescribed and administered antipsychotics (2) Documentation of antipsychotic-related information in residents’ notes. Results The administration of antipsychotics and prescribing of regular doses (±PRN) decreased about a quarter from 2011 to 2013: 50.4–38.2, and 49.1–36.5 % (ORs 0.60, 0.57 respectively, both p < 0.001), and prescribing for any antipsychotic dose (including PRN only) decreased: 60.5–50.6 % (OR 0.67, p = 0.003). Documenting of “target behaviour identified” significantly increased from 54.3 to 71.2 %, (OR 1.99, p = 0.017) and documenting of the “need to monitor for adverse effects” increased non-significantly (30.4–46.6 %, p = 0.098); both falling short of the 90 % goal set by bpacnz. Benzodiazepine prescribing significantly decreased [39.0–25.8 %, (OR 0.59, p < 0.001)]. Conclusions Following a range of interventions, antipsychotic prescribing, administration and some related documentation improved in dementia and psychogeriatric units in New Zealand. Future studies should aim to identify the most effective of these interventions so they can be considered for implementing in similar settings.
Similar content being viewed by others
References
World Health Organisation. Dementia. Fact sheet N°362. 2012. http://www.who.int/mediacentre/factsheets/fs362/en/. Accessed 15 Jan 2016.
Lyketsos CG, Steinberg M, Tschanz JT, Norton MC, Steffens DC, Breitner JC. Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry. 2000;157(5):708–14.
Zimmerman S, Sloane PD, Reed D. Dementia prevalence and care in assisted living. Health Aff (Millwood). 2014;33(4):658–66.
Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934–43.
Schneeweiss S, Setoguchi S, Brookhart A, Dormuth C, Wang PS. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ. 2007;176(5):627–32.
Food and Drug Administration (FDA). Public Health Advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. 2005. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm053171.htm. Accessed 15 Jan 2016.
Banerjee S. The use of antipsychotic medication in people with dementia: time for action. A report Commissioned by the Department of Health, UK. 2009. http://www.navarra.es/NR/rdonlyres/5CB1E6EB-F352-47B1-AE82-4CA073586C09/179929/PublicacionSubeBanerjee1.pdf Accessed 15 Jan 2016.
Royal Australian and New Zealand College of Psychiatrists (RANZCP). The use of antipsychotics in residential aged care. 2008. http://www.bpac.org.nz/a4d/ranzcpGuide.asp Accessed 3 Dec 2014.
Ballard C, Waite J, Birks J. Atypical anti-psychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev. 2006;1:CD003476.
Maher AR, Maglione M, Bagley S, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis. JAMA. 2011;306(12):1359–69.
Rolland Y, Andrieu S, Crochard A, Goni S, Hein C, Vellas B. Psychotropic drug consumption at admission and discharge of nursing home residents. J Am Med Dir Assoc. 2012;13(4):e7–12.
Huber M, Kölzsch M, Rapp MA, et al. Antipsychotic drugs predominate in pharmacotherapy of nursing home residents with dementia. Pharmacopsychiatry. 2012;45(5):182–8.
Rattinger GB, Burcu M, Dutcher SK, et al. Pharmacotherapeutic management of dementia across settings of care. J Am Geriatr Soc. 2013;61(5):723–33.
Tucker M, Hosford I. Use of psychotropic medicines in residential care facilities for older people in Hawke’s Bay, New Zealand. N Z Med J. 2008;121(1274):18–25.
Jackson G, Gerard C, Minko N, Parsotam N. Variation in benzodiazepine and antipsychotic use in people aged 65 years and over in New Zealand. N Z Med J. 2014;127(1396):67–78.
Best Practice Advocacy Centre (BPAC). Antipsychotics in Dementia: Best Practice Guide. 2008. http://www.bpac.org.nz/a4d/resources/guide/guide.asp. Accessed 3 Dec 2014.
Central Region Technical Advisory Services Limited (TAS). Health of older people. Age Related Residential Care Services Agreement for the Provision of Age Related Residential Care. 2015. http://centraltas.co.nz/assets/Health-of-Older-People/ARRC-Agreement-effective-1-July-2015-v-20May2015.pdf. Accessed 15 Jan 2016.
Central Region Technical Advisory Services Limited (TAS). Health of older people. Age Related Residential Care Services Agreement for the Provision of Age Residential Hospital Specialised Services 2015. http://centraltas.co.nz/assets/Health-of-Older-People/ARHSS-Agreement-effective-1-July-2015-for-website-v-22May2015.pdf. Accessed 15 Jan 2016.
Eden Alternative. Mission, Vision, Values, Principles. 2014. http://www.edenalt.org/about-the-eden-alternative/mission-vision-values/. Accessed 15 Jan 2016.
Centers for Medicare and Medicaid Services. Press release: New data show antipsychotic drug use is down in nursing homes nationwide. 2013. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-08-27.html. Accessed 15 Jan 2016.
Parsons C, Haydock J, Mathie E, et al. Sedative load of medications prescribed for older people with dementia in care homes. BMC Geriatr. 2011;11(56). doi:10.1186/1471-2318-11-56.
Nishtala PS, McLachlan AJ, Bell JS, Chen TF. Determinants of antipsychotic medication use among older people living in aged care homes in Australia. Int J Geriatr Psychiatry. 2010;25(5):449–57.
Chen Y, Briesacher BA, Field TS, Tjia J, Lau DT, Gurwitz JH. Unexplained variation across US nursing homes in antipsychotic prescribing rates. Arch Intern Med. 2010;170(1):89–95.
Hughes CM, Donnelly A, Moyes SA, et al. “The way we do things around here”: an international comparison of treatment culture in nursing homes. J Am Med Dir Assoc. 2012;13(4):360–7.
Morrison A. Antipsychotic prescribing in nursing homes: an audit report. Qual Prim Care. 2009;17(5):359–62.
Nishtala PS, McLachlan AJ, Bell JS, Chen TF. Psychotropic prescribing in long-term care facilities: impact of medication reviews and educational interventions. Am J Geriatr Psychiatry. 2008;16(8):621–32.
Westbury J, Jackson S, Gee P, Peterson G. An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUSe project. Int Psychogeriatr. 2010;22(1):26–36.
Madhusoodanan S, Bogunovic OJ. Safety of benzodiazepines in the geriatric population. Expert Opin Drug Saf. 2004;3(5):485–9.
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.
Rodda J, Morgan S, Walker Z. Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer’s disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine and galantamine. Int Psychogeriatr. 2009;21(5):813–24.
Nelson JC, Devanand DP. A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia. J Am Geriatr Soc. 2011;59(4):577–85.
Tan L, Tan L, Wang HF, et al. Efficacy and safety of atypical antipsychotic drug treatment for dementia: a systematic review and meta-analysis. Alzheimers Res Ther. 2015;7(1):20.
Coon JT, Abbott R, Rogers M, et al. Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: a systematic review. J Am Med Dir Assoc. 2014;15(10):706–18.
Fossey J, Masson S, Stafford J, Lawrence V, Corbett A, Ballard C. The disconnect between evidence and practice: a systematic review of person-centred interventions and training manuals for care home staff working with people with dementia. Int J Geriatr Psychiatry. 2014;29(8):797–807.
Kim DH, Brown RT, Ding EL, Kiel DP, Berry SD. Dementia medications and risk of falls, syncope, and related adverse events: meta-analysis of randomized controlled trials. J Am Geriatr Soc. 2011;59(6):1019–31.
Buckeridge D, Huang A, Hanley J, et al. Risk of injury associated with opioid use in older adults. J Am Geriatr Soc. 2010;58(9):664–70.
Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169(21):1952-60. Erratum in: Arch Intern Med. 2010;170(5):477.
Acknowledgments
We thank the staff in each unit for facilitating the data collection, and staff at the Best Practice Advocacy Centre New Zealand for support and advice.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Funding
The Residential Care Provider provided funding to support the study, and information on the interventions implemented, but took no part in the design, execution, analysis and interpretation of data, or writing.
Conflicts of interest
The investigators have no conflicts of interest to declare.
Rights and permissions
About this article
Cite this article
Tordoff, J.M., Ailabouni, N.J., Browne, D.P. et al. Improvements in the prescribing of antipsychotics in dementia and psychogeriatric units in New Zealand. Int J Clin Pharm 38, 941–949 (2016). https://doi.org/10.1007/s11096-016-0318-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11096-016-0318-1