A qualitative study of multiple voices to inform aftercare services for older persons following self-harm.

OBJECTIVES: Self-harm and suicide are closely related in older adults, highlighting the opportunity for Aftercare interventions in targeted suicide prevention. The study aims were to explore strengths and shortfalls of current Aftercare services for older adults from the perspective of key stakeholders and researchers; and inform a set of guiding principles for older persons' Aftercare. METHODS: Semi-structured interviews were undertaken with a convenience sample of older people with lived experience of self-harm, clinicians and suicide researchers (n = 22). Interviews were focussed on current practice (strengths and limitations), potential improvements, and identifying the core components of an acceptable Aftercare model. Interviews were audio-recorded, transcribed and subjected to a reflexive thematic analysis grounded in interpretive description. RESULTS: Current practice strengths included validation, a person-centred approach and optimising aftercare delivery. Limitations included ageism, practical limitations (lack of service awareness, fragmented service provision, barriers to access, and traumatising approaches), and limited services, funding and training. Overarching themes included anti-ageism; anti-stigma; empowerment and agency; conveying hope; patience and pace; accessible; and finding purpose: connections and meaningful activity. CONCLUSIONS: Older people who have self-harmed have complex, individualised needs. They sit within intersecting systems traversing healthcare, support services, family, and the social environment. Systemic, coordinated Aftercare founded upon core principles of anti-ageism, anti-stigma, partnership, empowerment, accessibility and provision of connections and meaning are needed.

A systematic review of evidence-based aftercare for older adults following self-harm.

OBJECTIVE: Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies. METHODS: Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently. RESULTS: Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs. CONCLUSION: Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

Educating Crisis Supporters About Self-Harm and Suicide in Older Adults.

OBJECTIVES: This study aimed to describe existing knowledge of crisis supporters (volunteers responding to crisis calls/texts/messages) regarding self-harm and suicide in older adults and investigate knowledge translation through use of a novel online adaptive learning tool. METHODS: The online educational tool was tested in an Australian national sample of crisis supporters (trained volunteers) aged 18+. Knowledge Transfer was evaluated utilizing a pre/post intervention methodology for data collection. The collaboratively developed online educational tool comprised a pre-test (10 questions), middle learning module (individualised for participant's incorrect pre-test responses) and post-test (10 questions) on suicidal behaviours in older adults. Data analysed included the demographic characteristics of the participants, individual question scores, and summed pre- and post-tests scores. Group differences in change scores were assessed with either one-way between subjects ANOVA or independent samples t-test, depending on the number of groups within each variable. Pre-post education comparisons on individual change in scores were made using a paired samples t-test. Statistical significance was defined as p <0.05. RESULTS: 104 crisis supporters completed the tool (pre-test, middle lesson and post-test). There was significant improvement in knowledge of crisis supporters after the intervention (pre-test scores Mean (M) = 4.56, SD = 1.62 and post-test scores M = 7.61, SD = 1.60; t (103) = 17.242, p <0.001.). CONCLUSION: Dedicated training about suicidal behaviors in older adults is needed given their high rates of suicide and differing underlying reasons and needs compared to younger adults.

Human Rights and Empowerment in Aged Care: Restraint, Consent and Dying with Dignity.

The aged care system in Australia is in crisis and people living with dementia are especially vulnerable to breaches of human rights to autonomy, dignity, respect, and equitable access to the highest quality of health care including meeting needs on account of disability. To be powerful advocates for themselves and others, people with dementia and the wider community with vested interests in quality aged care must be informed about their rights and what should be expected from the system. Prior to the Australian Royal Commission into Aged Care Quality and Safety, the Empowered Project was established to empower and raise awareness amongst people with dementia and their families about changed behaviours, chemical restraint, consent, end of life care, and security of tenure. A primary care-embedded health media campaign and national seminar tour were undertaken to meet the project aims of awareness-raising and empowerment, based on 10 Essential Facts about changed behaviours and rights for people with dementia, established as part of the project. Knowledge translation was assessed to examine the need and potential benefit of such seminars. We demonstrated that this brief educational engagement improved community knowledge of these issues and provided attendees with the information and confidence to question the nature and quality of care provision. With the completion of the Royal Commission and corresponding recommendations with government, we believe the community is ready to be an active player in reframing Australia's aged care system with a human rights approach.

Australia's problem with obtaining consent for psychotropic use in older people.

Frequent use of psychotropic medicines in people with dementia is a significant concern globally, doing this without informed consent is a violation of human rights, ethics and law. Capacity Australia piloted an intervention to address several hypothetical barriers to obtaining consent for psychotropic use in aged care and has developed a suite of resources to improve rights and health literacy for clinicians, patients and community alike.

Prolonged use of antipsychotic medications in long-term aged care in Australia: a snapshot from the HALT project.

OBJECTIVES: Use of antipsychotic drugs in long-term aged care (LTC) is prevalent and commonly exceeds the recommended duration, but contributors to this problem are not well understood. The objective of this study is to provide a snapshot of the features of and contributors to prolonged use of antipsychotic medications (>12 weeks) among a sample of LTC residents. DESIGN: We present retrospective and baseline data collected for the Australian Halting Antipsychotic Use in Long-Term Care (HALT) single-arm longitudinal deprescribing trial. SETTING: Twenty-four long-term care facilities in Sydney, Australia. PARTICIPANTS: The HALT study included 146 older people living in 24 Sydney LTC homes who had been prescribed a regular antipsychotic medication for at least 3 months at baseline. MEASUREMENTS: Detailed file audit was conducted to identify the date and indication recorded at initial prescription, consenting practices, longitudinal course of prescribing, and recommendations for review of antipsychotic medication. Behavioural and psychological symptoms of dementia (BPSD) and functional dependence at baseline were assessed via LTC staff interview. Cognition at baseline was assessed in a participant interview (where possible). RESULTS: Antipsychotics were prescribed for 2.2 years on average despite recommendations by a doctor or pharmacist for review in 62% of cases. Consent for antipsychotic prescription was accessible for only one case and contraindications for use were common. Longer use of antipsychotics was independently associated with higher dose of the antipsychotic drug and greater apathy, but not with other BPSD. CONCLUSION: Antipsychotic medications appeared to be prescribed in this sample as a maintenance treatment in the absence of active indicated symptoms and without informed consent. Standard interventions, including recommendations for review, had been insufficient to ensure evidence-based prescribing.

A missed opportunity to improve practice around the use of restraints and consent in residential aged care: Limitations of the Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019.

OBJECTIVE: To explore the meaning and potential role of new Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019, (Principles) which amend Quality of Care Principles 2014 in improving practice around physical and chemical restraint. METHODS: We examined both Principles and accompanying Explanatory Statement in light of best practices around consent and use of chemical and physical restraint. RESULTS: The chemical restraint definition is problematic by exclusion of medications for treating mental disorders, physical illness or physical conditions, which is not considered restraint. Inexplicably, physical restraint requirements are more rigorous than chemical restraint requirements, where assessment is optional, and consent sometimes obtained, after use, and from the person's "representative," rather than the person first, followed by their proxy decision-maker. CONCLUSIONS: Although a start in promoting best practice around physical restraint, the Principles do not address the status quo of poor practice around chemical restraint and may instead codify it.

Why deprescribing antipsychotics in older people with dementia in long-term care is not always successful: Insights from the HALT study.

INTRODUCTION: Antipsychotic medications are commonly used to manage behavioural and psychological symptoms of dementia despite their side effects and harms. While the Halting Antipsychotic Use in Long-Term care (HALT) deprescribing trial was successful at reducing antipsychotic use, 19% of participants had their antipsychotics represcribed or never reached a dose of zero. The aim of this study was to investigate the reasons for represcription of antipsychotic medication and factors associated with ongoing antipsychotic use, relating to care staff requests and perceived behavioural changes. MATERIALS AND METHODS: Thirty-nine of 133 HALT participants never ceased their antipsychotic medication or were represcribed a regular or pro re nata (PRN) antipsychotic after initial deprescribing. The views of nursing staff, general practitioner, and family on the circumstances leading up to these outcomes were collected via a questionnaire-based approach. This information was triangulated with observation and detailed file audit (including progress notes, medical notes, medication charts, incident reports, and hospital discharge summaries). A consensus panel reconstructed the represcribing context. RESULTS: Nurses were the most common drivers of represcribing (63.2%), followed by family members (39.5%), GPs (23.7%), specialists (13.2%), and hospital staff (10.5%). There were multiple drivers for antipsychotic use in 46.2% of participants. Increased agitated and aggressive behaviours were the most commonly reported reasons for represcribing even though these changes were not identified over time on objective measures. Consent and dosage practices remained poor despite education. DISCUSSION: Nursing staff are the key drivers of deprescribing particularly in response to perceived worsening agitation and aggression among male residents. The train-the-trainer model used in the HALT trial may have been insufficient on its own to improve staff competence and confidence in applying nonpharmacological approaches when responding to behaviour change.

Approaches to Deprescribing Psychotropic Medications for Changed Behaviours in Long-Term Care Residents Living with Dementia.

Psychotropic medications have a high risk of serious adverse events and small effect size for changed behaviours for people with dementia. Non-pharmacological approaches are recommended as first-line treatment for changed behaviours, yet psychotropic medications remain highly prevalent in long-term aged care settings. This narrative review describes the current evidence regarding deprescribing psychotropic medications for people with dementia in long-term care. Deprescribing psychotropic medications can be achieved without harm to the person with dementia, and most people experience no withdrawal symptoms. Interventions to deprescribe psychotropic medications should be multifactorial, including lowering the dose of the medication over time, educational interventions and psychological support. However, implementing this is a significant challenge due to the overreliance on psychotropic medications for behavioural management in long-term aged care. Facilitators to deprescribing psychotropic medications in long-term care include multidisciplinary teams with adequate training, education and managerial support, engaging residents and families and change 'champions'. Deprescribing practices should be person-centred, and an individualised deprescribing protocol should be in place, followed by careful monitoring of the individual. The person with dementia and their family, general practitioner, pharmacist, and allied health and direct care staff should all be involved throughout the deprescribing process. Direct care staff need adequate support, education and training, so they can effectively help the individual and implement person-centred approaches in the absence of psychotropic medications. Effective communication between residents and staff and amongst staff is consistently shown to be an important factor for deciding whether deprescribing of a medication should occur and the successful implementation of deprescribing psychotropic medications.

Critical Contextual Elements in Facilitating and Achieving Success with a Person-Centred Care Intervention to Support Antipsychotic Deprescribing for Older People in Long-Term Care.

Antipsychotic and other tranquilising medicines are prescribed to help care staff manages behaviour in one-quarter of older people living in Australian long-term care homes. While these medicines pose significant health risks, particularly for people with dementia, reliance on their use occurs when staff are not educated to respond to resident behaviour using nonpharmacological approaches. The Halting Antipsychotic use in Long-Term care (HALT) single-arm study was undertaken to address this issue with 139 people 60 years and over with behaviours of concern for staff living in 24 care homes. A train-the-trainer approach delivered person-centred care education and support for 22 HALT (nurse) champions and 135 direct care staff, dementia management education for visiting general practitioners (GP) and pharmacists, use of an individualised deprescribing protocol for residents, and awareness-raising for the resident's family. The HALT champions completed open-ended questionnaires and semistructured interviews to identify the contextual elements they considered most critical to facilitating, educating care staff, and achieving success with the study intervention. They reported that person-centred approaches helped care staff to respond proactively to resident behaviours in the absence of antipsychotic medicines; the champions considered that this required strong managerial support, champion empowerment to lead change, reeducation of care staff, and the cooperation of families and GPs.

Antipsychotic Deprescription for Older Adults in Long-term Care: The HALT Study.

OBJECTIVES: Despite limited efficacy and significant safety concerns, antipsychotic medications are frequently used to treat behavioral and psychological symptoms of dementia (BPSD) in long-term residential care. This study evaluates the sustained reduction of antipsychotic use for BPSD through a deprescribing intervention and education of health care professionals. DESIGN: Repeated-measures, longitudinal, single-arm study. SETTING: Long-term residential care of older adults. PARTICIPANTS: Nursing staff from 23 nursing homes recruited 139 residents taking regular antipsychotic medication for ≥3 months, without primary psychotic illness, such as schizophrenia or bipolar disorder, or severe BPSD. INTERVENTION: An antipsychotic deprescribing protocol was established. Education of general practitioners, pharmacists, and residential care nurses focused on nonpharmacological prevention and management of BPSD. MEASUREMENTS: The primary outcome was antipsychotic use over 12-month follow-up; secondary outcomes were BPSD (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory, and social withdrawal) and adverse outcomes (falls, hospitalizations, and cognitive decline). RESULTS: The number of older adults on regular antipsychotics over 12 months reduced by 81.7% (95% confidence interval: 72.4-89.0). Withdrawal was not accompanied by drug substitution or a significant increase in pro-re-nata antipsychotic or benzodiazepine administration. There was no change in BPSD or in adverse outcomes. CONCLUSION: In a selected sample of older adults living in long-term residential care, sustained reduction in regular antipsychotic use is feasible without an increase of BPSD.

Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia.

BACKGROUND: Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management. METHODS: LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations. CONCLUSION: While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.