Transcript Topic 9a slide set

Topic 9:
Use of antipsychotic medication in
people with a learning disability
Background, method and findings
from the baseline audit
Background
Topic background
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Antipsychotic medications are prescribed “off label” for
behavioural problems in people with a learning disability (LD).
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The use of antipsychotics to manage behavioural problems
which are not attributable to diagnosable mental illness,
in people with LD is controversial.
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A recent, influential, double-masked RCT called into question
the role of antipsychotics for aggression of nonpsychotic origin. No difference was found between the
efficacy of haloperidol, risperidone or placebo (Tyrer et al,
2008).
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A major consideration in LD prescribing practice is the
capacity of people with LD and behavioural problems to
participate in decisions about their treatment.
Background
Why this Topic was selected?
POMH-UK member Trusts indicated
their interest in benchmarking their
prescribing practice in this area
through participation in a quality
improvement programme.
LD clinicians often feel they lack
the
guidance
and
support
regarding best practice prescribing
that is available in other clinical
settings.
This audit is the first
time that national prescribing
practice in LD psychiatry has been
reviewed and benchmarked in this
way.
Audit standards
Audit standards
Whilst there is a lack of NICE guidance in this area, the literature
has been reviewed and standards set in “Using medication to
manage behaviour problems among adults with a learning
disability” (Deb et al., University of Birmingham, September
2006).
The audit standards used in
this report were derived from
these, and the third standard
is also supported by the NICE
clinical guideline for the
management of schizophrenia
CG82 (2009).
Audit standards
Audit standards
1. The indication for treatment with antipsychotic medication should
be documented in the clinical records (Deb, 2006).
2. The continuing need for antipsychotic medication should be
reviewed at least once a year (Deb, 2006).
3. Side effects of antipsychotic medication should be reviewed at least
once a year. This review should include assessment for the
presence of extrapyramidal side effects (EPS), and screening for
the 4 aspects of the metabolic syndrome: obesity, hypertension,
diabetes and dyslipidaemia (NICE clinical guidelines CG82, 2009).
Method
Sample
145 clinical teams from 39 mental health Trusts participated in the
audit, submitting data for 2,319 patients, all of whom had a
diagnosis of learning disability and were prescribed one or more
antipsychotics.
This is the largest audit of antipsychotic prescribing in people with a
learning disability that has been conducted to date.
Data collected
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Age, gender, ethnicity, severity of learning disability, co-morbid
psychiatric diagnoses and care setting
Diagnosis of epilepsy
The dose of each oral/short-acting IM and depot/long-acting
antipsychotic currently prescribed
The main indications for antipsychotic prescribing
Other medications for mental health, behavioural problems or epilepsy
Documented evidence of side effect monitoring
Documented evidence of formal review of medication
Key findings: Part 1
Key findings
1. For patients in whom antipsychotic treatment was initiated less than
12 months ago (n=328), the indication for treatment was
clearly described in 93% of the clinical records.
2. The most common indications for antipsychotic prescribing in the
total national sample (n=2,319) were comorbid psychotic
disorder (42%), followed by anxiety and agitation (42%), and
overt aggression (38%).
3. Of those patients in whom antipsychotic treatment was initiated
more than 12 months ago (n=1,991), 96% had their continuing
need for antipsychotic medication reviewed in the last year.
Key findings: Part 2
Key findings
4. Oral risperidone was the most commonly used antipsychotic,
being prescribed for 40% of the total national sample. Olanzapine
was prescribed for 20% of patients, and chlorpromazine, haloperidol
and quetiapine for 10% each.
5. Only 4% of the total national sample were prescribed a high dose
antipsychotic, and 15% were prescribed a combination of
antipsychotics.
6. In addition to an antipsychotic, almost three quarters (73%) of
patients were prescribed at least one other drug for the
treatment of mental illness, behavioural problems or epilepsy.
Key findings: Part 3
Key findings
7. For those patients in whom antipsychotic treatment was initiated more
than 12 months ago (n=1,991), documented evidence of side
effect assessment was as follows:
• Blood glucose: 60% of patients (range across Trusts 11-100%)
• Lipid profile: 57% of patients (12-100%)
• Weight/BMI: 56% of patients (5-100%)
• Extrapyramidal side effects: 41% of patients (0-100%)
• Blood pressure: 37% of patients (0-100%).
8. Of the side effect assessments listed above, 19% of patients had no
documented evidence of any of them being conducted in the last
year. 14% of patients had evidence of 1 assessment, 16% had
evidence of 2, and 52% had evidence of 3 or more.
Conclusions
Conclusions
•The indications for prescribing antipsychotic medication were clearly
documented in the clinical records.
•High doses and combinations of antipsychotics are prescribed less
commonly than in adult mental health services.
•The continuing need for antipsychotic medication was regularly reviewed
and documented in almost all patients in this sample. The high proportion of
patients having medicines changed at review suggests thoughtful and
thorough practice in this area.
•In just under three-quarters of patents, a general statement regarding
side effects had been documented in the last year.
•Documented evidence of systematic monitoring across a range of side
effects was far less common. Potentially remediable physical health
problems may therefore not be detected.
National findings
Indications* for antipsychotic prescribing:
Initiated within the last 12 months (n=328)
Agitation and anxiety
Co-morbid psychotic disorder
Overt aggression
Threatening behaviour
Obsessive behaviour
(n=142; 43%)
(138; 42%)
(120; 37%)
(87; 27%)
(37; 11%)
Initiated more than 12 months ago (n=1,991)
Co-morbid psychotic disorder
Agitation and anxiety
Overt aggression
Threatening behaviour
Self harm
(833;
(826;
(754;
(609;
(266;
42%)
42%)
38%)
31%)
13%)
*Note that individual patients may have been prescribed antipsychotic
medication for more than one indication.
Prescribing practice
Details for the 5 most commonly prescribed antipsychotics
Use: n (%)
Drug
Monotherapy
Combination
PRN
Risperidone
791 (86%)
134 (14%)
86 (9%)
Olanzapine
380 (81%)
91 (19%)
65(14%)
Chlorpromazine
143 (59%)
98 (41%)
112 (47%)
Haloperidol
117 (49%)
121 (51%)
110 (46%)
Quetiapine
183 (81%)
43 (19%)
25 (11%)
Prescribing practice
Dosing details for the 5 most commonly prescribed antipsychotics
Dose: Median (range)
Drug
Risperidone
Oral
IM
Oral PRN
IM PRN
2mg
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1mg
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(0.5-14mg)
10mg
Olanzapine
Haloperidol
Quetiapine
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(2.5-30mg)
100mg
Chlorpromazine
(0.3-8mg)
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(7.5-1000mg)
5mg
10mg
(2.5-20mg)
(2.5-20mg)
100mg
125mg
(15-1150mg)
(75-250mg)
6mg
10mg
10mg
15mg
(0.5-30mg)
(6-15mg)
(0.5-20mg)
(0.5-30mg)
250mg
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100mg
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(25-800mg)
(25-750mg)
Prescribing practice
Indication profiles for the most 5 most commonly
prescribed antipsychotics
Co-morbid psychotic disorder
Overt aggressive behaviour
Threatening behaviour
General agitation/anxiety
Obsessive behaviour
Self-harming behaviour
Motor stereotypies
Inappropriate sexual behaviour
Oppositional or defiant behaviour
Social withdrawal
Other
Unclear
Co-morbid psychotic disorder
Overt aggressive behaviour
Threatening behaviour
General agitation/anxiety
Obsessive behaviour
Self-harming behaviour
Motor stereotypies
Inappropriate sexual behaviour
Oppositional or defiant behaviour
Social withdrawal
Other
Unclear
National findings
Proportion of people with co-morbid diagnoses, across
mild/borderline, moderate and severe/profound diagnostic
subsamples (n=2,319)
National findings
Medicine review in the last year
National findings
Side effect monitoring in the last year
Borderline/mild
Moderate
Severe/profound
General statement that
side effects are present
223 (24%)
120 (21%)
81 (17%)
General statement that
side effects are not
present
442 (48%)
271 (47%)
241 (50%)
No statement about side
effects
260 (28%)
186 (32%)
167 (34%)
Trust level
Analyses presented in this section were conducted
for each Trust individually and for the total sample
to allow benchmarking.
Data from each Trust are presented by code.
Your Trust code is 40
Trust level
Patients’ learning disability severity by Trust and in the total
national sample
Trust level
Proportion of patients in each Trust for whom the indication
for antipsychotic prescribing is clearly documented
Trust level
Proportion of patients in each Trust for whom the continuing
need for antipsychotic medication was reviewed in the last
year
Trust level
Proportion of patients in each Trust and the total national
sample with documented evidence in their clinical records of
a general assessment of side effects in the last year.
Trust level
Proportion of patients in each Trust and the total national
sample with documented evidence in their clinical records of
assessment of EPS in the last year.
Trust level
Proportion of patients in each Trust and the total national
sample with documented evidence in their clinical records of
assessment of weight change in the last year.
Trust level
Proportion of patients in each Trust and the total national
sample with documented evidence in their clinical records of
assessment of blood pressure in the last year.
Trust level
Proportion of patients in each Trust and the total national
sample with documented evidence in their clinical records of
assessment of blood glucose in the last year.
Trust level
Proportion of patients in each Trust and the total national
sample with documented evidence in their clinical records of
assessment of lipid profile in the last year.
Team level
Analyses presented in this section were conducted for each clinical
team from your Trust individually, for your total Trust sample and
for the total national sample to allow benchmarking.
Data from each Trust clinical team are presented by code only.
The POMH-UK Central Project Team does not know the identity
of individual teams.
Only the Local Project Team lead for your Trust or organisation
has the key to team codes. You should contact this person if
you need to identify data for your own particular team.
Team level
Proportion of patients receiving antipsychotic treatment for
under a year (n=12) in each team for whom the indication for
antipsychotic prescribing is clearly documented
Team level
Proportion of patients receiving antipsychotic treatment for
over a year (n=9) in each team for whom the continuing need
for antipsychotic medication was reviewed in the last year
Team level
Proportion of patients in each team and the total national
sample with documented evidence in their clinical records of a
general assessment of side effects in the last year.
Proportion of patients in each team and the total national
sample with documented evidence in their clinical records of
assessment of EPS in the last year.
Proportion of patients in each team and the total national
sample with documented evidence in their clinical records of
assessment of weight change in the last year.
Proportion of patients in each team and the total national
sample with documented evidence in their clinical records of
assessment of blood pressure in the last year.
Proportion of patients in each team and the total national
sample with documented evidence in their clinical records of
assessment of blood glucose in the last year.
Proportion of patients in each team and the total national
sample with documented evidence in their clinical records of
assessment of lipid profile in the last year.
What happens next?
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Your Trust’s Local Project Team Lead (LPTL)
has a copy of the full report, please ask
them for a copy to see these findings in
more detail.
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POMH will consider developing bespoke
change interventions to be provided to each
participating Trust, including opportunities
for sharing good practice.
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A re-audit will be conducted in January
2011.
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If you have any questions, please ask your
LPTL or email POMH
[email protected]
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