We need to do better: most people with dementia living in aged care facilities use antipsychotics for too long, for off-label indications and without documented consent

Despite limited evidence for efficacy and clear evidence for harm, use of antipsychotics to manage behaviors and psychological symptoms of dementia (BPSD) is common. Australian estimates suggest that in the community setting the prevalence of use of antipsychotics is about 2 to 3% (Hálfdánarson, 2017) and in the aged care setting it ranges from 13 to 42% (Westaway et al., 2018), with at least half of the residents in aged care using antipsychotics for longer than 6 months (Kalisch et al., 2019). Prevalence of use is higher in the aged care setting because approximately 50% of aged care residents have a diagnosis of dementia, compared to a prevalence of around 10% in all Australians aged 65 years or over (Brown et al., 2017). Risperidone is the only antipsychotic approved by the Australian national medicines regulator, the Therapeutic GoodsAdministration, for use in the management of psychotic symptoms and aggression in people with dementia; however, off-label use of other antipsychotics for BPSD occurs, and off-label use of antipsychotics for BPSD other than psychosis and aggression also occurs. Since June 2015 in Australia, the approved indication for use of risperidone for BPSD has been limited to 12-week duration in people with moderate-to-severe Alzheimer’s dementia (Australian Government Department of Health Therapeutic Goods Administration, 2015). Prior to this, the approved indication included other types of dementia with no restriction on duration of use. The indication was amended due to new evidence showing a five-fold increased risk of cerebrovascular adverse events in people with non-Alzheimer’s dementia (Australian Government Department of Health Therapeutic Goods Administration, 2015). Although lower, the risk of stroke was still elevated two-fold in people with Alzheimer’s dementia (Australian Government Department of Health Therapeutic Goods Administration, 2015). Other harms associated with antipsychotic use include extrapyramidal side effects, somnolence and sedation, hip fracture, pneumonia, and death (Pratt et al., 2010; 2011; Yunusa et al., 2019). The benefits of using antipsychotics to manage BPSD are modest, with a network meta-analysis finding that risperidone, quetiapine, and olanzapine were no better than placebo at improving symptoms measured using the Neuropsychiatric Inventory (Yunusa et al., 2019). In light of the modest evidence for efficacy and clear evidence for significant harm associated with use of antipsychotics for BPSD, it would seem obvious that use of antipsychotics for BPSD should only occur in people with a clear and documented need, after nonpharmacological management options have been tried, for the shortest duration possible. It would also seem obvious that antipsychotic use for BPSD should only occur following a frank discussion of the risks and benefits associated with antipsychotic use and with documented informed consent for use by the person with dementia or their nominated decision maker. However, previous research indicates that this is not always the case, and a new study by Harrison and colleagues (2020) adds important information to this body of evidence. In this issue of International Psychogeriatrics, Harrison and colleagues (2020) present data for aged care residents with dementia who have had prolonged use of antipsychotics and identified factors that were associated with longer duration of use. They reanalyzed baseline data from the Halting Antipsychotic use in Long-Term Care (HALT) project, which involved 146 residents from 24 aged care facilities in Sydney, Australia, who had been using an antipsychotic medicine for at least 3 months (Brodaty, 2018). Participants had an average age of 85 years, two-thirds were female and nearly all (n= 144) had a documented diagnosis of dementia. The HALT study aimed to reduce inappropriate long-term use of antipsychotics by providing education and training in appropriate and nonpharmacological management of BPSD, followed by implementation of an intervention to promote deprescribing of antipsychotics (Brodaty, 2018). The analysis of baseline data from the HALT study presented in this issue of the journal used data collected before the deprescribing intervention commenced (Harrison et al., 2020). Harrison and colleagues found that the 146 study participants had been using antipsychotics for an average of 2.2 years International Psychogeriatrics (2020), 32:3, 299–302 © International Psychogeriatric Association 2020