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Reduced antipsychotic use feasible in nursing homes, disadvantageous without social, exercise interventions

Recent findings show that reducing antipsychotic use among individuals with dementia living in nursing homes is feasible using a ‘real-world intervention;’ however, it may not be beneficial unless nonpharmacological interventions are provided in parallel.

“In recent years there has been a concerted effort to reduce unnecessary prescribing of antipsychotics in people with dementia, which has led to a shift in the landscape of their use, with audits demonstrating 15% to 50% reductions in prescriptions across the United States and Europe,” Clive Ballard, MD, of the Wolfson Centre for Age-Related Diseases, King’s College London, and colleagues wrote. “This raises key questions regarding the potential to build an effective, feasible real-world intervention to manage neuropsychiatric symptoms and antipsychotic use in the complex landscape of nursing homes. It will be important to establish whether routine implementation of antipsychotic review and evidence-based nonpharmacological interventions can contribute to improved outcomes for people with dementia.”

To assess the impact of antipsychotic review, social interaction and exercise in conjunction with person-centered care on agitation, depression and antipsychotic use among individuals with dementia living in nursing homes, researchers conducted a cluster-randomized factorial-controlled trial. Sixteen nursing homes in the United Kingdom received person-centered care training. Eight homes were randomly assigned to antipsychotic review, social interaction intervention and to an exercise intervention for 9 months. Most were assigned to multiple interventions.

Antipsychotic use decreased by 50% among homes randomized to antipsychotic review (OR = 0.17; 95% CI, 0.05-0.6).

Antipsychotic review plus the social interaction intervention significantly reduced mortality (OR = 0.26; 95% CI, 0.13-0.51), compared with homes that received neither intervention.

Homes that received antipsychotic review but not the social interaction intervention exhibited significantly poorer neuropsychiatric symptom outcomes compared with homes receiving neither intervention, with a score difference of 7.37 (95% CI, 1.53-13.22; P = .02) . This impact was mitigated by concurrent delivery of the social intervention, according to researchers.

Exercise significantly improved neuropsychiatric symptoms (P < .05) but did not significantly affect depression.

There was no significant difference in Cohen-Mansfield Agitation Inventory scores between homes that did and did not receive antipsychotic review.

“Overall, the study demonstrates the feasibility of a real-world intervention to reduce antipsychotic use in people with dementia, but it highlights an urgent need to review current best practice guidelines to ensure that review of antipsychotics is in the best interests of people with dementia,” Ballard and colleagues wrote. “Updated guidance will also need to strongly emphasize the importance of evidence-based nonpharmacological interventions. Our study suggests that focused intervention to promote social engagement is an important component of combined interventions to enable effective antipsychotic discontinuation and clinical outcomes.” – by Amanda Oldt

Disclosure: Ballard reports grants and personal fees from Acadia; grants and personal fees from Lundbeck; and personal fees from Napp, Roche, Orion, Bial, Bristol-Myers Squibb, Otsuka, and Novartis. Please see the full study for a list of all authors’ relevant financial disclosures.