clinical focus those three key health professionals working together. I have to say, out of the three, the nurse was the most crucial.
What were the results, in terms of reducing sedative use, and also in terms of rebound? Throughout our 150 homes, we had a reduction in everyday antipsychotic use of 13 per cent, and we had a higher reduction with the use of benzodiazepines. However, instead of just [ examining ] percentages, we wanted to look at how the 150 agedcare homes responded, and I can say that two-thirds of our participant homes reduced the use of antipsychotics and benzodiazepines. We had about 30 per cent reducing the use at least of one, and we had a small proportion – only eight out of 150 homes – that did not reduce use in some way. It was overwhelmingly positive.
You asked about rebounds as well. We were able to track those medications reduced at three months, and see whether they were still reduced at six months. We found that if a medication was either reduced or ceased outright at three months, with antipsychotics, at least 80 per cent of those reductions stuck. With benzodiazepines, we had a 90 per cent success rate. We found that the belief that if you reduce or cease them, you’ re just going to have to restart was founded at all.
Why is reducing sedative use important and what benefits can it bring about for residents? There has been much evidence produced over the years to suggest that because there are modest benefits with these medications and substantial risks, it’ s important to use them judiciously. It’ s also important to review their use frequently. When they are used, you want them at the lowest dose for the shortest duration as possible.
There was quite a lot of research in the’ 90s and early 2000s that showed that when you officially used these medications in trials, they didn’ t work for the majority of people.
For instance, with antipsychotics, you have to treat five people to see measured effects in just one, and that’ s on the specific symptom of agitation. We know that antipsychotics often don’ t work on symptoms like wandering or calling out, or behaving inappropriately. They’ ve got quite a modest effect. And in 2005, 2006, there were quite substantial safety warnings about antipsychotics because research in the UK showed that using them increases the risk of stroke. American research followed suit pretty soon after and showed that people taking antipsychotics who had dementia had a shorter life span, it increased their mortality. Basically, putting people with dementia on these medications can often affect their long-term health. You have to weigh that against the modest benefits they offer.
I always try to emphasise as well that there are times when it’ s appropriate to use these medications. Guidelines consistently say it’ s when a resident is in significant distress or at risk of harming themselves, other residents or staff. However, if the problem is minimal and other strategies can be used, it’ s much better to use those strategies than to put someone on medications that will stop them from engaging and often have significant risk associated with their use.
[ With benzodiazepines ] the issue is that you put people on them for things like anxiety and sleep, sometimes for agitation as well. They work... they’ re quite effective to start with, but after a couple of weeks of continual use, you need to increase the dose to get the same effect. Then the longer you use them, the higher the chance that the person can become dependent on them, and then they need them to be able to function properly. We know benzodiazepines affect communication and engagement, they can’ t get as involved in activities. Sometimes, they can get problems like incontinence, and there has been increasing research that they also can affect cognition, so they can cause confusion and symptoms like that.
The use of both of types of drugs has to be measured. When you do use them, it must be when they’ re indicated, and you have monitor for effects and side-effects, and try to keep the use as short as possible at the lowest does possible.
Where to next for the project? The project was first piloted as a trial in Tasmania. That was in 2008. We got some good results out of that. Then we left it for a little while. We put it in at the end of 2012, funded under the Dementia and Aged Care Service Improvement Fund. That took three years and it was expanded from 25 homes out to 150 homes throughout Australia. That was the second roll-out. The results were improved from the trial. What we’ re hoping to do now is find a way we can establish the project as available for all homes that are interested in participating, and as a service community pharmacists can offer as well. We’ re looking for funding now, as an expanded community pharmacy program we hope, but we’ ll see what happens. ■ agedcareinsite. com. au 27