Less Is More: The Impact of Deprescribing Psychotropic Drugs on Behavioral and Psychological Symptoms and Daily Functioning in Nursing Home Patients. Results From the Cluster-Randomized Controlled COSMOS Trial

Highlights

• What is the primary question addressed by this study?

• Do systematic medication reviews conducted as a part of a multicomponent intervention in nursing homes reduce psychotropic drug prescription, and if so, does this lead to changes in behavioral and psychological symptoms of dementia and level of functioning?

• What is the main finding of this study?

• Compared to the control group, systematic medication reviews reduce the use of psychotropic drugs, leaving behavioral and psychological symptoms of dementia unchanged. The intervention group improves in level of functioning, in contrast to deterioration among the control group.

• What is the meaning of the finding?

• Medication reviews using collegial mentoring and systematic clinical evaluation equip physicians for successful deprescribing of psychotropic drugs in nursing homes.

Abstract

Objective

To investigate the impact of medication reviews using collegial mentoring and systematic clinical evaluation on psychotropic prescriptions, behavioral and psychological symptoms of dementia (BPSD), and activities of daily living (ADL).

Design

Four-month multicenter, multicomponent, cluster-randomized, single-blinded controlled trial.

Setting

Thirty-three Norwegian nursing homes including 67 nursing home wards (clusters).

Participants

A total of 723 enrolled patients, of which 428 participated in the study; 217 were randomized to the intervention and 211 to care as usual (control).

Intervention

The COSMOS intervention consisted of Communication, Systematic pain management, Medication reviews, Organization of activities, and Safety. During medication review, the nursing home physician evaluated treatment with colleagues systematically using the results from validated clinical assessments.

Measurements

Mean changes from baseline to month 4 in the number of prescribed psychotropic drugs (antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs); Neuropsychiatric Inventory Nursing Home Version (NPI-NH) and Cornell Scale of Depression in Dementia (CSDD); Lawton and Brody's Physical Self Maintenance Scale (PSMS).

Results

Compared to control, the mean change in prescribed psychotropic drugs was reduced both in total and regular number, while mean changes in NPI-NH and CSDD scores did not differ between the groups. Mean change in PSMS showed improvement in the intervention group, and deterioration in the control group.

Conclusion

Medication reviews using collegial mentoring and systematic clinical evaluation led to safe deprescribing, as the reductions in psychotropic drug use did not negatively affect BPSD, while ADL improved.