An intervention offering support with individualised psychological intervention as part of a programme promoting person centred care and good practice provides a viable alternative to neuroleptics for treating behavioural symptoms in patients with dementia.
In both intervention and control homes in our study, psychiatrists reviewed the prescriptions of the residents and recommended withdrawal of neuroleptics in accordance with best clinical practice, yet significantly fewer residents in the intervention homes remained taking these drugs. The percentage of residents (after excluding those with schizophrenia or other psychotic disorders) who were still prescribed neuroleptics at the end of 12 months was less than half that in the control homes. Levels of agitation and episodes of aggressive behaviour did not increase in homes with reduced prescribing of neuroleptics.
Cohen-Mansfield et al carried out a placebo controlled cross over trial of neuroleptic withdrawal in patients with dementia and found no significant worsening of behavioural symptoms when drugs were replaced with a tailored psychological intervention.8
In another study,9
89 people with dementia from a large community nursing home were randomised to receive either a complex intervention including activities, guidelines for drug use, and educational rounds, or treatment as usual. Patients who received the active intervention showed a significant improvement in behaviour and a trend towards a reduction in neuroleptic use.
Failure of the training and support intervention to have a significant effect on any of the secondary outcome measures may reflect difficulties inherent in affecting the culture of care within a nursing home enabling change to be measured in such a small scale trial.
In March 2004 the Committee on Safety of Medicines wrote to all doctors in the United Kingdom to advise against the prescription of risperidone and olanzapine in patients with dementia. The effect of this communication, which might have been expected to result in discontinuation of neuroleptics in a large number of participants in both arms of the trial, was only modest. Differences in the proportion of patients receiving neuroleptics at each review () between the groups were sustained over the year, and similarly affected by the ruling of the Committee on Safety of Medicines.
Neuroleptic use over study period, July 2003 to June 2004
The nursing homes that agreed to participate reflected a typical range of care provision for people with dementia in the United Kingdom and included three private individually owned and managed facilities, seven homes belonging to different large groups of care home providers, and two NHS managed facilities. Despite such heterogeneity between ownership and management of the homes and the geographical spread of the study, the training and support intervention was accompanied by significant reductions in the numbers of residents prescribed neuroleptics across the country.
What is already known on this topic
A high proportion of nursing home residents with dementia are treated with neuroleptics
The long term efficacy of neuroleptics in the management of behavioural disturbance in dementia has not been proved and their use is associated with increased morbidity and mortality
Withdrawal of neuroleptics does not acutely worsen behavioural symptoms of dementia
What this study adds
The training and support of care home staff reduced neuroleptic use in residents with dementia in nursing homes without worsening behavioural symptoms
The reduction in neuroleptic use was sustained for 12 months
This is Version 2 of the paper. In this version, has been amended to include all nursing homes [one was missing from the previous version].