Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Alongside its many reviews of possible treatments for dementia, the Cochrane Dementia and Cognitive Improvement Group produced reviews relevant to other aspects of the care of people with dementia. In this podcast, Tanja Richter talks with Julia Lühnen (Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Clinical Nursing Science, Berlin, Germany) about the August 2023 update of the 2012 review of psychosocial interventions for reducing the use of antipsychotic medicines for people with dementia living in care homes.

Julia: Hello Tanja, first of all, could you tell us about antipsychotic medicines and, also, why they are used for care home residents?

Tanja: Hello Julia. Antipsychotic medicines are mainly used to treat psychotic symptoms and severely disturbed behaviour in people with some mental illnesses, such as schizophrenia, bipolar disorder and severe depression. These symptoms include delusions, meaning beliefs in something which is not true and hallucinations, sensing things which are not really there. Antipsychotics are also used for people with dementia because many experience hallucinations and delusions. They may also show so called agitated behaviour, especially at later stages of the illness.
In care homes, many residents have dementia and the symptoms can be severe and distressing, for the residents themselves and for their carers. This means that antipsychotic medicines are often used to try to control these symptoms, but this can cause problems.

Julia: Why is that?

Tanja: Firstly, the medicines are not always effective, and they also have important harmful side effects in people with dementia. Therefore, it may be more important to try to understand what is driving the behaviours and to try non-pharmacological strategies; and guidelines recommend that antipsychotic medicines should only be used when non‐pharmacological strategies have been tried and failed.

Julia: Which brings us to your review of psychosocial interventions. Please tell us a little about these.

Tanja: We looked at psychosocial interventions that focus on the way care is organised and delivered, and which promote alternative non‐pharmacological strategies. The interventions can be quite different and often comprise several components, such as staff education, medication review, and additional support and activities for residents.

Julia: How might the interventions help in care homes?

Tanja: In several ways. They may aim to improve the well‐being of the residents, advance staff skills to support residents with dementia, or generate a care environment that suits the needs of people with dementia. One prominent approach, called person‐centred care, aims to emphasise the need of every person to be treated as an individual and receive attention for their individual needs.

Julia: So, why is it important to have a systematic review of the effects of the psychosocial interventions?

Tanja: The starting point is that the limited benefit and the potential for harm of antipsychotic medicines in people with dementia has led to much interest in finding ways to reduce their use in care homes. Psychosocial interventions might be one way to do this and we updated the review from 2012 to provide carers and policymakers with the best available evidence to support informed decisions.
Our main interest was the effect of psychosocial interventions on antipsychotic medicine prescriptions in care home residents. We found five studies that involved 120 care homes, with more than 8300 residents. These studies had compared psychosocial interventions with usual care or optimised usual care. 
All interventions 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, namely exercises, social activities, and medication review.

Julia:  And, what do these trials tell us?

Tanja: Unfortunately, not as much as we had hoped! The results were inconsistent. Two older studies found that the interventions they tested reduced antipsychotic medicine use. One of these used an educational intervention and the other used an intervention to promote person‐centred care in care homes in the UK. However, another study, that tried to repeat the latter in care homes in Germany, did not find a reduction in antipsychotic medication.
The study of the effects of adding different elements to person‐centred care found that additional medication review – but not additional exercise or social activities – may reduce antipsychotic medicine use. Finally, the fifth study found that staff education had no effect on antipsychotic medication.

Julia: Overall, then, what's your take-home message about psychosocial interventions to reduce the use of antipsychotic medicines for people with dementia in care homes?

Tanja: At the moment, we're uncertain whether or not psychosocial interventions in general reduce the use of antipsychotic medicines, and it's not clear if results from a study in one setting are a good guide to what would happen in other health and social care systems. 

Julia: Thanks Tanja. If people would like to read the review, how can they get hold of it?

Tanja: Thanks Julia. It's available online from Cochrane Library dot com with a search for "psychosocial interventions and antipsychotics".