Psychiatry Recommendation #12: Do not use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia.

Geriatrics Recommendation #4: Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia.

Choosing Wisely Canada: How have you implemented this recommendation in your practice?

Dr. John Crosby: In 2014, I sat down with my two pharmacists separately at each home and set out a plan to cut prescriptions for antipsychotic drugs.  We first sent in the BSO (behavioural support Ontario) nurses that we have at each home to try non-pharmacological interventions, such as redirecting patients who were exit seeking and calming patients with activities, music and hobbies. We made sure that behaviour such as calling out and verbal and physical aggression were not due to medical reasons such as constipation, pneumonia, urinary tract infections or the pain of osteoarthritis. I then set up a meeting late in the week with the pharmacist, the ward nurse and myself to go over every chart of every patient on an antipsychotic medication. We managed to slowly, over four weeks, wean patients off antipsychotics. We chose those people whom the nurse, the pharmacist, and myself, could be successful. There were only two people that had to go back on them. One thing we learned was to try analgesics, even if no pain was evident. This helped a lot of patients that were unable to tell us how they were feeling because of their dementia. We are now down to 20% of the patients on antipsychotic meds at both homes and have been for the last 11 months.

We now have a simple process we do each week, we spend five minutes on each person. The pharmacist lists the drug they are on, the nurse (who knows the patients personally and is closest to them daily) states whether or not they feel slowly tapering patients off their medications could work, and then we collectively conclude and start implementing more behavioural modifications if appropriate. There is pressure to sedate for sure. We had one patient who threw a fax machine through a window. It can be dangerous not to medicate demented patients. There’s a natural pressure there to sedate patients who are disruptive, they can be harmful. We try to deal with this by practicing behavioral modification and giving people meaningful tasks.

CWC: How have you brought the principles of Choosing Wisely to your relationship with patients?

JC: Time management is key to implementing Choosing Wisely, and to being a successful Family Physician. If you are rushed, there is a temptation to do the quickest and easiest thing – like write a prescription or order a test – than to take time to explain why it is not necessary. I see forty patients a day and have ten minutes with each. Every physician is in the same boat, everyone is overwhelmed with patients. The most crucial factor in being able to apply Choosing Wisely in your practice is time, because it’s a lot easier to say ‘yes’ to patients. You need time to explain why you’re not going to do something, and discuss the risks and benefits. There’s a reason physicians over prescribe and choose unwisely and it’s the pressures of keeping your patients happy.

I make rounds on Mondays, Tuesdays and Thursdays at 9 a.m. (not during meals) and the patients and their families know I will be there for them. Going in three times a week means I save time because I can diagnose diseases early on, when they are easier to treat, because the work is divided up amongst three days there isn’t so much pressure on me each time I go. I delegate my meeting and ensure that the questions families are asking are medically relevant, and that there isn’t someone else who can address them. I go through their parents drug treatments and ensure that the medications they are on are appropriate for their respective conditions. I go very gingerly with each drug, and feel the families out, and then we make a decision. I don’t fight the battles I won’t win, I make sure everyone is on board and that it’s a shared decision.

By the time Thursday comes around things are quiet because I’ve had a chance to ensure the immediate medical needs of my residents have been taken care of, their families have been contacted/communicated with, and all of my nurses needs are taken care of. Choosing Wisely has to fit into your schedule, and so your best chance of implementing is managing your time well, and then you have time to talk to people about appropriate use.

CWC: What does Choosing Wisely mean to you as a family physician?

JC: Choosing Wisely is about necessary health care, but it’s also about conversations. I’ve learned how to communicate over the years through trial and error. I’m 68 years old and I’ve had parents and people that are close to me pass away and have to deal with their very serious conditions. This has helped me and I try to impart my knowledge onto younger doctors by bringing them into family meetings and show them how to talk to families and that each family is different, and therefore the conversation need to reflect that. I always personalize it, I treat myself and my family the same. I ensure families know that Choosing Wisely is expert driven and that it’s what I do for myself as well.

To me Choosing Wisely is a reflection of the way medicine is changing. I used to always order an ECG, on every single patient, every year, and same with annual physicals. It was what I was taught at school, but when Choosing Wisely came out with evidence-based recommendations I realized it was time to rethink at the way I practiced. Just because it’s the way it’s always been done does not necessary mean it’s the correct thing to do, you need to be open to changing practice.

This article first appeared in Canadian Family Physician. The interview was prepared by Dr Kimberly Wintemute, Primary Care Co-Lead, and Hayley Thompson, Project Coordinator, for Choosing Wisely Canada.