The impact of psycholeptic reduction on residential aged care facility residents

\\(Introduction\\) Antipsychotics and benzodiazepines, collectively known as psycholeptics, are widely used in residential aged care facilities (RACFs), leading to concern that residents are being inappropriately sedated. Whilst antipsychotics are clinically appropriate for severe psychiatric illnesses (e.g., bipolar disorder, schizophrenia), they are often used long-term for neuropsychiatric symptoms, particularly in residents with dementia. Benzodiazepines are typically used for insomnia, anxiety, and acute agitation. Considering evidence of only modest efficacy for these indications and the risk of severe adverse effects, guidelines generally recommend reserving these medications for scenarios where non-pharmacological measures are ineffective and/or where there is a risk of harm or severe distress to the resident or others. Benzodiazepines, in particular, are not recommended for neuropsychiatric symptoms in people with dementia. If used, antipsychotics should be reviewed and reduced at a minimum of six to 12 weeks, depending on the country, and the use of benzodiazepines should be limited to a maximum of two to four weeks. Despite these recommendations, prolonged and widespread use suggests that these medications are not being reviewed and reduced regularly. Many interventions have, to varying degrees of success, reduced the use of these medications in RACFs. However, clinical outcomes for the RACF residents and staff, and the economic impact of these interventions are rarely reported (see Chapter 4). Concern of potential deterioration in resident symptoms resulting in increased workloads is one of the reasons for a lack of willingness to reduce these medications. Therefore, to address these gaps in the literature and minimise perceived barriers to sedative reduction, the focus of this thesis was to evaluate the impact that antipsychotic and benzodiazepine dose reduction had on resident- and RACF staff-related outcomes and health care costs within RACFs involved in a multicomponent program to improve antipsychotic and benzodiazepine use. \\(Methods\\) The national expansion of the 'Reducing Use of Sedatives' (RedUSe) program involved 150 Australian RACFs. The main components of RedUSe comprised two quality improvement cycles incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews. The program was implemented between March 2014 and April 2016. A prospective, observational, longitudinal study design was utilised to investigate outcomes related to changes in antipsychotic and/or benzodiazepine doses between baseline and four months among residents of a convenience sample of 28 RACFs involved in RedUSe between January 2015 and March 2016. \\(Resident-related\\) \\(outcomes\\) Permanent residents (n=206) taking antipsychotics and/or benzodiazepines on a daily basis, who did not have a severe psychiatric illness (where antipsychotic therapy should generally be maintained long-term e.g., bipolar disorder, schizophrenia) and were not considered end-stage palliative, were recruited. Neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and Cohen-Mansfield Agitation Inventory (CMAI)), quality of life (QoL; Assessment of Quality of Life-4D (AQoL-4D)), social withdrawal (Multidimensional Observation Scale for Elderly Subjects (MOSES)-withdrawal subscale) and activities of daily living (Physical Self-Maintenance Scale (PSMS)) were assessed at baseline and four months by nursing staff who completed psychometric tests as proxy raters. Lastly, the number and severity of falls and behavioural events, number and reason for general practitioner (GP) consultations and number, length and reason for hospitalisations of recruited residents were recorded by the nursing staff between baseline and four months. Figure 1 illustrates all data collection associated with this project. \\(Staff-related\\) \\(outcomes\\) The occupational disruptiveness of the neuropsychiatric symptoms was assessed at baseline and four months during psychometric testing with the NPI-NH. Additionally, a survey of job satisfaction (adjusted-Measure of Job Satisfaction) was made available to all RACF nurses and carers for anonymous completion at baseline and four months (Figure 1). \\(Basic\\) \\(costing\\) \\(analysis\\) Health care utilisation costs were estimated using the cost of prescribed medications at baseline and four months, and the estimated cost of GP consultations and hospitalisations between baseline and four months. \\(Statistical\\) \\(methodology\\) Considering the longitudinal design, analyses were restricted to residents who were followed up at baseline and four months. Associations between changes in the NPI-NH (total, factor and occupational disruptiveness scores), CMAI (total and factor scores), AQoL-4D (utility and dimension scores), MOSES-withdrawal subscale and PSMS, and changes in the antipsychotic and benzodiazepine doses between baseline and four months were investigated using regression models. The number of falls, behavioural events, GP consultations and hospitalisations were pro-rated to a monthly count. Associations between changes in the antipsychotic and/or benzodiazepine dose and these pro-rated counts were investigated using Spearman's Rank correlations. Differences in the adjusted-Measure of Job Satisfaction (total and factor) scores at baseline and four months were investigated using independent t-tests. Re-analysis was performed based on the occupation of the respondent. Lastly, estimated medication and health care costs of residents who had their antipsychotic and/or benzodiazepine dose reduced were extrapolated to 12 months and were compared to (i) residents who did not have their dose reduced and (ii) the overall costs for all residents involved in the clinical outcomes study regardless of dose change. \\(Results\\) Follow-up data were available for 179 residents. Thirty of 83 residents (36%) taking an antipsychotic and 42 of 118 residents (36%) taking a benzodiazepine at baseline had reductions in their dose at four months. This included 18 out of 83 residents (22%) taking an antipsychotic and 25 out of 118 residents (21%) taking a benzodiazepine who had their medication ceased. \\(Resident-related\\) \\(outcomes\\) There was no evidence that resident-related outcomes were worsened by dose reductions. Whilst there were no notable trends when measuring neuropsychiatric symptoms with the NPINH, dose reduction was associated with small, albeit non-significant, improvements in behaviour, particularly less physically nonaggressive behaviour with both drug groups (-0.36 points per 10% reduction in antipsychotic dose, -0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behaviour with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with nonsignificant improvements in QoL and benzodiazepine dose reduction was correlated with a lower rate of falls in mobile residents. \\(Staff-related\\) \\(outcomes\\) Like resident-related outcomes, there was no evidence that occupational disruptiveness was worsened by dose reductions. Instead, there were trends toward improved occupational disruptiveness related to agitation with antipsychotic dose reduction and night-time behaviour with benzodiazepine dose reduction. No differences in job satisfaction were detected between baseline and four months. \\(Basic\\) \\(costing\\) \\(analysis\\) Savings between $938 and $1,486/resident/year were found among residents who had their antipsychotic and/or benzodiazepine dose reduced. Savings were driven by lower hospitalisation (savings between $897 and $1,421/resident/year) and medication costs (savings between $163 and $257/resident/year). On the other hand, residents who had their antipsychotic and/or benzodiazepine dose reduced had higher costs associated with GP consultations (costs increased by $121 to $192/resident/year). \\(Discussion\\) Overall, the research presented in this thesis found no evidence to suggest that antipsychotic and/or benzodiazepine dose reduction was associated with deteriorations in neuropsychiatric symptoms, QoL, social engagement, activities of daily living, job satisfaction or occupational disruptiveness. Moreover, trends towards improved agitation with both antipsychotic and benzodiazepine dose reduction were identified as potential benefits. Similarly, occupational disruptiveness related to agitation and night-time behaviour tended to improve with antipsychotic and benzodiazepine dose reduction, respectively. There were also savings with antipsychotic and benzodiazepine dose reduction, driven by lower costs related to hospitalisations and medications. Whilst this research suggests that antipsychotic and benzodiazepine dose reduction was safe and potentially cost saving for most residents, future larger, prospective, controlled studies are required to investigate these outcomes further.