RedUSe Final steering group report 22/11/2018 Final outcomes of the RedUSe expansion: a national multi-strategic, interdisciplinary initiative aimed at reducing antipsychotic and benzodiazepine use in long term care homes Dr J Westbury, P Gee, Dr T Ling, Prof G Peterson IPA Congress 7th September 2016

RedUSe Final steering group report 22/11/2018 What education do aged care nursing staff want around the therapeutic management of older person’s mental health? Dr J Westbury, D Brown IPA Congress 7th September 2016

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre International comparison of LTC Home Use Many reasons why we are having the shift to home care. 1. consumers want this, costs a third of ACH costs, in Australia we have the highest proportion of our residents in ACH if you compare rates. The red bar represents the % of our population that is in a ACH and the green triangle is the % or care recipients who receive care at home… 7.8% of the Australian population aged 65+ (275,526 people) were in residential aged care over 2014–15 SCRGSP (Steering Committee for the Review of Government Service Provision) 2016. Report on government services 2016. Canberra: Productivity Commission. Australian Research Council. 2014. Aged care in Australia: Part 1. CEPAR research brief 2014/01

Mental health in long term aged care RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre Mental health in long term aged care The prevalence of common mental health conditions in Australian LTC homes is estimated to be:¹ sleep disorder 45-60%¹ anxiety 35%¹ dementia 63% 2 ¹ Brodaty H, Draper B et al. Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors. International Journal of Geriatric Psychiatry 2001;16:504-512. 2 Access Economics: Caring places: Planning for aged care and dementia: 2010-2050 2010

Wicking Dementia Research & Education Centre ‘Good Practice’ to manage changed behaviour in dementia, anxiety and sleep Seek other causes Use non-drug measures first line

RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre Another way to manage these conditions… Sedative: A medication that has a soothing, calming or tranquillizing effect II find when ever I refer to sedatives many people think I am refering to hypnotic agents or sleeping tablets- but in the context of this project sedatives are defined using the medterms definition which is medicines that calm,sooth or tranquilise. Many psychotropic drugs do this…but mostly the two main psychotropic drug classes that are used for their sedating properties in aged care homes are anxiolytics and hypnotics, mostly benzodiazepines and antipsychotics. And they are the two main mediations we aimed to reduce.. The main medications that are used for their sedating properties are anxiolytic/hypnotics – mostly benzodiazepines and I’ve listed some of the common meds Or Antipsychotics – newer ones and haloperidol antipsychotics benzodiazepines (hypnotics/anxiolytics) 6

RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre Benefits and Risks of sedative medication Increased risk of dementia with benzodiazepine use? Increased mortality and stroke risk with antipsychotics Why….well..Before medications are used we need to weigh up the benefits of the medicine against the risks associated with its use. Antipsychotics are highly effecting to treat people with schizophrenia. They are used in people with dementia because it was noted a long time ago that people with dementia often (about 30%) display similar symptoms of psychosis and many – up to 50% are aggressive like people with schizophrenia. However, probably because the disease is very different, various reviews tell us that antipsychotics are only effective in about 20% of people with dementia who display aggressive behaviour..that means that they don’t have effectiveness in about 80% of people. They appear to be less effective for psychosis. These meds are not effective for symptoms like calling out or, wandering. Recently there is some evidence that antipsychotics appear to be most effective in people with more severe symptoms. Now the risks…we know they decrease cognition, we know they increase movement disorders such as parkinsonism, they also increase the pneumonia risk. But over the past five years some more serious side effects have been detected. These drugs given to people with dementia increase the risk of stroke and TIA’s but also increase the risk of mortality Increased pneumonia risk Benzodiazepine effective only for 2 -4 weeks Increased falls risk 20% of people with aggression in dementia will benefit taking antipsychotics Cognition worsens

Wicking Dementia Research & Education Centre ‘Good Practice’ to manage changed behaviour in dementia, anxiety and sleep Seek other causes Use non-drug measures first line Antipsychotics should only be used in situations where a behaviour causes significant distress or risk of harm Benzodiazepines should only be used short term, intermittently Review regularly and stop as soon as possible Antipsychotics: review every 3 months Benzodiazepines: review after 2 weeks

Wicking Dementia Research & Education Centre What is ‘RedUSe’ (Reducing Use of Sedatives)? PhD thesis (measure, understanding why/who and an intervention) Controlled trial of 25 homes in Tasmania in 2008, (13 intervention) Expanded to 150 homes across Australia in 2014-15 (all intervention)

Wicking Dementia Research & Education Centre Key Quality Improvement strategies Review sedatives

Wicking Dementia Research & Education Centre Understanding LTC home psychotropic prescribing Qualitative research: pre-trial 40 semi-structured interviews, 2-post trial focus groups, 4 focus groups 2012 (3 LTC homes and pharmacist group) Why are antipsychotics and benzodiazepines prescribed? Not enough time and resources for non-drug management Review of these medications occurred rarely Limited knowledge about the risks and guidelines Many tended to over-rate the effectiveness of antipsychotics and benzodiazepines and believed this medication improved the resident’s quality of life. “It may not be nice to medicate somebody but surely it’s far nicer to have them medicated and calm than distressed. On the whole, they seem to have a positive impact, on their life.” (Enrolled Nurse 2)  

Wicking Dementia Research & Education Centre Understanding LTC home psychotropic prescribing Who is influencing their use? The nursing staff GPs limited availability and pharmacist visits are rare. “Every time I’m contacted for behavioural challenge, the expectation is from the Nurses is that I’ll prescribe some sort of medication.” GP 3 “For these two residents I was saying that they were getting difficult at teatime and bedtime. I spoke to one G.P. and she said, we might try a dose of risperidone and we tried it at 2 o’clock in the afternoon and that resident has settled totally so, when the other resident was being difficult too, I suggested to his GP who said ‘yes we’ll try it’ - so both those residents have risperidone at 2 o’clock in the afternoon and both of them are good.” Registered Nurse 9

Wicking Dementia Research & Education Centre Enhancing the educational sessions The educational sessions of RedUSe were primarily targeted at nursing staff and designed to: Provide education that challenged beliefs around psychotropic effectiveness, Include information about their risks, and Promote guidelines

Wicking Dementia Research & Education Centre Format of the nurse educational sessions Pre-session talk A 10 question quiz – Older Age Psychotropic Quiz (OAPQ) What is QOL for a resident? Video Case study – Beryl Didactic PowerPoint + guidelines Feedback on their own homes use Delivered by their pharmacist at the beginning of the project and then at 3 months

Wicking Dementia Research & Education Centre Key QI strategies Review sedatives

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre The audit: e-health tool

Wicking Dementia Research & Education Centre Sedative review plan

Wicking Dementia Research & Education Centre

Wicking Dementia Research & Education Centre Implementation plan

Wicking Dementia Research & Education Centre Key research measures Did the RedUSe project reduce antipsychotic and benzodiazepine use? Was there any difference in response from wave to wave? How does this initiative compare to the pilot trial & the U.S program? Was there an impact on the average dose of agent taken? Did substitution to other sedatives or ‘prn dosing’ occur? What proportion of residents were reduced/ceased? Did rebounds occur?

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre 1. Overall antipsychotic prevalence of use AP use reduced from 21.6% to 19.7% [95% CI 18.4%-20.9%] at 3 M and 18.8% [95% CI 17.7%-20.1%] at 6 M. These differences were significant (p <.001). The difference between 6 months and 3 months was also significant (p<.01) suggesting that continued intervention between 3 - 6 months has a further effect. Inferential statistics - Linear mixed effects model N = 150 homes n = 12,165 residents (av) Reduction: antipsychotics: 13%

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre 1. Overall benzodiazepine prevalence of use Use reduced from 22.3% to 19.6% [95% CI 18.4%-20.8%] at 3 M and 17.6% [95% CI 16.5%- 18.7%] at 6 M. These differences were significant (p <.001). The difference between 6 - 3 months was also significant (p<.001) suggesting that continued intervention between 3 and 6 months has a further effect. N = 150 homes n = 12,165 residents (av) Reduction: benzodiazepines: 21%

Wicking Dementia Research & Education Centre

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre

Wicking Dementia Research & Education Centre 3. Average dose: Antipsychotics N = 150 homes Average chlorpromazine equivalent dose/day/resident reduced from 22.9 to 20.2 mg Reduction: 12% decrease in chlorpromazine equivalent dose

Wicking Dementia Research & Education Centre 3. Average dose: benzodiazepines N = 150 homes Average diazepam equivalent dose/day/resident reduced from 1.4 to 1.0 mg Reduction: 23% decrease in diazepam equivalent dose

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre (n= 139 N= 11,383 av) 4. Substitution? mirtazapine: 12.0 – 11.8% (2% decline) TCAs: 4.6 – 4.3% (7% reduction)  Prn antipsychotics:11.1% – 9.5% (14% decline) Prn benzodiazepines: 30.3 – 27.9% (8% reduction)

Wicking Dementia Research & Education Centre 5. Review of sedative medication over 6 months N = 17 NSW LTC homes, 2014 N = 150 national LTC homes, 2014-2016 Yang Y, Chen T et al. An Audit of Psychotropic Medication Monitoring in Australian Aged Care Facilities. APSA conference. Dec 2014. ISBN-13: 978-0-646-93083-1

Wicking Dementia Research & Education Centre 6. Rebounds? (reduced/ceased at 3 months – what happened by 6 months) (n= 150 LTC homes)

Wicking Dementia Research & Education Centre Attendance of educational sessions Overall attendance data was recorded from 150 LTC homes Evaluation and quiz data was obtained from the full sample of 150 homes at the initial training session and 145 homes at the 3-month training session. More staff attended the first session (n=1414) than the follow-up session at 3-months (n=1129). Profession Baseline 3-month Registered Nurse 57.0% 57.1% Enrolled Nurse 31.9% 36.5% Carer 11.1% 6.4%

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre How did they rank the training? N= 1079 (76%) N = 899 (78%)

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre What did they like most about the sessions? Baseline session N= 1079 3-month session N = 899

Wicking Dementia Research & Education Centre RedUSe Final steering group report 22/11/2018 Wicking Dementia Research & Education Centre How could the sessions be improved? Baseline session N= 280/1079 (26%) 3-month session N = 189/899 (21%)

Wicking Dementia Research & Education Centre Qualitative feedback “I learnt about the importance of reviews on the use and effects of drugs for that resident. Upholding the dignity of that person and their Quality of life is important”. Enrolled nurse “(I'm) more proactive when doing rounds with the GP”. Registered nurse “Until the program we didn’t realise that temaze….you only needed it for 2 weeks and then there wasn’t much point having it” Champion nurse Nurses very, very rarely get a time when they can all get together and discuss in general how well their residents are going…..often I had night staff, morning staff and the evening staff…so you’d get all the people together that never get together at all to talk about some of their residents….and they love it” Pharmacist

Wicking Dementia Research & Education Centre Acknowledgements The RedUSe project is funded by the Australian Government under the Dementia and Aged Care Service Fund NHMRC Stakeholders: BUPA, SCC, LASA, ACSA, COTA, NPSMedicinewise, DATIS Australian Catholic University and the PSA