Choosing Wisely Canada recommendations

Canadian Psychiatry Association recommendation 5

Do not routinely use antipsychotics to treat primary insomnia in any age group.

Canadian Psychiatry Association recommendation 12

Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.

What shared decision making strategies or tools have you implemented in your practice around these recommendations?

In 2014–2015 the Alberta Health Services Seniors Health Strategic Clinical Network launched the Appropriate Use of Antipsychotics framework (www.albertahealthservices.ca/scns/auatoolkit.aspx) to reduce inappropriate use of antipsychotics among seniors. At our assisted-living facility in Calgary, Alta, staff received training on dementia care and physicians participated in a multidisciplinary process improvement workshop. The framework has helped us engage in tapering, deprescribing, and shared decision making with patients and their families. It has ensured our team’s alignment around the goal of safely minimizing antipsychotic use, which has helped us improve patients’ quality of life and reduce the prevalence of antipsychotic use from 20% to the current 10% (which is 7% below the provincial average of seniors in long-term care facilities).¹ As almost one-third of new patients are using antipsychotics upon arrival, this indicates that we are quite successful at deprescribing once they are settled at our facility.

For new patients, a multidisciplinary intake meeting, which includes a supportive decision maker, nurse practitioner, pharmacist, and nursing manager, takes place, where we review medications, discuss the indications for and risks of antipsychotics, and offer a deprescribing trial for any antipsychotics the patient is taking.

Various monitoring initiatives for patients taking antipsychotics also take place: documenting behaviour patterns to help objectively assess the medication’s effects; having quarterly medication reviews to aid in decision making (eg, relevant laboratory work); identifying triggers for adverse behavioural symptoms related to dementia; and developing individual care plans for patients. We also offer more formal activity time to keep patients engaged and happy.

What makes shared decision making around this topic challenging or rewarding?

It is very rewarding that our team is aligned around the goal of maximizing patient function and reducing medication risks. Our consistent communication about the benefits and risks of antipsychotic use and structured monitoring of patients gives everyone confidence that deprescribing efforts are safe and appropriate. Although there was a minor investment in time up front for staff, including myself, we now save time, as there are fewer laboratory results to review, as well as fewer medication interactions and antipsychotic side effects to manage.

Why is shared decision making around this specific Choosing Wisely recommendation or clinical topic essential to you?

Reducing the use of antipsychotics by 50% has been a massive victory at our facility. We have not found any adverse effects of our efforts to date. Workers’ compensation claims among staff, family complaints, co-resident injuries, staff turnover, and falls among patients have all decreased. I also notice my patients are happier and more engaged. I have less work to do initiating and managing prescriptions; I have fewer concerns about side effects; and I have been able to reduce routine laboratory work.

Most important, our effort to deprescribe antipsychotics has had a positive effect on patients’ quality of life and the team’s on-the-job satisfaction. I am so proud of our team’s efforts!