Australian researchers 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. Unfortunately, we still see a systematic use of these drugs in residential care facilities 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.

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," 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."