Transcript Audit on psychotropic medication prescribing in

Audit of psychotropic medication
prescribing in EMI nursing homes in
Monmouthshire
Dr
Dr
Dr
Dr
Pauline Ruth
Rui Zheng
Arpita Chakraborty
Usman Mansoor
Literature search






Dementia and BPSD are common in care
homes.
Various psychotropic drugs are commonly
used, despite weak evidence of efficacy.
40% of prescriptions for residents in nursing
homes may be inappropriate.
21% received a recent prescription of
antipsychotics in England and Wales. (Shah
et al 2011)
54000 elderly residents in care homes
without severe mental illness receive
antipsychotics. (Shah et al 2011)
Benzodiazepine use in nursing homes is
another major concern. 15-42% in Australian
NHs (Westbury et al 2010)
Literature search
What will help?

Davidsson et al 2011:


Medication reviews conducted by MDTs
can reduce the number of drugs and
the number of drug related problems
Forsetlund et al 2011:



Educational outreach
On-site education given alone or as
part of an intervention package
Pharmacist medication review
In Monmouthshire

4 EMI nursing homes: 154 residents

4 EMI residential homes
Audit aims


To ascertain whether psychotropic
medication prescribing in EMI nursing
homes is in keeping with NICE/SCIE
guidelines.
Includes: antipsychotics, antidementia
drugs, antidepressants, mood
stabilizers, and benzodiazepines.
To ascertain the level of awareness of staff
at the nursing homes re monitoring BPSD
and side effects of psychotropic medication.
Audit Standards
Audit standards:
In dementia patients with BPSD
Standards were based on NICE-SCIE guidelines on Dementia
(CG42):
Standard 1:
Non-pharmacological interventions should be offered as first line in
all cases.

Standard 2:
Target symptoms should be identified, quantified and documented in
all cases.

Standard 3:
If patients are prescribed antipsychotics there should be
documentation of severe distress or of immediate risk of harm to
themselves or others.

Standard 4:
The risks of starting antipsychotics should be discussed with the
person and/or carers and this discussion clearly documented.

Standard 5:
The dose should be low initially and then titrated upwards if needed.

Standard 6:
This should be time limited and reviewed every 3 months.

Audit standards:
In patients on antidementia drugs
Standards were based on NICE-SCIE guidelines
on Dementia (CG42):
Standard 1:
Only specialists should initiate treatment.

Standard 2:
Patients who continue on treatment should be reviewed
six monthly.

Standard 3:
Treatment should be reviewed by the specialist team.

Audit standards:
In patients on lithium

Standards were based on NICE guidelines on
bipolar disorder (CG38):
Standard 1:
Lithium level should be checked every 3 months in all
patients.

Standard 2:
U&Es, TFTs should be checked every 6 months in all
patients.

Standard 3:
All patients on lithium should have a lithium monitoring
card.

Audit standards:
In patients on benzodiazepines
Standards were based on Drug Misuse and
Dependence – UK Guidelines on Clinical
Management (Department of Health):
Standard 1:
All benzodiazepine prescribing should have a clear end date
or be part of a gradually reducing regime.
 Standard 2:
Only one benzodiazepine should be prescribed at a time.
 Standard 3:
Dose should be below 30mg Diazepam equivalent.
 Standard 4:
If standards not met, there should be documentation in the
notes giving clinical reason why.

Audit standards:
In all patients
Standard 1:
Glucose and blood pressure should be
checked annually.

Standard 2:
Lipids should be checked annually.

Methodology






4 EMI nursing homes in Monmouthshire to
be visited.
Medication charts to be reviewed.
All patients on psychotropic medication will
be included.
Clinical notes in CMHT to be reviewed.
Primary care to be contacted with the help
of community pharmacist.
Nursing home care records to be reviewed
and staff to be interviewed.
Results from the pilot station
Diagnosis
1
1
9
Dementia
Dementia & Depression
Psychotic illness
Psychotropic Medication
1
3
7
3
1
1
1
Benzodiazepines / 'Z' drugs
Antidementia, Antidepresant & Benzodiazepines / 'Z' drugs
Antidepressant & Benzodiazepines / 'Z' drugs
Antipsychotics
Antipsychotics & Benzodiazepines / Z drugs
Antipsychotics, Antidepressant & Benzodiazepines / 'Z' drugs
Antipsychotics, Mood stabilizers & Benzodiazepines / 'Z' drugs
Responsibility
9
11
Known to CMHT
GP
What do we aim to achieve?





Clearer monitoring agreements between
primary and secondary care
Better adherence to prescribing standards
Better training and increased awareness
of staff at nursing homes
Person-centred record of psychotropic
prescribing and monitoring focusing on
side effects staff might look for
To create a more standardized model of
inreach services