Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial

Fossey, Jane; Ballard, Clive; Juszczak, Edmund; James, Ian A.; Alder, Nicola; Jacoby, Robin; Howard, Robert

doi:10.1136/bmj.38782.575868.7c

Cited by 450 publications

(476 citation statements)

References 18 publications

(21 reference statements)

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“…The absence of a shared understanding of how end of life is recognised, or at what point end of life is defined for people with dementia, means that research that focused on improving symptom assessment for people with advanced dementia, on needs assessment in care homes, and on communication and the involvement of people with dementia in decision making were not included in the review (Fossey et al, 2006;Hancock et al, 2006;Zwakhalen et al, 2006). Data extraction ceased in 2006, however a rapid review of research and reviews published up till 2008 (Birch and Draper, 2008;Di Giulio et al, 2008;Lorenz and Lynn, 2008) indicate that the research focus and methods and findings discussed in this paper have not dramatically changed, and that there are still very few intervention studies that include people with dementia who are living at home or in a care home.…”

Section: Discussionmentioning

confidence: 99%

End of life care for community dwelling older people with dementia: an integrated review

Goodman

Evans

Wilcock

et al. 2009

Int J Geriat Psychiatry

106

102

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Objective: To review the evidence for end-of-life care for community dwelling older people with dementia (including those resident in care homes). Design: An integrated review synthesised the qualitative and quantitative evidence on end-of-life care for community dwelling older people with dementia. English language studies that focused on prognostic indicators for end-of-life care, assessment, support/relief, respite and educational interventions for community dwelling older people with dementia were included. A user representative group informed decisions on the breadth of literature used. Each study selected was screened independently by two reviewers using a standardised check list. Results: Sixty eight papers were included. Only 17% (12) exclusively concerned living and dying with dementia at home. Six studies included direct evidence from people with dementia. The studies grouped into four broad categories: Dementia care towards the end of life, palliative symptom management for people with dementia, predicting the approach of death for people with dementia and decision-making. The majority of studies were descriptive. The few studies that developed dementia specific tools to guide end of life care and outcome measures specific to improve comfort and communication, demonstrated what could be achieved, and how much more needs to be done. Conclusions: Research on end-of-life care for people with dementia has yet to develop interventions that address the particular challenges that dying with dementia poses. There is a need for investigation of interventions and outcome measures for providing end-of-life care in the settings where the majority of this population live and die.

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Section: Discussionmentioning

confidence: 99%

End of life care for community dwelling older people with dementia: an integrated review

Goodman

Evans

Wilcock

et al. 2009

Int J Geriat Psychiatry

106

102

View full text Add to dashboard Cite

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“…The number of days of antipsychotic use decreased by 72% in the education homes compared with 13% in the control homes (po0.001). A more recent study demonstrated that a training and support intervention delivered to nursing home staff decreased the use of antipsychotics (Fossey et al, 2006). Additionally, collaborative care management in primary care settings, when compared with augmented usual care, showed improvements in overall severity of neuropsychiatric symptoms (Callahan et al, 2006).…”

Section: Psychosocial and Psychotherapeutic Interventionsmentioning

confidence: 99%

ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with Dementia

Jeste

Blazer

Casey

et al. 2007

Neuropsychopharmacol

329

273

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In elderly persons, antipsychotic drugs are clinically prescribed off-label for a number of disorders outside of their Food and Drug Administration (FDA)-approved indications (schizophrenia and bipolar disorder). The largest number of antipsychotic prescriptions in older adults is for behavioral disturbances associated with dementia. In April 2005, the FDA, based on a meta-analysis of 17 double-blind randomized placebo-controlled trials among elderly people with dementia, determined that atypical antipsychotics were associated with a significantly (1.6-1.7 times) greater mortality risk compared with placebo, and asked that drug manufacturers add a 'black box' warning to prescribing information for these drugs. Most deaths were due to either cardiac or infectious causes, the two most common immediate causes of death in dementia in general. Clinicians, patients, and caregivers are left with unclear choices of treatment for dementia patients with psychosis and/or severe agitation. Not only are psychosis and agitation common in persons with dementia but they also frequently cause considerable caregiver distress and hasten institutionalization of patients. At the same time, there is a paucity of evidence-based treatment alternatives to antipsychotics for this population. Thus, there is insufficient evidence to suggest that psychotropics other than antipsychotics represent an overall effective and safe, let alone better, treatment choice for psychosis or agitation in dementia; currently no such treatment has been approved by the FDA for these symptoms. Similarly, the data on the efficacy of specific psychosocial treatments in patients with dementia are limited and inconclusive. The goal of this White Paper is to review relevant issues and make clinical and research recommendations regarding the treatment of elderly dementia patients with psychosis and/ or agitation. The role of shared decision making and caution in using pharmacotherapy for these patients is stressed.

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“…Although the limited evidence of efficacy does limit the potential value of quetiapine, this is probably helpful in indicating that atypical agents have a less detrimental impact on quality of life than typical antipsychotics. Important studies have highlighted the potential of specific non-pharmacological intervention programs to improve key outcomes such as the use of unnecessary antipsychotic drugs (Rovner et al 1996;Fossey et al, 2006), mood (Teri et al, 1997;2003) and behavioral symptoms (Cohen-Mansfield et al, 2007) with person-centered training for care staff, or structured approaches such as exercise, social interaction, pleasant events or assessment of needs, but disappointingly few studies have directly evaluated the impact of these interventions on quality of life directly, or the impact of stopping antipsychotics on quality of life amongst care home residents with dementia. The Focused Intervention Training and Support (FITS) study, in a cluster randomized trial, demonstrated the capacity of a training program focused on person-centered care to significantly reduce the use of antipsychotic drugs in care homes (Fossey et al, 2006).…”

Section: Antipsychotics and Quality Of Lifementioning

confidence: 99%

TOP CITED PAPERS IN INTERNATIONAL PSYCHOGERIATRICS: 6a. QUALITY OF LIFE FOR PEOPLE WITH DEMENTIA LIVING IN RESIDENTIAL AND NURSING HOME CARE: THE IMPACT OF PERFORMANCE ON ACTIVITIES OF DAILY LIVING, BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS, LANGUAGE SKILLS, AND PSYCHOTROPIC DRUGS

Ballard

Margallo-Lana

O’Brien

et al. 2009

Int. Psychogeriatr.

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The majority of people with dementia develop behavioral and psychological symptoms of dementia (BPSD) at some point during their illness (Jeste et al., 2008). These symptoms, which are especially common among care home residents, are frequently distressing for the patients who experience them (Gilley et al., 2006; Jeste et al., 2008) and problematic for their professional and/or family caregivers. The starting point for our paper “Quality of life for people with dementia living in residential and nursing home care: the impact of performance on activities of daily living, behavioral and psychological symptoms, language skills, and psychotropic drugs” (Ballard et al., 2001) was to try and understand the impact of BPSD, function and language skills on quality of life in care home residents with dementia. Although there were frequent statements in previous work referring to the capacity of psychiatric and behavioral symptoms to reduce quality of life, we had been unable to identify any empirical evidence to support this clinical impression in a thorough literature review. The parallel validation of Dementia Care Mapping (DCM), predominantly a practice development tool, as an observational measure of well-being/quality of life (Kitwood and Bredin, 1997; Fossey et al., 2002) provided an excellent opportunity to examine this issue in a care home setting. The study focused on 209 people with dementia living in residential and nursing home care in north-east England in the U.K., who received a detailed assessment of BPSD, function and cognition. A DCM evaluation was completed for 112 of these individuals, providing a detailed observational measure of well-being, activities and social withdrawal as indices of quality of life over a six-hour daytime period. To our surprise, there was actually no association between well-being, social withdrawal or activities and BPSD. In contrast, there was a significant association between antipsychotic medication and reduced well-being, social withdrawal and activities respectively, even after controlling for the severity of behavioral disturbance. Using an arbitrary definition of “ill-being”, defined as a well-being score of less than zero, 5% of people not taking antipsychotics, 10% of people taking atypical antipsychotics and 22% of people taking typical antipsychotics were defined as having ill-being. Lower levels of functional ability were also associated with significantly lower well-being, less activities and more social withdrawal. At first this latter finding appears to be contrary to one of the central principles of DCM – namely, that the assessment should be independent of dementia severity. Although high levels of well-being and engagement are possible for people with severe dementia, this probably requires higher staff numbers and a workforce with more specialized skills in order to achieve this.

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Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial

Cited by 450 publications

References 18 publications

End of life care for community dwelling older people with dementia: an integrated review

End of life care for community dwelling older people with dementia: an integrated review

ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with Dementia

TOP CITED PAPERS IN INTERNATIONAL PSYCHOGERIATRICS: 6a. QUALITY OF LIFE FOR PEOPLE WITH DEMENTIA LIVING IN RESIDENTIAL AND NURSING HOME CARE: THE IMPACT OF PERFORMANCE ON ACTIVITIES OF DAILY LIVING, BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS, LANGUAGE SKILLS, AND PSYCHOTROPIC DRUGS

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