Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia.

BACKGROUND: Antipsychotic agents are often used to treat neuropsychiatric symptoms (NPS) in people with dementia although there is uncertainty about the effectiveness of their long-term use for this indication and concern that they may cause harm, including higher mortality. When behavioural strategies have failed and treatment with antipsychotic drugs is instituted, regular attempts to withdraw them have been recommended in guidelines. Physicians, nurses and families of older people with dementia may be reluctant to stop antipsychotics, fearing deterioration of NPS.This is an update of a Cochrane Review published in 2013. OBJECTIVES: To evaluate whether withdrawal of antipsychotic agents is successful in older people with dementia and NPS in primary care or nursing home settings, to list the different strategies for withdrawal of antipsychotic agents in older participants with dementia and NPS, and to measure the effects of withdrawal of antipsychotic agents on participants' behaviour and assess safety. SEARCH METHODS: We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), theCochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, clinical trials registries and grey literature sources up to 11 January 2018. SELECTION CRITERIA: We included all randomised, controlled trials comparing an antipsychotic withdrawal strategy to continuation of antipsychotics in people with dementia who had been treated with an antipsychotic drug for at least three months. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures according to the Cochrane Handbook for Systematic Reviews of Interventions. We rated the quality of evidence for each outcome using the GRADE approach. MAIN RESULTS: We included 10 studies involving 632 participants. One new trial (19 participants) was added for this update.One trial was conducted in a community setting, eight in nursing homes and one in both settings. Different types of antipsychotics at varying doses were discontinued in the studies. Both abrupt and gradual withdrawal schedules were used. Reported data were predominantly from studies at low or unclear risk of bias.We included nine trials with 575 randomised participants that used a proxy outcome for overall success of antipsychotic withdrawal. Pooling data was not possible due to heterogeneity of outcome measures used. Based on assessment of seven studies, discontinuation may make little or no difference to whether or not participants complete the study (low-quality evidence).Two trials included only participants with psychosis, agitation or aggression who had responded to antipsychotic treatment. In these two trials, stopping antipsychotics was associated with a higher risk of leaving the study early due to symptomatic relapse or a shorter time to symptomatic relapse.We found low-quality evidence that discontinuation may make little or no difference to overall NPS, measured using various scales (7 trials, 519 participants). There was some evidence from subgroup analyses in two trials that discontinuation may reduce agitation for participants with less severe NPS at baseline, but may be associated with a worsening of NPS in participants with more severe NPS at baseline.None of the studies assessed withdrawal symptoms. Adverse effects of antipsychotics (such as falls) were not systematically assessed. Low-quality evidence showed that discontinuation may have little or no effect on adverse events (5 trials, 381 participants), quality of life (2 trials, 119 participants), or cognitive function (5 trials, 365 participants).There were insufficient data to determine whether discontinuation of antipsychotics has any effect on mortality (very low-quality evidence). AUTHORS' CONCLUSIONS: There is low-quality evidence that antipsychotics may be successfully discontinued in older people with dementia and NPS who have been taking antipsychotics for at least three months, and that discontinuation may have little or no important effect on behavioural and psychological symptoms. This is consistent with the observation that most behavioural complications of dementia are intermittent and often do not persist for longer than three months. Discontinuation may have little or no effect on overall cognitive function. Discontinuation may make no difference to adverse events and quality of life. Based on the trials in this review, we are uncertain whether discontinuation of antipsychotics leads to a decrease in mortality.People with psychosis, aggression or agitation who responded well to long-term antipsychotic drug use, or those with more severe NPS at baseline, may benefit behaviourally from continuation of antipsychotics. Discontinuation may reduce agitation for people with mild NPS at baseline. However, these conclusions are based on few studies or small subgroups and further evidence of benefits and harms associated with withdrawal of antipsychotic is required in people with dementia and mild and severe NPS.The overall conclusions of the review have not changed since 2013 and the number of available trials remains low.

Teaching young GPs to cope with psychosocial consultations without prescribing: a durable impact of an e-module on determinants of benzodiazepines prescribing.

BACKGROUND: Despite guidelines and campaigns to change prescribing behavior, General Practitioners (GPs) continue to overprescribe benzodiazepines (BZDs). New approaches to improve prescribing are needed. Using behavior change techniques and tailoring interventions to user characteristics are vital to promote behavior change. This study evaluated the impact of an e-module on factors known to determine BZD prescribing practice. METHODS: A tailored e-module that focuses on avoiding initial BZD prescriptions (and using psychological interventions as an alternative) was developed and offered to GPs in vocational training. Three self-report assessments took place: at baseline, immediately after the module (short term) and at least six months after completion (long term). Assessed determinants include GPs' attitudes concerning treatment options, perceptions of the patient and self-efficacy beliefs. Readiness to adhere to prescribing guidelines was evaluated through assessing motivation, self-efficacy and implementability of non-pharmacological interventions. Changes in determinants were analyzed using the Wilcoxon signed-rank test. Changes in readiness to adhere to guidelines was analyzed using the nonparametric McNemar Bowker test. RESULTS: A desirable, significant and durable impact on determinants of BZD prescribing was observed. GPs (n = 121) underwent desirable changes in their attitudes, perceptions and self-efficacy beliefs and these changes remained significant months after the intervention. Barriers to using a non-pharmacological approach often cited in literature remained absent and were not highlighted by the intervention. Furthermore a significant impact on GPs' readiness to adhere to guidelines was observed. Participants reported change in their ability to cope with psychosocial consultations and to have tried using non-pharmacological interventions. CONCLUSIONS: Tailoring an e-intervention to target group (GPs) characteristics appears to be successful in promoting behavioral change in GPs undertaking vocational training. Significant and lasting changes were observed in determinants of prescribing BZDs. The e-intervention resulted in a positive impact on participants' readiness to adhere to BZD prescribing guidance and their coping with psychosocial consultations. Investigating which mechanisms of change are responsible for the observed effectiveness could help to refine and improve future interventions.

Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia.

BACKGROUND: Antipsychotic agents are often used to treat neuropsychiatric symptoms (NPS) in dementia, although the literature is sceptical about their long-term use for this indication. Their effectiveness is limited and there is concern about adverse effects, including higher mortality with long-term use. When behavioural strategies have failed and drug therapy is instituted, regular attempts to withdraw these drugs are recommended. Physicians, nurses and families of older people with dementia are often reluctant to try to stop antipsychotics, fearing deterioration of NPS. Strategies to reduce antipsychotic use have been proposed, but a systematic review of interventions aimed at withdrawal of antipsychotic agents in older people with dementia has not yet been performed. OBJECTIVES: To evaluate whether withdrawal of antipsychotic agents is successful in older people with dementia in community or nursing home settings, to list the different strategies for withdrawal of antipsychotic agents in older people with dementia and NPS, and to measure the effects of withdrawal of antipsychotic agents on behaviour. SEARCH METHODS: ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, clinical trials registries and grey literature sources were searched on 23 November 2012. The search included the following terms: antipsychotic* or neuroleptic* or phenothiazines or butyrophenones or risperidone or olanzapine or haloperidol or prothipendyl or methotrimeprazine or clopenthixol or flupenthixol or clothiapine or metylperon or droperidol or pipamperone or benperidol or bromperidol or fluspirilene or pimozide or penfluridol or sulpiride or veralipride or levosulpiride or sultopride or aripiprazole or clozapine or quetiapine or thioridazine combined wither terms such as discontinu* or withdraw* or cessat* or reduce* or reducing or reduct* or taper* or stop*.ALOIS contains records from all major healthcare databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS), as well as from many clinical trials registries and grey literature sources. SELECTION CRITERIA: Randomised, placebo-controlled trials comparing an antipsychotic withdrawal strategy to continuation of antipsychotics in people with dementia. DATA COLLECTION AND ANALYSIS: Review authors independently assessed trials for inclusion, rated their risk of bias and extracted data. MAIN RESULTS: We included nine trials with 606 randomised participants. Seven trials were conducted in nursing homes, one trial in an outpatient setting and one in both settings. In these trials, different types of antipsychotics prescribed at different doses were withdrawn. Both abrupt and gradual withdrawal schedules were used. The risk of bias of the included studies was generally low regarding blinding and outcome reporting and unclear for randomisation procedures and recruitment of participants.There was a wide variety of outcome measures. Our primary efficacy outcomes were success of withdrawal (i.e. remaining in study off antipsychotics) and NPS. Eight of nine trials reported no overall significant difference between groups on the primary outcomes, although in one pilot study of people with psychosis and agitation that had responded to haloperidol, time to relapse was significantly shorter in the discontinuation group (Chi(2) = 4.1, P value = 0.04). The ninth trial included people with psychosis or agitation who had responded well to risperidone therapy for four to eight months and reported that discontinuation led to an increased risk of relapse, that is, increase in the Neuropsychiatric Inventory (NPI)-core score of 30% or greater (P value = 0.004, hazard ratio (HR) 1.94, 95% confidence interval (CI) 1.09 to 3.45 at four months). The only outcome that could be pooled was the full NPI-score, used in two studies. For this outcome there was no significant difference between people withdrawn from and those continuing on antipsychotics at three months (mean difference (MD) -1.49, 95% CI -5.39 to 2.40). These two studies reported subgroup analyses according to baseline NPI-score (14 or less versus > 14). In one study, those with milder symptoms at baseline were significantly less agitated at three months in the discontinuation group (NPI-agitation, Mann-Whitney U test z = 2.4, P value = 0.018). In both studies, there was evidence of significant behavioural deterioration in people with more severe baseline NPS who were withdrawn from antipsychotics (Chi(2) = 6.8; P value = 0.009 for the marked symptom score in one study).Individual studies did not report significant differences between groups on any other outcome except one trial that found a significant difference in a measure of verbal fluency, favouring discontinuation. Most trials lacked power to detect clinically important differences between groups.Adverse events were not systematically assessed. In one trial there was a non-significant increase in mortality in people who continued antipsychotic treatment (5% to 8% greater than placebo, depending on the population analysed, measured at 12 months). This trend became significant three years after randomisation, but due to dropout and uncertainty about the use of antipsychotics in this follow-up period this result should be interpreted with caution. AUTHORS' CONCLUSIONS: Our findings suggest that many older people with Alzheimer's dementia and NPS can be withdrawn from chronic antipsychotic medication without detrimental effects on their behaviour. It remains uncertain whether withdrawal is beneficial for cognition or psychomotor status, but the results of this review suggest that discontinuation programmes could be incorporated into routine practice. However, two studies of people whose agitation or psychosis had previously responded well to antipsychotic treatment found an increased risk of relapse or shorter time to relapse after discontinuation. Two other studies suggest that people with more severe NPS at baseline could benefit from continuing their antipsychotic medication. In these people, withdrawal might not be recommended.

Incidence, patient characteristics and treatment initiated for GP-diagnosed depression in general practice: results of a 1-year nationwide surveillance study.

BACKGROUND: Despite its public health significance, data about depression in general practice are often unavailable. OBJECTIVE: To study (i) the incidence of GP-diagnosed depression during 2008, (ii) associations between patient characteristics, appraised severity and initiated treatment, (iii) GPs' usual care compared to diagnostic criteria from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition guidelines and the newly developed practice guideline of the Society of Flemish GPs (2008) and (iv) GPs' initiated treatments compared to the Flemish Guideline. METHODS: General practice-based data were collected on all patients of ≥18 years who were diagnosed by their GP with a new episode of depression in Belgian sentinel general practices (SGP) during 2008. RESULTS: Data on 1739 persons were recorded by 172 sentinel general practices. Incidence rates for GP-diagnosed depression were estimated at 719/100 000 men and 1440/100 000 women. Thirty-one per cent of patients had mild, 50% had moderate and 19% had severe GP-diagnosed depression. Although only 43% of the patients at risk for suicide were considered to have severe depression, having thoughts of death or suicide was the main factor associated with increased severity of depression. Seventy-five per cent of patients received a prescription for an antidepressive agent; 29% received a prescription for another psychoactive agent; in 36%, non-pharmaceutical support was initiated by the GP and 25% received a referral. In contrast with the Flemish GP guideline criteria: (i) 69% of patients with a new episode of mild or a first episode of moderate depression were prescribed an antidepressive agent and (ii) only 39% of the patients with severe depression were both prescribed an antidepressive agent and referred to a mental health service. CONCLUSIONS: This study has yielded original data on the incidence and management of depression in Belgian general practice. Our findings show that efforts are needed to improve depression management in Belgian general practice.

Barriers to nonpharmacologic treatments for stress, anxiety, and insomnia: family physicians' attitudes toward benzodiazepine prescribing.

OBJECTIVE: To explore the attitudes of FPs toward benzodiazepine (BZD) prescribing and the perceived barriers to nonpharmacologic approaches to managing stress, anxiety, and insomnia. DESIGN: A questionnaire including 32 statements about treatment of insomnia, stress, and anxiety. SETTING: Local quality groups for FPs in Belgium. PARTICIPANTS: A total of 948 Belgian FPs. MAIN OUTCOME MEASURES: Barriers to using nonpharmacologic approaches in family practice. RESULTS: We identified 3 different groups of FPs according to their attitudes about BZD prescribing. A first relatively big group of FPs (39%) were not really concerned about the risks of BZD prescribing. Those in the second group (17%) were aware of the problems associated with BZDs, but did not perceive it to be their role to use nonpharmacologic approaches in family practice. Those in the third group (44%) were concerned about BZD prescribing and found it to be a "bad solution," but were faced with various barriers to applying nonpharmacologic approaches. Surprisingly, we found that nearly 97% of FPs thought that most people were eligible for nonpharmacologic approaches, but experienced implementation barriers at the level of the patient, the level of the FP, and the level of the health care system. CONCLUSION: Using different education and behavioural-change strategies for different FP groups seems important. A large group of FPs does not find prescribing BZDs to be problematic. Sensitizing and alerting FPs to this issue remains very important.

Inter-professional collaboration reduces the burden of caring for patients with mental illnesses in primary healthcare. A realist evaluation study.

Background: The implementation of primary care for mental health is often insufficient, which leaves its mark on staff. A team-based approach of mental healthcare prevents poor staff morale. A community health centre (CHC), therefore, set up a project promoting interprofessional collaboration with a mental health team (MHT).Objectives: This study aimed to understand how an MHT would influence staff morale in a primary care setting, aiming to formulate some recommendations for future projects.Methods: In 2017, interviews and a focus group discussion were conducted among the staff of a CHC. Using a qualitative approach, we aimed to unravel contextual factors and mechanisms that determine the effect of an MHT on staff morale.Results: The project relieved the burden of the patient encounters and staff members felt more valuable to patients. Underlying mechanisms were recognition, altered attitudes towards patients and role clarity. Facilitating factors were intercultural care mediators and a positive team atmosphere, whereas inhibiting factors were inefficient time management and communicative issues.Conclusion: Our study elucidated mechanisms and the contextual factors by which an MHT in general practice improves staff morale.[Box: see text].

Late-life depression: issues for the general practitioner.

Late-life depression (LLD) is both a prevalent and life-threatening disorder, affecting up to 13.3% of the elderly population. LLD can be difficult to identify because patients mainly consult their general practitioner (GP) for somatic complaints. Moreover, patients may be hesitant to express the problem to their GP. Increased vigilance on the part of the GP can only benefit older people with depression. To recognize the risk of LLD, screening tools are provided in addition to treatment options for LLD. This review aims to provide the GP with guidance in recognizing and treating LLD. It tries to connect mainstream etiologies of LLD (e.g., vascular, inflammation, hypothalamo-pituitary-adrenal axis) with risk factors and current therapies. Therefore, we provide a basis to the GP for decision-making when choosing an appropriate therapy for LLD.

Discontinuation of Long-Term Antipsychotic Drug Use for Behavioral and Psychological Symptoms in Older Adults Aged 65 Years and Older With Dementia.

BACKGROUND: Antipsychotic drugs are often used to treat behavioral and psychological symptoms (BPSD) in adults aged 65 years and older with dementia, although there is uncertainty about the effectiveness of long-term use for this indication and there are concerns that they may cause harm. OBJECTIVES: To evaluate whether discontinuation of long-term antipsychotic drugs for BPSD is successful in adults aged 65 years and older with dementia. This article is based on a Cochrane review updated in 2018. DESIGN: A Cochrane systematic review and meta-analysis. SETTING AND PARTICIPANTS: Eight databases were searched in January 2018 to identify 10 randomized controlled trials with 632 older adults. MEASURES: We used standard methodological procedures according to the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the number of patients completing the study. We considered sustained withdrawal of antipsychotics until the end of the study period as successful outcome. RESULTS: Based on assessment of 7 studies (n = 446), discontinuation may make little or no difference to whether or not participants complete the study (low-quality evidence). In 2 trials, including participants with psychosis, agitation, or aggression who had responded to antipsychotic treatment, discontinuation of antipsychotics was associated with a higher risk of leaving the study prematurely because of symptomatic relapse or a shorter time to symptomatic relapse. We found low-quality evidence from 7 trials (n = 519) that discontinuation may make little or no difference to overall BPSD, measured using various scales. There was some evidence from subgroup analyses in 2 trials that discontinuation may be associated with a worsening of BPSD in participants with more severe BPSD at baseline. CONCLUSIONS: Our meta-analysis revealed that there is low-quality evidence that long-term antipsychotic drugs for BPSD may be successfully discontinued in most adults aged 65 and older.