Why deprescribing antipsychotics in older people with dementia in long-term care is not always successful: insights from the HALT study
Abstract
INTRODUCTION: Antipsychotic medications are commonly used to manage behavioural and psychological symptoms of dementia despite their side effects and harms. While the Halting Antipsychotic Use in Long-Term care (HALT) deprescribing trial was successful at reducing antipsychotic use, 19% of participants had their antipsychotics represcribed or never reached a dose of zero. The aim of this study was to investigate the reasons for represcription of antipsychotic medication and factors associated with ongoing antipsychotic use, relating to care staff requests and perceived behavioural changes. MATERIALS AND METHODS: Thirty-nine of 133 HALT participants never ceased their antipsychotic medication or were represcribed a regular or pro re nata (PRN) antipsychotic after initial deprescribing. The views of nursing staff, general practitioner, and family on the circumstances leading up to these outcomes were collected via a questionnaire-based approach. This information was triangulated with observation and detailed file audit (including progress notes, medical notes, medication charts, incident reports, and hospital discharge summaries). A consensus panel reconstructed the represcribing context. RESULTS: Nurses were the most common drivers of represcribing (63.2%), followed by family members (39.5%), GPs (23.7%), specialists (13.2%), and hospital staff (10.5%). There were multiple drivers for antipsychotic use in 46.2% of participants. Increased agitated and aggressive behaviours were the most commonly reported reasons for represcribing even though these changes were not identified over time on objective measures. Consent and dosage practices remained poor despite education. DISCUSSION: Nursing staff are the key drivers of deprescribing particularly in response to perceived worsening agitation and aggression among male residents. The train-the-trainer model used in the HALT trial may have been insufficient on its own to improve staff competence and confidence in applying nonpharmacological approaches when responding to behaviour change.
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In seven studies, psychotropic medication was used to manage behaviours and BPSD.
“In seven studies, psychotropic medication was used to manage behaviours and BPSD [49, 53, 57, 63, 65, 80, 81].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [49]
Nurses were identified as the main driver of prescribing.
“Nurses were identified as the main driver of prescribing [49, 62, 81].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [49]
Doctors and nurses were of the view that assessing whether psychotropic medication was appropriate in older people was challenging.
“Doctors and nurses were of the view that assessing whether psychotropic medication was appropriate in older people was challenging [49, 53–56, 62, 65, 80–82].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [49]
The importance of a holistic assessment of any underlying needs such as pain or constipation which may be causing distress was highlighted by healthcare professionals.
“The importance of a holistic assessment of any underlying needs such as pain or constipation which may be causing distress was also highlighted by healthcare professionals [49, 53, 57, 80, 81].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [49]
Some were of the view that medication reviews could help identify inappropriate use while acknowledging that these were not always carried out.
“Some were of the view that medication reviews could help identify inappropriate use while acknowledging that these were not always carried out [49, 55, 56, 62].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [49]
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- Authors
- Aerts, L., Cations, M., Harrison, F., Jessop, T., Shell, A., Chenoweth, L., & Brodaty, H.
- Affiliations
- UNSW Sydney (AU)
- Corresponding author
- Brodaty, Henry
- Venue
- International Journal of Geriatric Psychiatry
- Publisher
- Wiley
- Published
- 2019-07-15
- Volume
- 34
- Issue
- 11
- Pages
- 1572-1581
- ISSN
- 0885-6230 (ISSN-L)
- 1099-1166
- OpenAlex
- W2954518847
- Cited by
- 33
- References
- 37
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 7 · 2023: 3 · 2022: 6 · 2021: 9 · 2020: 3 · 2019: 1
- FWCI
- 2.50
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Geriatric Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Department of Health, Australian Government
- Topics
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- dementia, long-term care, behavioral and psychological symptoms of dementia, agitation, aggression, nurses, train-the-trainer model, non-pharmacological treatment, older adults
- MeSH terms
- Aged, Aged, 80 and over, Aggression, Attitude of Health Personnel, Dementia, Female, Humans, Long-Term Care, Longitudinal Studies, Male, Middle Aged, Problem Solving, Psychotic Disorders, Antipsychotic Agents
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