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Dr Alex Bahar-Fuchs (left) is a clinical
neuropsychologist and NHMRC Early Career
Research Fellow, Centre for Research on Ageing,
Health, and Wellbeing, Research School of
Population Health, Australian National University,
Canberra, and the Joseph Sagol Neuroscience
Centre, Sheba Medical Centre, Ramat-Gan,
Israel, and a Principal Investigator with the
Dementia Collaborative Research Centre: Early
Diagnosis and Prevention (DCRC: EDP). Alex’s
research has been supported by funding from
DCRC: EDP, and The Alzheimer’s Australia
Dementia Research Foundation; Dr Aleksandra
Kudlicka (centre) is a Post-doctoral Fellow,
School of Psychology, University of Exeter, UK;
and Professor Linda Clare is also from the School
of Psychology, University of Exeter, UK. To follow
up on this article, contact Alex at:
The Halting Antipsychotic use in
Long Term Care (HALT) Project is an
Australian study, running since 2014,
aiming to reduce the use of antipsychotic
medication in long-term care residents
with behavioural and psychological
symptoms associated with dementia
(BPSD).
Inappropriate prescribing of
antipsychotics for people with dementia
is common, particularly for those living
in care homes where multiple residents
may present with distressed behaviour.
As a result, GPs and geriatricians may
feel pressure to prescribe psychotropic
medications, including antipsychotics, in
response to BPSD in care home residents
– despite best practice guidelines
suggesting non-pharmacological
approaches should be tried before
resorting to medication and then only for
three months before reviewing.
The tight regulations around the use of
these medications are due to the
significant risks and side effects
associated with their use in older people.
These include dizziness, accelerated
cognitive decline, falls, pneumonia,
stroke and death. The modest potential
benefit of these medications needs to be
weighed carefully against these risks in
each individual and they should be
prescribed with caution.
One antipsychotic, Risperidone, is
currently indicated for psychotic
symptoms, or persistent agitation or
aggression inAlzheimer’s disease but not
other dementias. Despite this, we still see
antipsychotics administered in response
to behaviours for which there is no
evidence of benefit such as wandering,
calling out and delirium, in residents with
comorbid vascular conditions or other
forms of dementia, and for long periods
without review. Until the HALT
intervention, participants had been taking
their current course of antipsychotics for
an average of two years.
We are now heading into the final three
months of the trial, involving 140
residents across 23 NSW care facilities.
Preliminary results indicate that the
HALT deprescribing intervention
successfully eliminated antipsychotic
medications from the treatment plan in
the majority of participants.
Initially, over 90% of study participants
ceased antipsychotic medication, but not
all remained off the medication during
the follow-up period. Fourteen
recommenced regular antipsychotic
medication within three months, and a
further 10 within six months and two (to
date) before the final visit at 12 months (a
total of 21% of the sample who originally
ceased the antipsychotic medication).
Importantly, preliminary analyses
show behavioural and psychological
symptoms remain stable up to six and 12
months after deprescribing for all
participants, regardless of whether an
antipsychotic was restarted or never
ceased after deprescribing commenced.
We have almost completed 12-month
follow-up data collection from
participating residents and final results
will be available at the end of this year.
Controlled deprescribing
The reduction in antipsychotic use was
achieved through controlled
deprescribing involving community
pharmacists, facility staff, participants’
GPs and family members. Long-term
care facility nurses (HALT champions)
were also trained to recognise potential
causes of BPSD and encourage the use of
non-pharmacological and person-centred
approaches, including environmental
modifications, to manage symptoms.
Participants were assessed for
neuropsychiatric symptoms, agitation,
cognition, activities of daily living and
quality of life twice before deprescribing
and then three months, six months and
12 months after deprescribing started.
Feedback from HALT champions
The research team has also spent a
substantial amount of time talking with
the HALT champions to understand how
the project was received by staff and
management and what, if any,
sustainable impact it has had on the
residents as well as the facilities. The
HALT champions are a critical
component of the project. These
champions are, for the most part,
DCRC SPEC I AL I SSUE : THE B I G P I CTURE I N DEMENT I A RESEARCH
40 Australian Journal of Dementia Care October/November 2016 Vol 5 No 5
Trial HALTs unnecessary
use of antipsychotics
Preliminary results from the HALT Project show that the majority of people
with dementia in aged care homes who are prescribed antipsychotic
medications to control BPSD do not need them. Tiffany Jessop reports