National Surveillance Using a Clinical Quality Indicator for Prolonged Antipsychotic Use Among Older Australians Living With Dementia Who Access Aged Care Services

Background: Dementia guidelines recommend antipsychotics are only used for behavioural and psychological symptoms when non-pharmacological interventions fail, and to review antipsychotic use after 12 weeks. Little is known about prolonged antipsychotic use in aged care settings.

Objectives: To develop a clinical quality indicator (CQI) for antipsychotic use of >90 days among people with dementia accessing aged care services and examine trends in annual CQI incidence, associated factors, and geographical and facility variation.

Methods: A retrospective cohort study was undertaken using the Registry of Senior Australians National Historical cohort. Non-Indigenous individuals aged 65-105 years living with dementia between July 2008 and June 2016 who accessed home care packages (HCPs) or permanent residential aged care (PRAC) were included. The CQI was calculated as the number of individuals dispensed antipsychotics for >90 consecutive treatment days, divided by the number of individuals with dementia (excluding those with schizophrenia or Huntington’s disease). Trends in annual CQI incidence (2011-12 to 2015-16) were determined using Poisson regression models adjusting for age, sex, comorbidities and prior antipsychotic use. Associations between covariates and CQI incidence in 2015-16 were estimated using backward stepwise multivariable Poisson regression, and geographical and PRAC facility variation was examined using funnel plots.

Results: 50257 individuals accessing an HCP (median age 83 years (IQR 78-87), 62.5% female) and 250212 PRAC recipients (median age 85 years (IQR 80-89), 64.6% female) were included. Between 2011-12 and 2015-16, cumulative incidence of antipsychotic use for >90 days decreased in HCP recipients from 10.7% (95%CI 10.2-11.1) to 10.1% (95%CI 9.6-10.5; adjusted incidence rate ratio (aIRR) 0.97 (95%CI 0.95-0.98)) and in PRAC residents from 24.5% (95%CI 24.2-24.7) to 21.8% (95%CI 21.5-22.0, aIRR 0.97 (95%CI 0.96-0.98)). Prior antipsychotic use was associated with higher incidence in both cohorts. Being male and having the least socioeconomic disadvantage were also associated with higher antipsychotic incidence in the PRAC cohort. Despite little geographical variation observed for HCP recipients, PRAC facility-level variation was observed, with 10 of 2204 facilities (0.5%) sitting above the upper 95%CI and 149 (6.8%) below the lower 95%CI.

Conclusions: While small decreases in the incidence of prolonged antipsychotic use were observed among aged care recipients with dementia between 2011-12 and 2015-16, findings suggest antipsychotic use can be further improved. The CQI developed and tested in this study should be considered for use by care providers, government, and registries to monitor dementia care quality.