Use of antipsychotic medicines: a literature review
Date
2020
Authors
Hilmer, S.
Gnjidic, D.
Reeve, E.
Kalisch, L.
Wu, H.
Raymond, J.
Editors
Advisors
Journal Title
Journal ISSN
Volume Title
Type:
Report
Citation
Statement of Responsibility
Conference Name
Abstract
The variation in utilisation of antipsychotic medications by older Australians identified in the Australian Atlas of Healthcare Variation is a problem because it suggests antipsychotics are being used outside of their evidence-based place in care, particularly in older people with behavioural and psychological symptoms of dementia (BPSD) and in people with delirium. In older people with these conditions there are considerable risks of antipsychotic medication use, including death, cerebrovascular events and falls. These risks are only outweighed by the therapeutic benefits of antipsychotics if they are used at low doses for short periods, in cases of severe agitation with risk to the person or carer, and where alternative strategies have failed. The burden of disease associated with BPSD and delirium is high and likely to rise in our ageing population. The prevalence of BPSD in people living with dementia is up to 90% and delusions and hallucinations are associated with increased carer burden and institutionalisation. Australian studies report that the prevalence of delirium in older people in acute care is 11-29%. There is a paucity of research on the terms most acceptable to clinicians and consumers to describe BPSD and delirium. Australian and international dementia advocacy groups have published guidance on preferred language for BPSD, but empirical data supporting these recommendations is lacking. Based on commentaries, the reported goals for terminology include accuracy of diagnosis to inform clinical care and research, avoiding stigmatising the person living with dementia, avoiding blaming the carer, and prompting of appropriate (not inappropriate) treatment. The predominant terminology used in the Australian multidisciplinary clinical literature over the past year has been BPSD and delirium. However, other terms for BPSD, such as changed behaviours, expressions of unmet need and responsive behaviours, have also been used in consumer resources. We identified 36 national and international guidelines and recommendations providing guidance on the management of BPSD and dementia, which involved treatment with antipsychotics and/or non-pharmacological strategies. We identified some guidelines for both BPSD and delirium that were rated as high in quality according to the AGREE II criteria. While the evidence for most recommendations was reported as weak-moderate, the strength of recommendations was moderate-high. The recommendations were consistent across all guidelines reviewed. Key recommendations can be considered in terms of the Quality Use of Medicines Framework from our National Medicines Policy:1. Selecting management options wisely; Antipsychotics are only indicated after addressing precipitants and trialling non-pharmacological strategies, for persistent severe symptoms of psychosis or agitation that put the patient/carer at risk. 2. Choosing suitable medicines if a medicine is considered necessary; Choose a medicine with evidence of efficacy for the symptom that is being treated. Consider the risks and benefits for the individual, including co-existing conditions (e.g. Parkinson’s disease, Lewy Body Dementia, cardiovascular disease, arrhythmias), and co-medications (e.g. concurrent psychotropics, drugs that prolong the QT interval, drugs that increase falls risk). Discuss the risks and benefits with the patient +/- surrogate and obtain informed consent. 3. Using medicines safely and effectively. Use the lowest possible dose for the shortest possible time. Monitor safety and efficacy. Frequently review safety and efficacy, and consider tapering/cessation. The main difference between management guidelines for BPSD and dementia relates to duration of antipsychotic treatment in cases where it is indicated and tolerated, which may reflect the differences in the natural history of the conditions. For symptomatic treatment of BPSD, antipsychotic treatment is recommended for weeks-months, while in delirium a single dose or up to a week of treatment is recommended. Our scoping reviews identified a considerable body of work in the black and grey literature on Australian practice, on the extent of provision of evidence based care and obtaining of informed consent for use of antipsychotic medications. We found a number of recent relevant systematic reviews on the effectiveness of use of non-pharmacological strategies for BPSD and delirium. Summarising the findings of these reviews is likely to be informative. We identified a wide range of data sources to measure care improvement in Australia across the community, residential aged care facilities (RACF) and acute care settings. Indicators for quality use of antipsychotics are being developed nationally and internationally. Systematically reviewing these, predominantly from the grey literature, is a substantial and important piece of work yet to be conducted. In conclusion, BPSD and delirium are common across settings and are likely to increase with the ageing of our population. While the evidence on optimal use of antipsychotics in older people with BPSD and delirium is not very strong, national and international guidelines make consistent recommendations about their use, which are consistent with quality use of medicines principles and supported by existing regulations. Further work is required to understand the variation in evidence-based care in Australia, key recommendations for non-pharmacological management strategies, and indicators and data sources for measurement of recommended care.
School/Discipline
Dissertation Note
Provenance
Description
Access Status
Rights
Copyright 2020 Australian Commission on Safety and Quality in Health Care. With the exception of any material protected by a trademark, any content provided by third parties and where otherwise noted, all material presented in this publication is licensed under a Creative Commons Attribution–NonCommercial–NoDerivatives 4.0 International licence