Transcript Antipsychotic use in Dementia Patients

Prescribing of
Antipsychotic Medication
in Patients with Dementia
Powys-wide, Primary care audit
Rhiannon Davies, Powys tHB Medicines
Management Team
 Dementia is a family name for a number of
disorders. All have in common a loss of memory
and other intellectual functions and a reduction in
the persons ability to care for himself/herself,
often accompanied by emotional changes and
disturbances in behaviour
 The most common form of dementia is
Alzheimer’s disease, accounts for around 60% of
all cases; two other most common dementias are
Vascular Dementia and Dementia with Lewy
bodies. These account for 15–20% of cases each.
Behaviours that challenge are a major cause
of distress to patients and their carers, and a
frequent reason for transfer to nursing home
care
People with dementia who develop noncognitive symptoms or behaviours that
challenge should be offered drug treatment
ahead of non-drug interventions only if they
are severely distressed or there is immediate
risk to themselves or others
Benefits of antipsychotics are small and
offset by an increased risk of
cerebrovascular events and death, but can
be used after full discussion of the
risks/benefits with the person with dementia
and/or their carers, and with frequent reviews
Background
In 2004, CSM published guidance
highlighting the effects of regular use of
Antipsychotics in elderly patients with
dementia.
Nov 2006, NICE/SCIE issued guidelines
(CG42). on the management of patients with
dementia. Included a chapter on
‘interventions for non-cognitive symptoms
and behaviour that challenges’
April 2008, the All Party Parliamentary Group
on Dementia produced ‘Always a last Resort’
Banerjee report, Time for
Action, Nov 2009
 Unacceptable level of people dying as a result of
prescribing antipsychotics
 Clear evidence that they are currently being over
prescribed
 Alternative, non-pharmacological approaches to
dealing with anxiety and behavioural problems
should be used first-line
 Recommendations for prioritisation, improvements
in leadership, audit, training of staff and
improvements in services offered to people with
dementia were accepted by the Secretary of State for
Health in November 2009.
What’s happening in Wales
National Dementia Action Plan for
Wales
1000 Lives Plus - Improving
Dementia Care.
1000 Lives plus Driver- Reducing
inappropriate use of antipsychotic
medications in accordance with
NICE/SCIE guidelines
Antipsychotic Usage
240.00
220.00
200.00
Aneurin Bevan - GP - [DB1]
Cwm Taf - GP - [DB1]
180.00
Hywel Dda - GP - [DB1]
160.00
Betsi Cadwaladr Uni - GP - [DB1]
140.00
Powys Teaching - GP - [DB1]
Cardiff And Vale Uni - GP - [DB1]
120.00
Nov/2010
Sep/2010
Jul/2010
May/2010
Mar/2010
Jan/2010
Nov/2009
Sep/2009
Jul/2009
May/2009
Mar/2009
Jan/2009
Nov/2008
100.00
Sep/2008
Items per patient (annual)
Abertawe Bro Morgannwg Uni GP - [DB1]
Aim of the audit:
To establish whether antipsychotics are
being prescribed for the treatment of
behavioural and psychological symptoms of
dementia (BPSD) within the existing
guidelines.
NICE/SCIE guidance: “antipsychotic drugs
should only be prescribed when a person is
a risk to themselves or others, and where all
other methods have been tried. This should
be for a short period of three months only,
whilst a care plan is put in place”.
Audit: inclusions and
exclusions
Inclusions: All patients over the age of
65 diagnosed with dementia who have
been prescribed an antipsychotic in the
past 12 months
Exclusions: Patients with a diagnosis of
schizophrenia or other psychosis
Audit criteria: NICE/SCIE
Anti-psychotics should only be considered
for severe non-cognitive symptoms
Target symptoms have been identified,
quantified and documented and regularly
assessed
Benefits of treatment have been discussed
and recorded with patient or carer
Treatment is time-limited and regularly
reviewed
Search Criteria
Patient ID
Residence - Residential home, Nursing home, own home
Diagnosis
Anti-dementia medication prescribed
Name and dose of Antipsychotic
medication prescribed and date started
Who initiated?
Record of challenging behaviour?
Search Criteria
 Documented record of severe stress or
immediate risk of harm to themselves or others?
 If no record of challenging behaviour, reason
initiated (name)?
 Benefits and risks of treatment discussed and
recorded?
 Evidence of review/assessment every 3 months?
 Who is reviewing/managing the patients care
routinely?
 June 2010, all medical practices in Powys asked
to audit their prescribing of antipsychotics for
patients with dementia.
 To date, responses have been received from 12
of the 17 Practices (88 patients).
 Data to patient level has been received from 10
of these (70 patients).
 Patient numbers highest around those practices
with Community EMI beds (Brecon, Llandrindod
and Builth Wells).
Powys recorded diagnosis
Patients on antipsychotics
Initiated by GP
Initiated by specialist
Number in Care homes
Record of challenging behaviour
Record of stress or harm
Risks benefits discussed
Patients on antipsychotics >3m
Regular review of treatment
last review by GP
last review by 2 care
Total
88
21
56
66
74
35
16
86
46
58
33
Percent
23.9%
63.6%
75.0%
84.1%
39.8%
18.2%
97.7%
52.3%
65.9%
37.5%
Average length of treatment 786 days
(2.15 years);
• Min treatment length 2 days, Max treatment
length 2225 days (6.10 years)
Only 9 patients concurrently taking
medication for dementia.
1 patient has dementia with Lewy bodies
and is taking Haloperidol 3mg BD, despite
increased safety concerns about using
these drugs in this type of dementia.
35 patients (of 70 analysed) had regular
reviews.
• Of these, 12 were managed by GPs
(irrespective of who initiated treatment).
• Average treatment length 733.77 days
35 also had no regular review.
• Of these, 25 were managed solely by GPs.
• Average treatment length 839.06 days
 27 patients were reviewed by a mixture of GPs, CPNs
and Consultants:
• Average Treatment length 786.41 days (min 112.00
days, max 1784.00 days)
 37 reviewed by GP only:
• Average Treatment length 816.27 days (min 108.00
days, max 2007.00)
 Unclear who is reviewing 6 patients:
• Average treatment length 707.17 days (min 2.00
days, max 2225.00 days)
amisulpiride
haloperidol
olanzapine
promazine
quetiapine
quetiapine +
pericyazine
risperidone
 Despite advice going back to 2004, antipsychotics continue to
be prescribed for patients with dementia outside of guidelines.
 Less clear whether these are prescribed as a “last resort”,
although it does seem that prescribing is not short term (but we
didn’t measure the number of patients with dementia who only
received short courses).
 Half of patients (35 of 70) audited do not have a regular review,
and of these most (25) are managed solely by a GP.
 When care is shared between GPs and CMHT / consultants,
reviews appear to be more frequent.
 Need also to identify if patients have care plans?
 Do patients / GPs have access to the “alternative methods of
managing behavioural problems” mentioned in the report: if
not, will this evidence provide the spur for developing these
services?
 Dementia management will form part of the GPs
Quality and Outcomes Framework (QOF) for
20011/12
 Presentation to be made at next Primary Care
Drugs and Therapeutics Committee
 To discuss the outcomes
 To discuss and identify where the issues lie
 To identify what support GPs require in
implementing the Guidelines
 To identify what other measures need to be put in
place to improve the quality of care of this
vulnerable patient group.
Good Practice: Brecon
Medical Practice
First undertook Audit: Nov 2009
Re-audited in June 2010, Next re-audit
scheduled July 2011
41 patients were included in one or both of
the audits (41 in first and 32 in second)
Comparing data: 9 patients’ doses had been
reduced and 2 had stopped
Care home GP devised staff template for
monitoring behavioural and psychological
symptoms of dementia, ongoing use.