Key messages
We are uncertain whether or not psychosocial interventions in general are an effective way to reduce the use of antipsychotic medicines in care homes. The research used a variety of approaches and showed inconsistent results, but it seems difficult to generalise results for different health and social care systems. There is no evidence that psychosocial interventions lead to harmful events such as accidental falling or hospital admissions.
Why are care home residents given antipsychotic medication?
Many care home residents have dementia, experiencing emotional or behavioural problems at some time during the course of the illness, but more common in the later stages. Symptoms can be severe and distressing, both for the residents themselves and for their carers and include anxiety, restlessness and wandering, hallucinations (seeing or hearing things which are not really there), and aggressive behaviour towards others. Carers are challenged by residents' challenging behaviours and by analysing the causes, antecedents, or consequences of the behaviours.
Frequently antipsychotic medicines are used to control these symptoms and behaviours. These medicines are mainly used to treat psychosis-related conditions (mental health problems that causes people to perceive or interpret things differently from other people), but also for other illnesses with symptoms similar to psychosis, such as dementia. It is known that these medicines are not always effective and that they can have harmful effects in people with dementia. Therefore, guidelines suggest that they should only be used when non-medicine strategies have not worked.
What did we want to find out?
Because of the limited benefit and the potential harm of antipsychotic medicines in people with dementia, there is much interest in finding ways to reduce the use of antipsychotics in care homes. These ways could include, for example, organisational factors, staff training, or other interventions. We were interested in so-called psychosocial interventions, focussing on the way care is organised and delivered, and promoting alternative non-medicine strategies. These interventions often comprise different components, such as education for staff, specialist medication review, and additional support and activities for residents. These interventions may improve the well-being of care home residents, or improve staff skills to support residents with dementia. One approach is called person-centred care, aiming to emphasise the need of every person to be treated as an individual and receive attention of their individual needs.
What did we do?
We searched for studies that compared psychosocial interventions designed to reduce antipsychotic use with usual care. We looked at the effect of these interventions on the number of people given antipsychotic medication and on measures of residents' mental and physical health and quality of life. We also looked for information about harmful events such as falls and admissions to hospital.
We summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size.
What did we find?
We found five studies that involved 120 care homes with 8342 residents. One study was carried out in the US, one in Canada, two in the UK, and one in Germany. The studies lasted for six to 12 months. All of the interventions in the studies included education for nursing staff and other team members. Two studies specifically promoted person-centred care and another investigated person-centred care with additional interventions (exercise, social activities, or medication review).
Main results
We decided that the studies were too different to combine their results. Overall, we cannot be certain that psychosocial interventions lead to less use of antipsychotic medication as study results were not consistent. The two oldest studies found that their interventions did reduce antipsychotic use. One of these used an educational intervention and the other an intervention to promote person-centred care in care homes in the UK. A later attempt to repeat this intervention in Germany was not successful. The study that looked at the effects of additions to person-centred care found that additional medication review (but not additional exercise or social activities) may reduce antipsychotic use. The final study of an educational intervention for staff found no effect on antipsychotic medication.
Three studies gave information about harmful events such as falls or admissions to hospital, and there was no evidence that their interventions had any effect on these events. We also did not find clear evidence of effects of the interventions on other measures of physical or mental health or quality of life.
What are the limitations of the evidence?
Because of the small number of studies, the differences between studies, and their inconsistent results, our confidence in the results of the review was low. The studies were done in different countries, where usual care may be different. Not all of the studies provided data about all aspects we were interested in.
How up to date is this evidence?
This review updates our previous review. The evidence is up to date to July 2022.
All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.
Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012.
To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention.
We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022.
We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions.
We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2. adverse events. Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13. costs. We used GRADE to assess certainty of evidence.
We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches.
Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty.
We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits.
Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not.