Don’t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior.
Careful differentiation of cause of the symptoms (physical or neurological versus psychiatric, psychological) may help better define appropriate treatment options. The therapeutic goal of the use of antipsychotic medications is to treat patients who present an imminent threat of harm to self or others, or are in extreme distress–not to treat nonspecific agitation or other forms of lesser distress. Treatment of BPSD in association with the likelihood of imminent harm to self or others includes assessing for and identifying and treating underlying causes (including pain; constipation; and environmental factors such as noise, being too cold or warm, etc.), ensuring safety, reducing distress and supporting the patient’s functioning. If treatment of other potential causes of the BPSD is unsuccessful, antipsychotic medications can be considered, taking into account their significant risks compared to potential benefits. When an antipsychotic is used for BPSD, it is advisable to obtain informed consent.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
1–5: AMDA – The Society for Post -Acute and Long-Term Care Medicine convened a work group made up of members from the Clinical Practice Steering Committee (CPSC). Members of the CPSC include board certified geriatricians, certified medical directors, multi-facility medical directors, attending practitioners, physicians practicing in both office-based and nursing facility practice, physicians in rural, suburban and academic settings, those with university appointments, and more. It was important to AMDA that the workgroup chosen represent the core base of the AMDA membership. Ideas for the “five things” were solicited from the workgroup. Suggested elements were considered for appropriateness, relevance to the core of the specialty and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. A literature search was conducted to provide supporting evidence or refute the activities. The list was modified and a second round of selection of the refined list was sent to the workgroup for paring down to the final “top five” list. Finally, the work group chose its top five recommendations before submitting a final draft to the AMDA Executive Committee, which were then approved.
6–10: The AMDA Choosing Wisely® endeavor utilized a similar procedure as published in JAMA Intern Med. 2014;174(4):509-515 – A Top 5 List for Emergency Medicine for our five items.
The AMDA Clinical Practice Committee acted as the Technical Expert Panel (TEP).
Phase 1 – The Clinical Practice Steering Committee (CPSC) along with the Infection Advisory Committee clinicians brainstormed an initial list of low-value clinical decisions that are under control of PA/LTC physicians that were thought to have a potential for cost savings.
Phase 2 – Each member of the CPSC selected five low-value tests considering the perceived contribution to cost (how commonly the item is ordered and the individual expense of the test/treatment/action), benefit of the item (scientific evidence to support use of the item in the literature or in guidelines); and highly actionable (use decided by PA/LTC clinicians only).
Phase 3 – A survey was sent to all AMDA members. Statements were phrased as specific overuse statements by using the word “don’t,” thereby reflecting the action necessary to improve the value of care.
Phase 4 – CPSC members reviewed survey results and chose the five items.
For more information, visit www.paltc.org.
American Medical Directors Association. Dementia in the long term care setting clinical practice guideline. Columbia, MD: AMDA 2012.
Perkins, R. Evidence-based practice interventions for managing behavioral and psychological symptoms of dementia in NH residents. Ann LTC. 2012:20(12):20-4.
Flaherty J, Gonzales J, Dong B. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. JAGS. 2011;59:S269-76.
American Medical Directors Association. Delirium and acute problematic behavior clinical practice guideline. Columbia, MD: AMDA 2008.
Ozbolt LB, Paniagua MA, Kaiser RM. Atypical antipsychotics for the treatment of delirious elders. J Am Med Dir Association. 2008;9:18–28.
U.S. Food and Drug Administration. Information for healthcare professionals: antipsychotics. FDA Alert, [Internet]. 2008 Jun 16. [Cited 2008 Sep 23]. Available from: http://www.fda.gov/cder/drug/InfoSheets/HCP/antipsychotics_conventional.htm.
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Schneeweiss S, Setoguchi S, Brookhart A, Dormuth C, Wang PS. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ 2007;176(5): 627–32.
Gill SS, Bronskill SE, Normand SL, Anderson GM, Sykora K, Lam K, Bell CM, Lee PE, Fischer HD, Herrmann N, Gurwitz JH, Rochon PA. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med. 2007;146(11):775–86.
Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934–1943.
Schneider LS, Tariot PN, Dagerman KS. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355(15):1525–38.
Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA. 2005;293:596–608.
U.S. Food and Drug Administration, U.S. Department of Health and Human Services. FDA public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. [Internet]. 2005 Apr 11. [Cited 2013 Jul 23]. Available from http://www.fda.gov/cder/drug/advisory/antipsychotics.htm.