LAUSR

Concerns about the appropriateness of psychotropic medicines use among residents of long-term care facilities (LTCFs) have been voiced for many years. In 1980, a study of 173 LTCFs in the United States reported a high prevalence of antipsychotic prescribing and called for further research to identify techniques for the management of neuropsychiatric symptoms which rely less upon psychotropics (Ray et al., 1980). More recent studies report that approximately one in five residents of LTCFs in the United States, England, and Australia are prescribed antipsychotics (Briesacher et al., 2013; Harrison et al., 2020; Szczepura et al., 2016). Benzodiazepines, which are often used for conditions such as sleep disturbance and anxiety, are dispensed to nearly one in three residents in Australian LTCFs (Harrison et al., 2020). Typical and atypical antipsychotics have been associated with a higher risk of serious adverse drug events (ADEs) including cerebrovascular events and death among older people living with dementia (Maust et al., 2015; Schneider et al., 2006). Benzodiazepines and antipsychotics have also been associated with increased risk of falls in older people. Treatment with these medicines may be appropriate when used in line with guideline recommendations and with concurrent nonpharmacological strategies and monitoring. However, the high prevalence of antipsychotic and benzodiazepine use in LTCFs suggests that not all use is in accordance with guidelines. Antipsychotics are often used in the absence of documented consent from residents or family members and continued for long durations (Westaway et al., 2020). In accord, improving psychotropic use in LTCFs was identified as an urgent priority in the interim report of the ongoing Royal Commission into Aged Care Quality and Safety in Australia (Royal Commission into Aged Care Quality and Safety, 2019). Widespread concern about psychotropic use among people living with dementia has led to a substantial expansion in the evidence base for nonpharmacological approaches, such as functional analysis interventions, which involve exploring the meaning or purpose of a person’s behavior, and music therapy (Moniz Cook et al., 2012; Tsoi et al., 2018). Although the quality of evidence is not as high as for traditional pharmacological studies, nonpharmacological approaches have shown similar effect sizes to psychotropics for managing neuropsychiatric symptoms, without the risk of serious ADEs (Dyer et al., 2018). Internationally, clinical guidelines for care of people with dementia recommend the use of nonpharmacological interventions as first-line approaches, and to only use antipsychotics when other approaches have failed or when the person is at risk to themselves or others. Despite recommendations from international guidelines, a well-developed nonpharmacological evidence base, increased awareness of the harms of antipsychotic use in people with dementia and black box warnings, prescribing restrictions, and indicatormonitoring systems in some countries, psychotropic use is still unacceptably high in LTCFs. In this issue of International Psychogeriatrics, Hoyle and colleagues (2020) determine the impact of an interdisciplinary antipsychotic and benzodiazepine reduction intervention in LTCFs on resident outcomes. The study was undertaken within 28 LTCFs participating in the Reducing Use of Sedatives (RedUSe) program that was implemented in 150 Australian LTCFs between 2014 and 2016 (Westbury et al., 2018). The multicomponent RedUSe intervention included auditing and benchmarking of antipsychotic and benzodiazepine prescribing, education to nursing staff, pharmacists and prescribers on evidence-based psychotropic use, and a multidisciplinary review of psychotropic prescribing for residents. At 6-month follow-up, a statistically significant reduction in the proportion of residents prescribed antipsychotics (from 21.6% to 18.9%, p< 0.001) and benzodiazepines (from 22.2% to 17.6%, p< 0.001) in the 150 LTCFs was observed. In 39% of residents in the RedUSe study who were prescribed antipsychotics or benzodiazepines at baseline, these medicines had been stopped or were prescribed at a lower dose at 6-month follow-up. In the current paper, Hoyle and colleagues explore the impact of the intervention and subsequent reduction in antipsychotic and benzodiazepine International Psychogeriatrics (2021), 33:6, 543–546 © International Psychogeriatric Association 2021