Clinical impact of antipsychotic and benzodiazepine reduction: Findings from a multicomponent psychotropic reduction program within long-term aged care.

Abstract

Introduction: Antipsychotics and benzodiazepines are widely used in long-term aged care despite modest efficacy and risk of adverse effects. Whilst interventions to reduce the use of these medications have been developed, clinical outcomes remain under-reported. Concern that symptoms may worsen is a potential barrier to dose reduction. To fill this evidence gap, we determined the clinical impact that dose reduction had within the Reducing the Use of Sedatives (RedUSe) program (Westbury et al. 2018). Methods: RedUSe involved 150 Australian homes and comprised: auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews. Residents (n=206) taking antipsychotics and/or benzodiazepines regularly, without a severe psychiatric illness, were recruited from 28 participating homes. Changed behaviours (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), social withdrawal (Multidimensional Observational Scale for Elderly Subjects-withdrawal subscale) and quality of life (QoL) (Assessment of Quality of Life-4D) were measured at baseline and four months through psychometric testing of nursing staff. Associations between changes in these outcomes and percentage changes in the antipsychotic and benzodiazepine doses were investigated using regression models. 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 antipsychotic and benzodiazepine dose; predominantly cessations. There was no evidence of worsening psychometric measures. Dose reduction was associated with small, albeit non-significant, improvements in changed behaviour - particularly less physically non-aggressive behaviour (e.g. wandering and restlessness) 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 (e.g. calling out) with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Although not significant, antipsychotic reduction was associated with improved QoL (0.01 per 10% dose reduction) and social engagement (-0.16 per 10% dose reduction). Discussion: Antipsychotic and benzodiazepine dose reduction was not associated with deterioration in behaviours, social withdrawal or QoL. In fact, trends towards improved agitation with antipsychotic and benzodiazepine dose reduction, and QoL and social engagement with antipsychotic dose reduction, were identified as potential benefits. These outcomes require confirmation in larger prospective studies.