Conference Coverage
TORONTO—Approximately 80% of elderly people with dementia in nursing homes do not have a reemergence of behavioral symptoms after cessation of antipsychotic drugs, according to research presented at the Alzheimer’s Association International Conference. The results may indicate that the antipsychotics are not necessary in these patients.
Many residents of nursing homes receive antipsychotics, but the drugs’ effect size is modest, said Henry Brodaty, MD, DSc, Professor of Aging and Mental Health and Codirector of the Center for Healthy Brain Aging at the University of New South Wales in Sydney. Antipsychotics can cause extrapyramidal side effects, falls, anticholinergic side effects such as worse cognition, urinary outflow difficulties and constipation, and orthostatic hypotension. The medicines also are associated with increased rates of stroke and death. In a UK study, Ballard and colleagues found no difference in the reemergence of behavioral symptoms between patients on continuous antipsychotics who were randomized to withdrawal and patients who continued their antipsychotics. However, Devenand and colleagues reported reemergence of behavioral symptoms when patients ceased antipsychotics.
Henry Brodaty, MD, DSc
Nurses Used Behavioral Strategies
To investigate the matter further, Dr. Brodaty and colleagues initiated the Halting Antipsychotics in Long-Term Care (HALT) study. The single-arm, 12-month, longitudinal study took place in 23 nursing homes in the Australian state of New South Wales. A nurse at each nursing home was named a “nurse champion” and identified residents who were receiving continuous antipsychotics. The researchers obtained permission from the nursing homes, the patients’ families, and the patients’ physicians to include the patients in the study.
During three days of training, each nurse champion learned how to manage behavioral symptoms and how to use person-centered care and behavioral strategies. These nurse champions subsequently trained the other nurses at their respective facilities in these techniques. Next, investigators monitored the patients for a month to establish their baseline conditions. Antipsychotics were stopped for all patients according to a protocol, and the researchers reassessed participants three, six, and 12 months later.
Participants’ mean age was about 85, and approximately two-thirds of patients were female. More than half of the sample was separated, widowed, or divorced. Approximately one-third of participants were married. About half of the sample had a high level of education, and half had a low level. A chart review indicated that one-third of patients had Alzheimer’s disease, and less than one-third had unspecified dementia. Smaller portions of the population had vascular or other dementias.
Participants received an average of 2.3 psychotropic medications and an average of nine medications for other indications. The total of about 11 medications per person was “about average,” said Dr. Brodaty. The most common antipsychotic was risperidone, followed by quetiapine, olanzapine, and haloperidol. Participants had been taking their antipsychotics for about two years and their current doses for at least one year. More than half of participants started antipsychotic medication after admission to the nursing home. About 20% of participants started antipsychotics during hospitalization before transfer to the nursing home, and 8% started antipsychotics in the community. For others, this information was not available.
Neuropsychiatric Symptoms Did Not Change
In all, 150 participants completed the prebaseline assessment, 139 completed the baseline assessment, 133 participants completed the three-month follow-up, and 118 participants completed the six-month follow-up. The 12-month follow-up was incomplete at the time of the presentation.
Of the 125 patients who had stopped their antipsychotics, the drugs were represcribed to 15 patients during the first three months. At six months, 10 of 118 patients for whom data were available had antipsychotics represcribed. In the final six months of the study, one patient had an antipsychotic represcribed. “In other words, almost 80% remained deprescribed, usually completely ceased,” said Dr. Brodaty. Many physicians wrote prn prescriptions, mainly for oxazepam as rescue medication, but the investigators have not analyzed the data to determine whether they were filled.
Despite the cessation of antipsychotics for most of the residents, there was no significant change in participants’ total Neuropsychiatric Inventory (NPI) score over the five follow-up visits, nor in their agitation (as measured by the Cohen Mansfield Agitation Inventory), aggression (as measured by the NPI), delusions, or hallucinations.
Should Standard of Care Change?
It was difficult to recruit patients for the study, said Dr. Brodaty. The investigators approached 58 nursing homes, and more than half declined to participate. Nurse champions also may not have included all patients on antipsychotics in the study. The results thus may have been influenced by selection bias. Staff at the nursing homes, physicians, and families appeared to be ignorant about the potential benefits of stopping antipsychotics such as preventing anticholinergic and other side effects.