Original Title: Avis: usage optimal des antipsychotiques et la prise en charge non pharmacologique des symptômes comportementaux et psychologiques de la démence chez les personnes atteintes de troubles neurocognitifs majeurs qui résident en centre d’hébergement et de soins de longue durée

Authors' objectives: The growing use of antipsychotics in elderly residents of residential and long-term care facilities (RLTCCs) with major neurocognitive disorders (NCDs) is a concern to health authorities and many clinicians. This is because a large proportion of antipsychotic prescriptions are for off-label indications, such as the treatment of various behavioural and psychological symptoms of dementia (BPSD). Furthermore, it has been known for a number of years that antipsychotics are associated with serious adverse effects. In light of the foregoing, and as part of its major project on « chantier de pertinence clinique » of interventions, Québec’s Ministère de la santé et des services sociaux (MSSS) asked the Institut national d’excellence en santé et en services sociaux (INESSS) to propose strategies for promoting optimal antipsychotic use in RLTCC residents who have major NCDs with BPSD. More specifically, this project was aimed at developing clinical recommendations for RLTCC care teams to guide them towards the most effective strategies for preventing and managing BPSD and to promote appropriate antipsychotic use.

Authors' results and conclusions: RESULTS: The effectiveness of the political and administrative measures for reducing antipsychotic use in RLTCCs is not the subject of any scientific articles that meet the search criteria used for the systematic review and could therefore not be determined. However, we did identify legislative and institutional documents in North America and the United Kingdom aimed at governing practices in health and long-term care facilities. Special attention was given to the rules governing the use of control measures, since antipsychotics, when administered for no specific indication or therapeutic goal, qualify for this type of measure. The systematic review revealed two effective clinical strategies for reducing or discontinuing antipsychotic use, when appropriate, in health and long-term care facility residents who have major NCDs with BPSD: the deprescibing of antipsychotics and multiple-intervention programs. Indeed, the results of this systematic review indicate, with a moderate level of evidence, that deprescribing antipsychotics can be attempted in most persons with BPSD, this with no significant change in their behaviour. However, the studies’ statistical power, which was potentially insufficient to demonstrate intergroup differences, warrants a cautious interpretation of the data. The recommendations in the best clinical practice guidelines (CPGs) and the members of the advisory committee are also in favour of deprescribing antipsychotics in persons with major NCDs. However, certain conditions should apply, depending on the patient’s clinical situation and according to the type and severity of the BPSD for which the antipsychotic was initially prescribed. The benefit of multiple-intervention programs in reducing antipsychotic use has been demonstrated in the literature with a low to moderate level of evidence. Such programs involve the simultaneous use of several interventions and consist mainly of training programs for care teams that work with this type of patient. The CPG recommendations and the opinion of the advisory committee’s members enabled us to outline what such programs involve and the principles for implementing them in all of Québec’s RLTCCs. The results of the systematic review that concern nonpharmacological modalities for managing BPSD are mixed. Nonetheless, modalities such as music therapy and behaviour management techniques seem promising, especially if they are individualized. Supervised training on the person-centred approach and strengthening related skills are recommended in practice as effective tools for reducing BPSD. The main factors for success for the nonpharmacological clinical approach to managing BPSD are the introduction of a structured approach generally used by professionals with clearly defined skills and roles, teamwork, and an administration that supports its employees in the activities, strategies or interventions necessary for reducing BPSD. The results of the systematic review of the safety of atypical antipsychotics enabled us to delineate the adverse effects profile of the class as a whole as well as of each drug, such as aripiprazole, olanzapine, quetiapine, clozapine and risperidone, in persons with major NCDs. These safety data should be j compared with the efficacy results, which suggest, with a level of evidence ranging from low to high, depending on the antipsychotic, that these drugs have a modest effect in the treatment of psychotic or aggressive symptoms. The conditions for initiating or reevaluating antipsychotic therapy, whether administered on a regular or PRN basis, have been defined with the help of the best CPGs, grey literature documents from independent, recognized organizations, and the experiential knowledge provided by the advisory committee’s members. Therefore, it appears that antipsychotics should be considered solely for the short-term management of psychotic or aggressive symptoms in persons with major NCDs who do not respond to nonpharmacological approaches, if they present a danger to themselves or to others. In any event, using or not using antipsychotics should be based on an informed and shared decision following a risk-benefit assessment of such therapy for each individual case. It should be noted that, according to Health Canada, persons with vascular or mixed NCDs treated with antipsychotics are at greater risk for cerebrovascular adverse events than those with NCDs due to Alzheimer’s disease. CONCLUSION: The recommendations in this report should help better equip RLTCC care teams to prevent and manage, without using antipsychotics, BPSD considered disruptive, disturbing or dangerous. They should also make it possible for antipsychotics, when indicated, to be used as judiciously as possible in light of the information obtained on the individual’s clinical situation, of the type of BPSD observed and of the in-depth analysis of the risk-benefit ratio. Antipsychotic doses can be reduced, or antipsychotics can be withdrawn once this treatment is no longer warranted. These recommendations, which have been included in the knowledge transfer tools for the care teams, will be disseminated and implemented in Québec’s RLTCCs via the launch of the OPUS-AP collaborative approach, which is based on the Canadian Foundation for Healthcare Improvement (CFHI)’s initiative, in close partnership with the foundation, and on leading-edge expertise available in Québec.

Authors' recommendations: The recommendations developed in this project are presented on pages 66 to 74 of this report.

Authors' methods: Six research questions were drawn up to ultimately answer the decision question: What strategies could be implemented in Québec to promote optimal antipsychotic use in RLTCC residents who have major NCDs with BPSD? The methodology used to answer this question is based on the triangulation of three types of data: scientific data obtained from systematic reviews of the scientific literature and best clinical practice guidelines; experiential data from the clinical experience of the Québec health and social services professionals who participated in the work of the advisory committee formed for this project; and contextual data regarding the implementation context (e.g., available resources and health professional training). To answer all the research questions in a rigourous and unambiguous manner, several systematic reviews were performed. The methodology used for these reviews meets INESSS’s production standards [2013]. The methodological details for each of these reviews are provided in the related systematic review report [INESSS, 2017].

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/usage-optimal-des-antipsychotiques-et-la-prise-en-charge-non-pharmacologique-des-symptomes-comportementaux-et-psychologiques-de-la-demence-chez-les-personnes-atteintes-de-troubles-neurocognitifs-majeurs-qui-resident-en-centre-dhebergement-et-de-soins-de-l.html

Year Published: 2017

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/usage-optimal-des-antipsychotiques-et-la-prise-en-charge-non-pharmacologique-des-symptomes-comportementaux-et-psychologiques-de-la-demence-chez-les-personnes-atteintes-de-troubles-neurocognitifs-majeurs-qui-resident-en-centre-dhebergement-et-de-soins-de-l.html

Requestor: Minister of Health

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec