Objective:

A multidisciplinary quality improvement team (“Halt-Haldol") was formed to implement DIAMOND-Lewy evidence-based guidelines with the objective of educating ED providers, reducing haloperidol use, and improving adherence to low dose use of APs for ED patients with dementia.

Background:

Persons with dementia are twice as likely to visit the Emergency Department (ED) compared to patients without dementia (1). Leading causes for visits include neuropsychiatric symptoms (2), frequently treated with antipsychotics (APs). APs carry high risk of worsening symptom burden throughout all stages of dementia, negatively impacting quality of life (3). We currently lack better pharmacologic alternatives, and not enough hospitals are implementing safety guidelines (4).

Design/Methods:

This is a single-site quality improvement study at an academic hospital. We emailed case-based survey to residents in emergency medicine, psychiatry, and neurology. The clinical case illustrated dementia with Lewy bodies and the participant had to choose appropriate pharmacologic management. Evidence-based guidelines from DIAMOND-Lewy studies (5,6) were then provided and knowledge was reassessed. Electronic medical record query (7) provided the number of patients ≥65 years old receiving APs in the ED (baseline data). We placed visual signs and modified ED order sets regarding agitation care, including removing haloperidol as a first-line therapy for geriatric patients.

Results:

From 2022-2023, there were 24,695 geriatric patients in the ED and 13% received APs. One-third of APs were haloperidol, increasing to 54% in patients over 85. The educational survey was sent to 91 residents and 66 (73%) responded. Pre-guideline top choices: 30% haloperidol, 27% olanzapine, and 29% quetiapine. Post-guidelines: 11% haloperidol, 9% olanzapine, and 52% quetiapine (chi-square p-value <0.003).

Conclusions:

While haloperidol was the most commonly used AP for older adults in our ED, education on the guidelines demonstrates an intention to switch to other APs. Future work will assess if education and order set changes will affect culture change and guideline adherence.