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The Impact of Psycholeptic Reduction on Residential Aged Care Facility The impact of psycholeptic reduction on residential aged care facility residents by Daniel Jake Hoyle BPharm (Hons) BCGP School of Pharmacy and Pharmacology | University of Tasmania Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy University of Tasmania November, 2020 Declaration of originality This thesis contains no material which has been accepted for a degree or diploma by the University or any other institution, except by way of background information and duly acknowledged in the thesis, and to the best of my knowledge and belief no material previously published or written by another person except where due acknowledgement is made in the text of the thesis, nor does the thesis contain any material that infringes copyright. Name: Daniel Hoyle Signed: Dated: 17/02/2020 Authority of access This thesis may be available for loan and limited copying and communication in accordance with the Copyright Act 1968. Name: Daniel Hoyle Signed: Dated: 17/02/2020 ii | Page Daniel J. Hoyle Statement of ethical conduct The research associated with this thesis abides by the international and Australian codes on human and animal experimentation, the guidelines by the Australian Government's Office of the Gene Technology Regulator and the rulings of the Safety, Ethics and Institutional Biosafety Committees of the University. Ethics Approval Number H0013999. Name: Daniel Hoyle Signed: Dated: 17/02/2020 Statement regarding published work contained in thesis Chapter 4 has been modified from a published paper. The publisher of that paper holds the copyright for that content and access to the material should be sought from the respective journal. The remaining non-published content of the thesis may be available for loan and limited copying and communication in accordance with the Copyright Act 1968. Name: Daniel Hoyle Signed: Dated: 17/02/2020 Statement of co-authorship Given that this thesis contains work that has been published, a statement of co-authorship is provided for each chapter that includes published work. The following people and institutions contributed to the publication of work undertaken as part of this thesis: iii | Page Daniel J. Hoyle Candidate: Daniel J. Hoyle1 Author 1: Juanita L. Breen2 Author 2: Ivan K. Bindoff1 Author 3: Lisa M. Clinnick3 Author 4: Aidan D. Bindoff2 Author 5: Gregory M. Peterson1 1School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Private Bag 26, Hobart, TAS 7001 2Wicking Dementia Research & Education Centre, College of Health and Medicine, University of Tasmania, Private Bag 143, Hobart, TAS 7001 3Aged Operations, Ballarat Health Services Contribution of work by co-authors for each paper: PAPER 1: Incorporated into Chapter 4 Hoyle DJ, Bindoff IK, Clinnick LM, Peterson GM, Westbury JL. Clinical and economic outcomes of interventions to reduce antipsychotic and benzodiazepine use within nursing homes: a systematic review. Drugs & Aging. 2018;35(2):123-34. Author contributions: Candidate acted as the corresponding author and contributed towards conception and design of the systematic review; data extraction and synthesis; data analysis and interpretation; and writing the manuscript. Authors 1, 2, 3 and 5 contributed towards the conception and design of the systematic review; data analysis and interpretation; and revising the manuscript critically for intellectual content. iv | Page Daniel J. Hoyle PAPER 2: Incorporated into Chapter 6 Hoyle DJ, Peterson GM, Bindoff IK, Clinnick LM, Bindoff AD, Breen JL. Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care. International Psychogeriatrics. 2020; Under review. Candidate is acting as the corresponding author and contributed to the conception and design of the study; data collection; data analysis and interpretation; and writing the manuscript. Authors 1, 2, 3 and 5 contributed towards the conception and design of the study; data analysis and interpretation; and revising the manuscript critically for intellectual content. Author 4 provided statistical support and reviewed the manuscript critically for intellectual content. We, the undersigned, endorse the above stated contribution of work undertaken for each of the published (or submitted) peer-reviewed manuscripts contributing to this thesis: Signed: Daniel Hoyle Dr Juanita Breen Associate Professor Candidate Primary Supervisor Glenn Jacobson School of Pharmacy and Wicking Dementia Research Head of School Pharmacology & Education Centre School of Pharmacy and University of Tasmania University of Tasmania Pharmacology University of Tasmania Date: 29/01/2020 29/01/2020 03/02/2020 v | Page Daniel J. Hoyle Abstract Introduction Antipsychotics and benzodiazepines, collectively known as psycholeptics, are widely used in residential aged care facilities (RACFs), leading to concern that residents are being inappropriately sedated. Whilst antipsychotics are clinically appropriate for severe psychiatric illnesses (e.g., bipolar disorder, schizophrenia), they are often used long-term for neuropsychiatric symptoms, particularly in residents with dementia. Benzodiazepines are typically used for insomnia, anxiety, and acute agitation. Considering evidence of only modest efficacy for these indications and the risk of severe adverse effects, guidelines generally recommend reserving these medications for scenarios where non-pharmacological measures are ineffective and/or where there is a risk of harm or severe distress to the resident or others. Benzodiazepines, in particular, are not recommended for neuropsychiatric symptoms in people with dementia. If used, antipsychotics should be reviewed and reduced at a minimum of six to 12 weeks, depending on the country, and the use of benzodiazepines should be limited to a maximum of two to four weeks. Despite these recommendations, prolonged and widespread use suggests that these medications are not being reviewed and reduced regularly. Many interventions have, to varying degrees of success, reduced the use of these medications in RACFs. However, clinical outcomes for the RACF residents and staff, and the economic impact of these interventions are rarely reported (see Chapter 4). Concern of potential deterioration in resident symptoms resulting in increased workloads is one of the reasons for a lack of willingness to reduce these medications. Therefore, to address these gaps in the literature and minimise perceived barriers to sedative reduction, the focus of this thesis was to evaluate the impact that antipsychotic and benzodiazepine dose reduction had on resident- and RACF staff-related outcomes and health vi | Page Daniel J. Hoyle care costs within RACFs involved in a multicomponent program to improve antipsychotic and benzodiazepine use. Methods The national expansion of the ‘Reducing Use of Sedatives’ (RedUSe) program involved 150 Australian RACFs. The main components of RedUSe comprised two quality improvement cycles incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews. The program was implemented between March 2014 and April 2016. A prospective, observational, longitudinal study design was utilised to investigate outcomes related to changes in antipsychotic and/or benzodiazepine doses between baseline and four months among residents of a convenience sample of 28 RACFs involved in RedUSe between January 2015 and March 2016. Resident-related outcomes Permanent residents (n=206) taking antipsychotics and/or benzodiazepines on a daily basis, who did not have a severe psychiatric illness (where antipsychotic therapy should generally be maintained long-term e.g., bipolar disorder, schizophrenia) and were not considered end-stage palliative, were recruited. Neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and Cohen-Mansfield Agitation Inventory (CMAI)), quality of life (QoL; Assessment of Quality of Life-4D (AQoL-4D)), social withdrawal (Multidimensional Observation Scale for Elderly Subjects (MOSES)-withdrawal subscale) and activities of daily living (Physical Self-Maintenance Scale (PSMS)) were assessed at baseline and four months by nursing staff who completed psychometric tests as proxy raters. Lastly, the number and severity of falls and behavioural events, number and reason for general practitioner (GP) consultations and number, length and reason for hospitalisations of vii | Page Daniel J. Hoyle recruited residents were recorded by the nursing staff between baseline and four months. Figure 1 illustrates all data collection associated with this project. Staff-related outcomes The occupational disruptiveness of the neuropsychiatric symptoms was assessed at baseline and four months during psychometric testing with the NPI-NH. Additionally, a survey of job satisfaction (adjusted-Measure of Job Satisfaction) was made available to all RACF nurses and carers for anonymous completion at baseline and four months (Figure 1). Basic costing analysis Health care utilisation costs were estimated using the cost of prescribed medications at baseline and four months, and the estimated cost of GP consultations and hospitalisations between baseline and four months. Statistical methodology Considering the longitudinal design, analyses were restricted to residents who were followed up at baseline and four months. Associations between changes in the NPI-NH (total, factor and occupational disruptiveness scores), CMAI (total and factor
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