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Can Fam Physician. 2018 Jan;64(1):17-27.

Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline.

Author information

1
Assistant Professor in the Department of Family Medicine and in the School of Epidemiology and Public Health at the University of Ottawa in Ontario, Scientist in the C.T. Lamont Primary Health Care Research Centre of the Bruyère Research Institute, and Adjunct Scientist at the Institute for Clinical Evaluative Sciences (ICES). lbjerre@bruyere.org.
2
Assistant Professor in the Department of Family Medicine at the University of Ottawa, Adjunct Assistant Professor in the School of Pharmacy at the University of Waterloo in Ontario, and Scientist at the Bruyère Research Institute at the University of Ottawa.
3
Research Associate at the Bruyère Research Institute at the time of guideline development.
4
Medical Director of St Patrick's Home of Ottawa and Assistant Professor in the Department of Family Medicine at the University of Ottawa.
5
Assistant Professor of Medicine at the University of Ottawa, Chief of Geriatric Services at Hôpital Montfort, and a staff geriatrician with the Ottawa Hospital Division of Geriatrics.
6
Scientist at the Women's College Research Institute of Women's College Hospital in Toronto, Ont, and Assistant Professor with the Leslie Dan Faculty of Pharmacy and the Department of Family and Community Medicine at the University of Toronto.
7
Associate Professor and Associate Dean of Professional Programs in the Leslie Dan Faculty of Pharmacy at the University of Toronto at the time of guideline development.
8
Schlegel Research Chair in Geriatric Pharmacotherapy at the Schlegel-UW Research Institute on Ageing and the School of Pharmacy at the University of Waterloo at the time of guideline development.
9
Director of Geriatrics at Mount Sinai Hospital and the University Health Network hospitals in Toronto, Assistant Professor in the Department of Medicine, the Department of Family and Community Medicine, and the Institute for Health Policy, Management and Evaluation at the University of Toronto, and Assistant Professor in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine in Baltimore, MD.
10
Master's student in the School of Epidemiology and Public Health at the University of Ottawa at the time of guideline development.
11
Director of the Methods Centre at the Bruyère Research Institute and Assistant Professor in the School of Epidemiology and Public Health at the University of Ottawa at the time of guideline development.
12
Associate Professor and Head of the Division of Geriatric Psychiatry in the Department of Psychiatry at the University of Ottawa.

Abstract

OBJECTIVE:

To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper and stop antipsychotics; to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development, review, and endorsement processes.

METHODS:

The overall team comprised 9 clinicians (1 family physician, 1 family physician specializing in long-term care, 1 geriatric psychiatrist, 2 geriatricians, 4 pharmacists) and a methodologist; members disclosed conflicts of interest. For guideline development, a systematic process was used, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence was generated from a Cochrane systematic review of antipsychotic deprescribing trials for the behavioural and psychological symptoms of dementia, and a systematic review was conducted to assess the evidence behind the benefits of using antipsychotics for insomnia. A review of reviews of the harms of continued antipsychotic use was performed, as well as narrative syntheses of patient preferences and resource implications. This evidence and GRADE quality-of-evidence ratings were used to generate recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and stakeholders for review and revisions were made at each stage.

RECOMMENDATIONS:

We recommend deprescribing antipsychotics for adults with behavioural and psychological symptoms of dementia treated for at least 3 months (symptoms stabilized or no response to an adequate trial) and for adults with primary insomnia treated for any duration or secondary insomnia in which underlying comorbidities are managed. A decision-support algorithm was developed to accompany the guideline.

CONCLUSION:

Antipsychotics are associated with harms and can be safely tapered. Patients and caregivers might be more amenable to deprescribing if they understand the rationale (potential for harm), are involved in developing the tapering plan, and are offered behavioural advice or management. This guideline provides recommendations for making decisions about when and how to reduce the dose of or stop antipsychotics. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients and families.

PMID:
29358245
PMCID:
PMC5962971
[Indexed for MEDLINE]
Free PMC Article

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