Canadian Psychiatric Association

Association des psychiatres du Canada

In Review Series

Antipsychotic Use in Dementia: Is There a Problem and Are There Solutions? Utilisation d’antipsychotiques dans la de´mence : y a-t-il un proble`me et y a-t-il des solutions?

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2017, Vol. 62(3) 170-181 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716673321 TheCJP.ca | LaRCP.ca

Julia Kirkham, MD, FRCPC1, Chelsea Sherman, BSc1, Clive Velkers, BSc1, Colleen Maxwell, PhD2, Sudeep Gill, MD, MSc, FRCPC3, Paula Rochon, MD, MPH, FRCPC4, and Dallas Seitz, MD, PhD, FRCPC1

Abstract Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exists over the role of antipsychotics in the management of neuropsychiatric symptoms (NPS) in persons with dementia. Although some NPS may be appropriately and safely treated with antipsychotics, a fine balance must be achieved between the benefits of these medications, which are often modest, and adverse events, which may have significant consequences. Approximately one-third of all persons with dementia are currently prescribed antipsychotic medications, and there is significant variation in the use of antipsychotics across care settings and providers. Reducing the inappropriate or unnecessary use of antipsychotics among persons with dementia has been the focus of increasing attention owing to better awareness of the potential problems associated with these medications. Several approaches can be used to curb the use of antipsychotics among persons with dementia, including policy or regulatory changes, public reporting, and educational outreach. Recently, there has been encouraging evidence of a downward trend in the use of antipsychotics in many long-term care settings, although prescribing rates are still higher than what is likely optimal. Although reducing the inappropriate use of antipsychotics is a complex task, psychiatrists can play an important role via the provision of clinical care and research evidence, contributing to improved care of persons with dementia in Canada and elsewhere. Abre´ge´ Les antipsychotiques sont ne´cessaires chez bien des adultes aˆge´s pour traiter des maladies mentales majeures ou re´duire des symptoˆmes psychiatriques e´prouvants. Il existe pre´sentement une controverse sur le roˆle des antipsychotiques dans la prise en charge des symptoˆmes neuropsychiatriques (SNP) chez les personnes souffrant de de´mence. Bien que certains SNP puissent eˆtre traite´s ade´quatement et en se´curite´ par des antipsychotiques, un e´quilibre de´licat doit eˆtre observe´ entre les avantages de ces me´dicaments, qui sont souvent modestes, et les effets inde´sirables, qui peuvent avoir d’importantes conse´quences. Des me´dicaments antipsychotiques sont pre´sentement prescrits a` environ un tiers de toutes les personnes souffrant de de´mence, et il y a une variation significative de l’utilisation des antipsychotiques dans les e´tablissements et chez les fournisseurs de soins. Re´duire l’utilisation inapproprie´e ou non ne´cessaire des antipsychotiques chez les personnes souffrant de de´mence est au centre de l’attention croissante que l’on doit a` une meilleure connaissance des proble`mes e´ventuels associe´s a` ces me´dicaments. Plusieurs approches peuvent eˆtre utilise´es pour freiner l’utilisation des antipsychotiques chez les

1 2 3 4

Department of Psychiatry, Queen’s University, Kingston, Ontario Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, Ontario Division of Geriatric Medicine, Department of Medicine, Queen’s University, Kingston, Ontario Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario

Corresponding Author: Dallas Seitz, MD, PhD, FRCPC, 752 King St. West, Providence Care–Mental Health Services, Kingston, ON K7L 4X3, Canada. Email: [email protected]

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personnes souffrant de de´mence, notamment des changements de politiques ou de re`glements, des rapports publics et des programmes e´ducatifs. Re´cemment, il y a eu des preuves encourageantes d’une tendance vers le bas de l’utilisation d’antipsychotiques dans de nombreux e´tablissements de soins de longue dure´e (SLD), bien que les taux de prescription soient encore plus e´leve´s que ce qui est probablement optimal. Meˆme si la re´duction de l’utilisation inade´quate des antipsychotiques est une taˆche complexe, les psychiatres peuvent jouer un roˆle important en fournissant des soins cliniques et les donne´es probantes de la recherche, et en contribuant a` de meilleurs soins pour les personnes souffrant de de´mence au Canada et ailleurs. Keywords antipsychotics, dementia, quality of care, adverse events, quality improvement, long-term care

There are increasing numbers of older adults in Canada, and an aging population will result in a greater proportion of persons with dementia. A doubling of dementia prevalence is anticipated in the future, with more than 1 million persons with dementia living in Canada by 2030.1 Neuropsychiatric symptoms (NPS), also known as behavioural and psychological symptoms of dementia or responsive behaviours, affect 80% of all persons with dementia.2 NPS include a variety of symptoms, some of which can result in significant distress for individuals with dementia or those around them. Although nonpharmacological treatments are recommended as first-line treatments for NPS,3-6 these approaches are not always effective, and research evidence on these approaches may not be readily translated to clinical practice because of the limited availability of resources in many regions.7 Given the high prevalence of NPS, it is not surprising that psychotropic medication use is common among persons with dementia, with atypical antipsychotics being the most extensively studied class of medications. Guideline recommendations suggest that some atypical antipsychotics can be considered for the treatment of agitation, aggression, and psychosis that is severe, persistent, and either results in significant distress for the patient or poses a safety risk for the persons with dementia or those around them.3,4,6 The clinical benefits of antipsychotics for NPS are modest,8 and the types of NPS that respond to antipsychotics are limited.9 Furthermore, the use of antipsychotics in persons with dementia is associated with increased risks of mortality,10 stroke,11 and more common side effects such as falls,12 sedation,8 and cognitive decline.13 Despite these concerns, upward of 20% to 30% of persons with dementia are currently prescribed antipsychotic medications.14 There is wide variation in the use of antipsychotics across long-term care (LTC) facilities beyond what can be explained by differences in underlying resident characteristics,15,16 and variability in antipsychotic prescribing rates is associated with individual family physicians17 and psychiatrists,18 suggesting that antipsychotics may be used inappropriately in many instances. Other factors associated with increased use of antipsychotics include larger size of LTC facilities16,19 and urban location of LTC facilities.15,19 LTC facilities in which caregivers perceive lower access to recreational activities, less perceived availability of LTC

staff, and less staff engagement with residents also have increased rates of antipsychotic use.19 Antipsychotic prescribing in LTC is also highly correlated with other measures of quality of care such as overall mortality.20 Inappropriate use of antipsychotics in LTC settings has recently become a focus of public scrutiny in Canada and has been the subject of numerous media reports.15,21,22 Choosing Wisely, an international initiative to reduce ineffective or harmful health care interventions, has identified antipsychotic use among persons with dementia as one of its major recommendations for the care of older adults.23 In this article, we review the patterns of antipsychotic use among persons with dementia and discuss factors associated with variation in antipsychotic use. We then provide an overview of strategies that have been adopted to minimize inappropriate prescribing. Our review will conclude with recent trends in antipsychotic use and initiatives that are under way in Canada to reduce inappropriate prescribing.

Antipsychotic Use in Dementia Prevalence of Antipsychotic Use in Dementia We completed a systematic review and meta-analysis to estimate the prevalence of antipsychotic use among persons with dementia. The electronic databases MEDLINE and Embase from inception until January 2014 were searched using standardized key words and medical subject headings to identify relevant studies. We included only studies that examined study populations with dementia diagnosed using standardized diagnostic criteria and that also reported on the proportion of the study sample who received antipsychotic medications. Information on study country, setting (community compared with LTC), and severity of dementia were extracted from studies. Random-effects meta-analysis was undertaken using the statistical program R to determine the pooled estimates of antipsychotic prescribing among individuals with dementia, and subgroup analyses were undertaken to evaluate factors associated with antipsychotic prescribing. A total of 45 studies reported on the prevalence of antipsychotics among persons with dementia16,24-68 (Table 1), with 43 studies containing sufficient information to be included in a meta-analysis. In the meta-analysis of these

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Finland England France United States Belgium Belgium England England England France Finland Belgium Spain United States United States Scotland United States Sweden Sweden Scotland Finland Finland United States United States France Germany Sweden/Finland Sweden Germany England England Canada Netherlands Italy Finland United States United States United States United States Norway United States Italy Netherlands

Alanen, 200624 Alldred, 200725 Arbus, 201026 Arling, 199127 Azermai, 2011a29 Azermai, 2011b28 Ballale, 201030 Ballard, 200131 Barnes, 201232 Barro-Belaygues, 201133 Bell, 201034 Bourgeois, 201236 Calvo´-Perxas, 201237 Chan, 200738 Chen, 201016 Connelly, 201039 Dhawan, 200840 Forsell, 199741 Gustafsson, 201342 Guthrie, 201043 Hartikainen, 200344 Hosia-Randell, 200545 Kamble, 200946 Kim, 200647 Larrayadieu, 201148 Linden, 200449 Lo¨vheim, 200850 Lo¨vheim, 200651 Majic, 201052 Margolla-Lanna, 200153 Martinez, 201354 Maxwell, 201355 Nijk, 200956 Nobili, 200957 Raivio, 200759 Rhee, 201160 Sapra, 200961 Schubert, 200662 Seitz, 200963 Selbæk, 200764 Semla, 199565 Toscani, 201366 Zuidema, 201167 LTC LTC Community LTC LTC LTC LTC LTC Community, LTC LTC LTC LTC Community, hospital Community LTC LTC, hospital Community Community LTC Unclear Community LTC LTC LTC Assisted living Community Community, LTC hospital LTC, hospital LTC LTC Community Community LTC LTC LTC, hospital Community Medical centre outpatient Community LTC LTC Community Home care, LTC LTC

Setting

MMSE ¼ Mini–Mental State Examination; LTC ¼ long-term care.

Country

Study (first author, year)

Questionnaire, chart review Clinical interview Interview and chart review Survey Chart review Interview Primary care database Home care administrative data Interview and chart review Interview Interview Clinical evaluation Administrative data Interview Survey Interview Chart review and interview

Database (RAI-MDS) Chart review Clinical evaluation Interview Clinical evaluation, chart review Clinical evaluation, chart review Chart review Clinical evaluation Primary care database Research survey Chart review Clinical evaluation, chart review Health care database Chart review Health care database (MDS, claims) Interview Chart review Clinical interview Survey Primary care database Clinical interview Chart review Survey

Data source

Table 1. Studies evaluating antipsychotic prescribing rates among persons with dementia.

782 146 686 1997 825 1730 50 209 10 199 1005 781 1730 952 285 7659 83 173 154 2019 10058 77 1380 692 566 107 1746 140 247 2017 304 209 50349 104 802 1322 349 254 307 4000 107 665 217 933 325 410 1322

Sample size (N)

(80.3) (69.9) 7067 (70.3) 57 (74.0)

92.3 84.6

201 (81.4) 1394 (69.1) 216 (71.1) 170 (73.0) 32929 (65.0) 66 654 (63.6) 1056 (79.9) 278 (79.7) 215 (85.4) 209 (68.3) 67 (62.6) 507 560 (76.3) 210 (64.6) (80.3) 1031 (80.0)

91.6 (4.7) 83.5 (6.8) 81.6 (10.5) 83.0 (8.0) 82.0 83.2 (7.6) 83.0 (8.1) 81.2 (7.3) 86.0 84.4 (6.9) 75.6 (6.2) 84.8 74.7 (7.8) 86.0 83.0 (8.1)

87.1

532 419 (76.9) 94 (88.0)

1349 (78.0) 24 (48.0) 184 (79.5) 6322 (62.0) 776 (51.3) 597 (76.5) 1349 (78.0) 600 (63.0) 235 (76.6)

85.0 (8.0) 79.6 (8.0) 82.5 (6.8) 82.0 86.0 (6.4) 82.4 85.0 79.5 (6.6) 81.7 (7.0)

83.0 (5.0) 83.7 (7.7)

488 (71.0) 1518 (76.0)

Number female (%)

77.9 (6.8)

Mean (SD) age (years)

15.3 (7.6)

17.7 (5.3)

7.8 (7.0)

8.6 (8.0)

12.3 (7.7)

17.4 (5.2) 17.5 (7.0)

8.4 (7.2)

20.0 (4.2)

Mean MMSE score (SD)

255 (32.6) 46 (32.0) 41 (6.0) 472 (24.0) 383 (46.4) 570 (33.0) 32 (64.0) 52 (46.0) 1902 (19.0) 269 (45.5) 334 (42.8) 569 (32.9) 243 (25.5) 14 (4.9) 3313 (43.3) 48 (57.8) 29 (17.0) 14 (9.1) 514 (25.5) 1785 (17.7) 25 (32.5) 598 (43.3) 227 722 (32.9) 40 (37.4) 591 (33.8) 12 (8.5) 55 (22.3) 531 (26.3) 159 (52.3) 87 (41.0) 6293 (12.5) 23 580 (22.5) 826 (62.6) 209 (60.0) 123 (48.4) 58 (19.1) 140 (35.0) 4 (3.7) 230 830 (34.7) 240 (25.8) 43 (13.2) 105 (25.6) 476 (37.0)

Any antipsychotic, n (%)

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Figure 1. Forest plot of the prevalence of antipsychotic prescribing in community and long-term care settings.

studies, the pooled prevalence of any antipsychotic use among persons with dementia was 27.5% (95% CI 25.7% to 29.3%, P < 0.0001). There was evidence of significant statistical heterogeneity in the prevalence of antipsychotics reported in these studies (Q ¼ 16 930, P < 0.0001, I2 ¼ 99.8%). There were significant differences in antipsychotic prescribing among studies with communitybased samples when compared with LTC (Figure 1). In subgroup analyses, studies conducted in community settings (N ¼ 11) had a lower prevalence of antipsychotic use when compared with LTC settings (N ¼ 21; 12.3% compared with 37.5%; Q ¼ 61.77, P < 0.0001). There was increasing prevalence of antipsychotic use with increasing severity of dementia from a rate of 6.7% reported in one study of mild dementia, 12.2% in studies with moderate dementia (N ¼ 5), and 45.1% in studies involving severe dementia (N ¼ 3; Q ¼ 32.89, P < 0.0001).

Trends in Antipsychotic Use Meta-regression was used to examine whether there have been changes in antipsychotic prevalence over time in the studies included in our review. We observed a small but significant reduction in the prevalence of antipsychotics in community settings (b ¼ –0.06, P < 0.0001) and a small increase in antipsychotic prescribing rates reported over time from studies conducted in LTC (b ¼ 0.03, P < 0.0001). Analysis of antipsychotic prescribing over time within health regions is encouraging, with recent studies generally showing reductions. Analysis of data reported to the Canadian Institute of Health Information (CIHI) between 2001 and 2007 found a 37.7% prevalence of antipsychotic use among all older adults in LTC. In the time periods preceding and following Health Canada warnings about antipsychotics in 2005, there was an overall increase in the use of

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France, 77 whereas a study of antipsychotic trends in Germany did not find significant reductions in use among persons with dementia.78 In studies that have evaluated outcomes potentially related to lower antipsychotic use, other psychotropic medication or restraint use has generally not increased,72,74,79,80 although a few have documented small increases in the use of antidepressants.76,81,82 This is in keeping with several large-scale studies indicating that antipsychotics can be successfully discontinued in most individuals without significant worsening of behavioural symptoms.83,84 Risk factors for relapse following antipsychotic discontinuation include greater severity of NPS at the time of antipsychotic initiation83 and shorter duration of antipsychotic treatment when compared with chronic use.85 Together, these findings are encouraging, although current rates are still higher than what is likely optimal in many settings. Figure 2. Provincial rates of inappropriate prescribing of antipsychotics in long-term care in Canada using Canadian Institutes of Health Information Indicator. NA ¼ not applicable due to data not being available. All numbers indicate provincial average of antipsychotic indicator across all reporting long-term care sites within each province. Reprinted with permission from the Canadian Institutes of Health Information Indicator, available at www.yourhealth system.cihi.ca, accessed August 23, 2016.

Figure 3. Trends in rates of inappropriate antipsychotic use in longterm care facilities in Canada using the Canadian Institutes for Health Information (CIHI) Inappropriate Use of Antipsychotics Indicator. Rate reflects the average rate of inappropriate antipsychotic use of all long-term care facilities reporting to CIHI. Adapted from the Canadian Institutes of Health Information Indicator, available at http://www.yourhealthsystem.cihi.ca, accessed April 26, 2016.

antipsychotics in Ontario, but the rate of increase in the use of antipsychotics decreased following the warnings when compared with the time period immediately preceding them.69,70 Updated information on antipsychotic use in LTC using the CIHI indicator have shown reductions in inappropriate antipsychotic use from 2010 and 201571 (Figure 2). Antipsychotic prescribing rates in US LTC homes have decreased significantly since rates approaching 50% were observed in the mid-1990s,72,73 and reductions among persons with dementia in US outpatient settings have also been observed.74,75 Similar reductions in antipsychotic use have been observed over time in the United Kingdom76 and

Measuring Appropriateness of Antipsychotic Prescribing Crude rates of antipsychotic prescribing do not provide any information on the potential appropriateness of use, and antipsychotic prescribing rates are commonly adjusted to account for differences in patient characteristics between facilities. The inappropriate use of antipsychotics indicator is calculated by CIHI using data that are routinely collected and reported by approximately 57% of all LTC facilities in Canada71 using the number of individuals receiving an antipsychotic on 1 or more days within the 7 days preceding their most recent LTC assessment, divided by the total number of individuals in the facility or region who do not meet exclusion criteria.86 The CIHI indicator excludes individuals with schizophrenia, Huntington’s disease, those with active delusions or hallucinations, and those at the end of life (all potential indications for antipsychotics). To compare rates across facilities or regions, adjustments are made for heterogeneity in underlying clinical populations and for differences in age, severity of dementia (as measured by the Cognitive Performance Scale), and agitation.87,88 The CIHI indicator is currently publicly reported for all LTC facilities in Ontario, Alberta, British Columbia, and the Yukon, with partial reporting in Newfoundland, Nova Scotia, and Manitoba. In the most recent data, the overall rate of potentially inappropriate prescribing of antipsychotics among reporting LTC homes is 27.5% (Figure 3). Reporting of the CIHI indicator is limited to LTC facilities; data from community, hospital, or other settings are not reported on. There are significant limitations to the CIHI indicator when applied at an individual level. Some potential indications for antipsychotics among people with dementia, most importantly significant symptoms of aggression, are not captured in the exclusion criteria for the CIHI indicator. The CIHI indicator lists only schizophrenia as a mental health exclusion criterion, whereas other mental health conditions such as bipolar disorder and major depression may also be appropriate indications for antipsychotics in older adults. Given that there are appropriate indications for antipsychotic

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use in some instances, a proportion of individuals who are receiving antipsychotics appropriately will be misidentified on the CIHI indicator. Polypharmacy, either with multiple antipsychotics or antipsychotics in combination with other psychotropics, is common in LTC settings20,82 but also not captured by the CIHI indicator.

Approaches to Reduce Inappropriate Antipsychotic Use Several approaches have been employed to reduce inappropriate antipsychotic use among persons with dementia. These strategies can include policy or regulatory approaches, public reporting, and interventions directly targeting health care providers. We review the history and the strengths and limitations of each in the remainder of this review.

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In the United Kingdom, the Department of Health in collaboration with the Alzheimer’s Society created a dementia strategy in 2009.100 Appropriate antipsychotic use was included within the strategy’s initiatives to improve overall care in LTC.100 The strategy recommended national efforts be made to reduce the use of antipsychotics in persons with dementia across care settings by creating structures for auditing of antipsychotic use, skills development in primary care and LTC, and improved access to mental health services support.101 Following introduction of the strategy, statistics from the National Health Service demonstrated a 10% absolute reduction in antipsychotic prescribing in communitybased settings from 2006 (17% prescribing rate) to 2011 (7% prescribing rate), despite increasing numbers of individuals with dementia.102 Antipsychotic prescribing rates in LTC settings have not been reported to date.

Public Reporting Policy and Regulatory Approaches Administrative approaches, including policy change and the use of legislation, have the potential to broadly affect prescribing practices. The United States and United Kingdom are among the first jurisdictions to implement national policy approaches aimed at reducing unnecessary use of antipsychotics. Although other countries have since implemented similar policies, a broad regulatory framework has yet to be developed in Canada. In response to concerns regarding poor quality care in nursing homes in the United States, including high rates of antipsychotic use89 and recommendations from an Institute of Medicine study,90 the United States enacted legislation to improve care in nursing homes in the Federal Nursing Home Reform Act from the Omnibus Budget Reconciliation Act of 1987, referred to as OBRA-87.91 For residents with dementia and NPS, OBRA-87 recommended a trial of nonpharmacological approaches, review, and dose reductions after 6 months of treatment89 and limited the appropriate use of antipsychotics to individuals with psychotic disorders or severe agitation.92 New care standards following OBRA-87 were enforced beginning in 1990. Early studies during this time period found relative reductions in antipsychotic prescribing rates of 32% to 36%.79,93 Several subsequent studies demonstrated relative reductions in antipsychotic use by approximately 30% in most regions.94 Prescribing patterns for other categories of psychotropic medications remained relatively stable overall, although some studies found small increases in the use of anxiolytics and antidepressants.79,80,89,92,95 Although OBRA-87 did lead to early reduction of antipsychotics in LTC, most studies have questioned the impact on overall quality of care.96 Rates increased again in subsequent years, possibly because of the availability of atypical antipsychotics and expanded indications for their use, 97,98 although the use of antipsychotics did decline specifically among those with dementia.98,99

Public reporting of quality information, such as inappropriate antipsychotic use, may result in improvements via several proposed mechanisms. Public availability of this information allows the public to select for better performance and for government and other funders to allocate resources or determine accreditation based on quality of care.103 This selection process can increase demand for high-quality care, motivating providers to improve the care they deliver.104 Other rationales have been proposed, including public reporting as a tool for regulation, as in the case of OBRA-87, or as a method for ensuring individual and organizational accountability.105 In general, public reporting alone has mixed effects on quality of care. Reporting may stimulate quality improvement activities; however, relatively few studies have focused on its effect on clinical outcomes.106 There is evidence suggesting that public reporting may be more effective in influencing changes at organizational and administrative levels, rather than at the level of individual providers or patients.105,107 Starting in 2015, CIHI has provided publicly reported antipsychotic prescribing at the level of individual LTC facilities and by health regions in Canada (available at http://yourhealthsystem.cihi.ca/hsp/indepth#). In the United States, an antipsychotic indicator similar to the CIHI indicator is reported.108-110 Unlike the CIHI indicator, the presence of delusions or hallucinations is not an exclusion criteria, whereas bipolar disorder is.109 The US Centers for Medicare and Medicaid Services has been publicly reporting information on LTC quality indicators since 2002, although public reporting of antipsychotics began only in 2012.108 In 2012, a national, multidimensional initiative to reduce the unnecessary use of antipsychotics was implemented, including public reporting of antipsychotic rates (LTC facility level information is available at https://www.medicare.gov/nursinghomecompare/search.html).108,111 This initiative proposed an initial goal of 15% relative reduction in antipsychotic prescribing rates from a baseline rate of

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23.9% to 20.3%.110 The most recent information on antipsychotic prescribing in US LTC facilities reported a rate of 17.4% at the end of 2015. This has prompted development of new benchmarks to reduce antipsychotic use to 16.7% by the end of 2016.73 Comparison between LTC facilities included and excluded in this reporting indicated that during and following implementation of public reporting, the proportion of residents using antipsychotic medications declined in all facilities, but the difference in the short term was significantly larger (approximately 40% greater reduction) in those required to publicly report.108,111 However, all facilities eventually experienced similar decreases, suggesting that public reporting broadly incentivized changes in prescribing.108 Of note, the use of all psychoactive medications declined during this time, with no significant difference between reporting and nonreporting facilities.108

Educational Approaches to Reducing Antipsychotic Use In addition to systems-level approaches to reducing inappropriate antipsychotic use such as policy or public reporting, there is increasing evidence for a variety of approaches focused on individual health care providers. A recent systematic review by Coon et al112 identified 22 studies that have been used to reduce inappropriate antipsychotic use in LTC settings. The quality of studies included in this review varied, as did the components and duration of the interventions, which precluded a meta-analysis. Most studies in the review examined educational strategies (n ¼ 11) directed at LTC staff or physicians. Most high-quality studies in this review demonstrated absolute reductions in antipsychotic use of 12% to 20%. Educational in-reach approaches involving education and individual patient review (n ¼ 6) were also largely effective in reducing antipsychotic use in studies that evaluated these approaches. Multicomponent interventions (n ¼ 5), which variably included elements such as education, prescribing audit and feedback, and medication review by interdisciplinary teams, all showed consistent reductions in antipsychotic prescribing, although only 1 study was a randomized controlled trial. The long-term effects of these interventions beyond the implementation period were evaluated in only 4 studies, with mixed results on the sustainability of improvements noted following implementation. A recent well-designed, randomized controlled trial evaluated the impact of medication review, social interaction, or exercise in 16 LTC facilities in the United Kingdom.113 All participating LTC homes received education on personcentered approaches to care. Eight homes were randomized to receive each of the 3 interventions, with most facilities receiving more than 1. Antipsychotic review was associated with a 50% reduction in antipsychotic use. However, antipsychotic review in isolation was associated with a worsening of overall NPS when compared with antipsychotic review in the presence of the social interaction intervention. Exercise was also associated with overall improvements in

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NPS. This study demonstrates that although significant decreases in antipsychotics can be achieved with educational approaches, in the absence of improved access to nonpharmacological treatments, there may be detrimental effects of reducing antipsychotics on NPS.

Future Directions to Improve Antipsychotic Prescribing in Canada Initiatives to Reduce Inappropriate Use of Antipsychotics in Canada There are currently no national regulatory or policy strategies in Canada related to reducing inappropriate use of antipsychotics. Public reporting of the CIHI inappropriate use of antipsychotic indicator is now available for approximately half of all LTC facilities in Canada, although at this time it is difficult to assess the impact of this initiative on prescribing rates. Several provinces and health regions in Canada have initiated widespread programs to reduce inappropriate use of antipsychotics. Of these programs, the Appropriate Use of Antipsychotics initiative in Alberta114 is the most extensive antipsychotic reduction intervention in Canada to date. The program, initiated in 2011, includes both policy and regulatory approaches involving a provincial clinical guideline115 and program implementation including staff education, use of person-centered approaches to reduce NPS, and monthly interdisciplinary team rounds to support reduction or discontinuation of antipsychotics114 (additional details are available at http://www.albertahealthservices.ca/scns/aua toolkit.aspx). The most recent information available in Alberta demonstrates a current inappropriate antipsychotic prescribing rate of approximately 18%.71 Alberta currently has the lowest provincial average for antipsychotic prescribing, likely reflecting the initial impact of this initiative. Other initiatives currently under way in Canada include the Canadian Foundation for Healthcare Improvement Reducing Antipsychotic Medication Use Collaborative, involving more than 200 LTC facilities across Canada,116 the Call for Less Antipsychotics in Residential Care program in British Columbia,117 and the Ontario Ministry of Health and Long-Term Care Appropriate Prescribing Demonstration Project in Ontario.87,118 Health Quality Ontario has recently developed draft quality standards for behavioural symptoms of dementia, establishing several process indicators to improve prescribing, documentation, and review of psychotropic medications.119

Areas for Future Research Although there is emerging evidence that a number of strategies can reduce inappropriate antipsychotic use in dementia, several areas require further research and evaluation. The optimal rate of antipsychotic use in dementia has not been determined. Based on changes in prescribing rates observed in which widespread initiatives for reducing antipsychotics

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have been implemented (such as the United States and Alberta), rates of inappropriate antipsychotic prescribing below 20% are likely feasible in many regions provided that similar processes to support reductions are available. Health Quality Ontario has proposed a provincial benchmark of 19% for performance on the CIHI potentially inappropriate antipsychotic prescribing indicator (N. Degani, manager, Health System Performance, e-mail message, August 17, 2016). Although reductions in antipsychotic use are possible within most LTC settings through modifying prescribing practices and existing care processes, the impact of factors such as the physical design of LTC facilities or changes to staffing models have not been examined in detail. There is also significant variation in antipsychotic prescribing in acute care, where antipsychotic rates may be as high or higher than those reported in LTC120,121 and uncertainty regarding the prevalence of their use in other care settings where dementia is common, such as assisted living or supportive housing. Although some nonpharmacological strategies have proven effective in research studies, their feasibility in real-world settings and long-term efficacy have not been established, access to effective nonpharmacological approaches for NPS needs to be improved,122 and the development of safe and effective pharmacological treatments for NPS is necessary. The outcomes associated with the prescribing of multiple antipsychotics or combinations of antipsychotics with other psychotropic medications also require future study. We have attempted to provide an overview related to the prescribing of antipsychotics among persons with dementia and a summary of evidence-based strategies to reduce inappropriate use of antipsychotics. However, this is not a systematic review and as such may not include all the strategies that can address this complex topic. In general, the literature on optimal strategies for reducing inappropriate use of antipsychotics in dementia is relatively sparse and mostly from settings outside of Canada.

Conclusions Antipsychotic use among persons with dementia is common and higher than what is indicated in many circumstances. Both broad, systems-level approaches and provider-level interventions have a role in reducing inappropriate use of antipsychotics. It is encouraging that rates of antipsychotics appear to be decreasing with time, but sustained effort will be needed to maintain current gains, and additional work is required to further reduce antipsychotics to more optimal levels of prescribing. Reaching desired goals for antipsychotic use in dementia care will require collaboration among psychiatrists, health care funders and regulators, fellow physicians, and front-line staff across a variety of health care settings. Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this

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article: Dr Julia Kirkham is supported by an Interdisciplinary Fellowship Program Award through the Canadian Frailty Network. Dr Seitz receives consulting fees funding from Cancer Care Ontario in his role as the Provincial Medical Lead for Dementia Capacity Planning in Ontario. Dr. Rochon is the Retired Teachers of Ontario Chair in Geriatric Medicine at Women’s College Research Institute and the University of Toronto.

Funding The author(s) declared receipt of the following financial support for the research, authorship, and/or publication of this article: This review was supported through research funding provided through the Canadian Institutes of Health Research through the Canadian Consortium on Neurodegeneration in Aging.

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Antipsychotic Use in Dementia.

Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exi...
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