Antipsychotic Stewardship for Older Patients in Acute Care: Promoting Appropriate Prescribing
Mental Health and Geriatric Care
The goal of this project is to implement and evaluate the impact of an antipsychotic stewardship program. The stewardship team reviews cases to: ensure that appropriate assessment and investigations have been undertaken; decide if the antipsychotic is necessary, ensuring the best choice of drug and appropriate dose; reinforce the use of non-pharmacological interventions; and ensure response is monitored. We have developed and disseminated antipsychotic dosing guidelines for older patients. Based on preliminary results from 71 patients, the number of doses of regularly scheduled antipsychotics exceeding recommended dose has dropped from 24% to 2%. In 50% of cases the team recommended discontinuing the antipsychotic. This project will serve as a pilot for a quality improvement strategy that can be disseminated to other areas of the hospital and to other organizations.
Older patients are at high risk for delirium while in hospital. Delirium is often accompanied by responsive behaviours that may include agitation, aggression and hallucinations. Evidence supports the use of multicomponent, non-pharmacological strategies to prevent and manage delirium symptoms however there are circumstances which may necessitate the use of antipsychotics. Antipsychotics are associated with significant adverse effects including increased mortality and evidence to guide the choice of a specific antipsychotic and the appropriate dose is not robust.
To date there has been little research focused on use of antipsychotics in older patients on acute medical-surgical units and practice is dependent on expert consensus and clinician knowledge of the pharmacological profiles of the antipsychotic medication. It is imperative that use of these medications be evidence-informed and adjusted for the specific clinical circumstances.
The stewardship program is an innovative program that is accompanied by case-based learning sessions that integrate and reinforce evidence-based practices on delirium and responsive behaviours with front-line staff. The dyad of physician and nurse practitioner as a stewardship team, has served as a valuable interprofessional opportunity to reinforce non-pharmacological interventions in the care of patients with behaviours. Other antipsychotic stewardship programs in LTC have focused on audit and feedback of prescribing patterns. In contrast, our approach has been to provide education and reinforce non-pharmacologic approaches to behaviour management as an alternative or adjunct to antipsychotic use. This program is an example of leveraging AFP innovation funding with aligned corporate and system priorities such as the senior friendly hospital strategy, to achieve greater impact.