Transcript Mental Health Update

1000 Lives + Improving medicines
management / Dementia Driver 3
1st May 2012
Multidisciplinary team
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Team meet every 6 -8 weeks to review progress and
agree ongoing actions and interventions.
At present group includes:
Consultant psychiatrist (Older People, Swansea)
Staff grade doctors x 2 (Swansea and Neath Port
Talbot)
CPNs x 2 (Swansea and NPT)
Pharmacists x 3 (from each locality and mental health)
Pharmacy technician x 1 (NPT locality)
Work plan agreed
Baseline data collection
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Data was collected from the following:
6 GP practices ( 2 from each locality)
Collected in April – May 2011.
In addition, a set of 37 case notes from a
CMHT in Swansea were audited to collect
similar information, between October 2010 and
April 2011
Combined Results for common data
Number of
patients
Number of patients with dementia audited
362
Number of patients with dementia,
prescribed an antipsychotic
104
28.7%
Number of patients on an antipsychotic,
reviewed in last 3 months
50
48.1%
Discussion of risk / benefit with patient
and/ or carer
3
2.9%
Psychotic symptoms (including delusional
or paranoid ideas, aggression)
23
22.1%
Restless /agitated (including at night)
38
36.5%
Unknown
43
41.4%
% of
patients
Indication for the antipsychotic:
Pilot Sites
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5 ‘pilot ‘ sites have been identified:
Site 1: Care Home in Neath Port Talbot Locality
Site 2: GP practice in Neath Port Talbot Locality
Site 3: Cohort of patients from CMHT Swansea
Site 4: Care home in Swansea Locality
Site 5: GP Practice in Bridgend Locality:
Process measures
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Initial audit done in 3 pilot sites so far, and reaudited in 2
Some results shown in table on next slide
Progress will be monitored by re-auditing
process measures will be audited every 3/12
Measure
Result
For how many patients is the following is
documented?
Site 1
Site 2
Site 3
1. Indication for the antipsychotic
100%
89%
88%
2. A full discussion has taken place with the patient
and/or carer about benefits or risks of treatment
100%
53%
11%
3. The clinical need for the antipsychotic has been
reviewed in the last 3 months
100%
32%
44%
4. An attempt to reduce the dose or stop the
antipsychotic
33%
16%
55%
5. Other approaches have been tried before
antipsychotic medication is initiated
100%
68%
33%
Compliance with care bundle (all 5 above
interventions documented)
100%
0%
0%
Variation across 3 localities
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Different approaches are being used within
each locality
Due to different service models in place
Brief update for each ......
Antipsychotic Prescribing for
Older Adults
Dr Robert Colgate
Consultant Psychiatrist
Bridgend, April 2012
Background
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Potential problems with antipsychotic
medication have been clearly described:
Committee on Safety of Medicines (2004)
Identified risk of stroke damage
Department of Health or “Banerjee” report
‘recommendations (to) reduce the use of these
drugs to the level where benefit will outweigh
risks (page 6)’ 2009
Bridgend Care Home In-Reach
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Old Age Liaison Psychiatry service established
in late 2009 at Princess of Wales Hospital
Multidisciplinary Care Home In Reach team
identified ‘drugs of interest’
Antipsychotics, lithium and drugs for dementia
Baseline survey of antipsychotic use within the
local residential and nursing care homes
Statistics
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August 2009: ~ 800 care home residents
36% prescribed antipsychotic medication
August 2010
33% prescribed antipsychotic medication
August 2011: ~ 850 care home residents
33.5% prescribed antipsychotics
(285 individuals)
Percentage of Care Home Residents Prescribed Antipsychotics
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
2009
2010
40.00%
2011
30.00%
20.00%
10.00%
0.00%
CH1
CH4
CH7
CH10
CH13
CH16
Care Home Code
CH19
CH22
CH25
CH28
Number of Residents Prescribed Antipsychotic Medication (August 2011)
45
40
Number of Residents
35
No of those
prescribed
antipsychotics
without a dementia
diagnosis
30
25
20
No of those
prescribed an
antipsychotic
with documented
dementia diagnosis
15
10
5
0
CH27
CH25
CH23
CH21
CH19
CH17
CH15
CH13
CH11
CH9
CH7
CH5
CH3
CH1
Care Home Code
Examples
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75 year man with
moderate dementia and
previous history of
aggression associated
with hallucinations.
Remains irritable …
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75 year woman with mild
dementia and history of
mild agitation associated
with transition into care
home setting.
Now oversedated …
A Mantra … ?
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Indiscriminate reduction or discontinuation of
antipsychotics is hazardous …
1000 Lives+ Campaign (Wales)
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Aim: to reduce inappropriate prescribing of
antipsychotics in adults with dementia
Objective: establish safe reduction strategy
Relevant to Driver 3 of Intelligent Targets for
dementia and also Medicines Management
A Good Intention …
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Establish a simple and systematic means of
describing the antipsychotic prescription
Summarised as …
… an antipsychotic statement
Antipsychotic Statement
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Any decision to alter a prescription of
antipsychotic medication should be based on:
Knowledge of diagnosis
Knowledge of target signs and symptoms
Frequency of the target signs and symptoms
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… so that an assessment of risk can be made
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Antipsychotic Statement
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Optimum management should include follow
up in written documentation
Specifically when and by whom …
Bridgend Care Home In-Reach
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Regular monthly care home visits since 2010
Annual survey (August) of antipsychotic
prescribing across twenty four care homes
Traffic light system of individual reviews
Introduction of ‘embedded’ antipsychotic
statements in mid 2011
Work in progress to incorporate into Care and
Treatment plan documentation
Examples
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75 year man with
moderate dementia and
previous history of
aggression associated
with hallucinations.
Remains irritable …
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75 year woman with mild
dementia and history of
mild agitation associated
with transition into care
home setting.
Now over sedated …
Examples
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This antipsychotic is prescribed for a diagnosis
of dementia with psychotic symptoms,
specifically delusional misidentification of care
home staff, which are still present
The dose should be increased to xxmg and will
next be reviewed by the Care Home In Reach
team in the care home in one month
Examples
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The antipsychotic is prescribed for a diagnosis
of dementia associated with anxiety and some
agitation in September 2011, symptoms which
are no longer evident
The antipsychotic should be withdrawn now
and the situation will be reviewed by telephone
contact by the Care Home In Reach team in
two weeks
Neath Port Talbot
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Care Home Liaison Nurse reviews patients in
care homes and makes recommendations to
medical staff based on her findings
Working more closely with locality medicines
management team
Auditing process measures in 2 pilot sites
Care Home- Neath Port Talbot
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Process measures audited
Patients reviewed regularly by CPN
Results showed 100% compliance
Continue to audit process measures to ensure
these are maintained.
GP Practice- Neath Port Talbot
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Process measures audited for patients with
dementia and on antipsychotic
Several patients not reviewed
Pharmacist discussed results with consultant
Records/ notes checked ? reviews done
Communication with GPs identified as an area
for improvement
2 patients highlighted as needing a review
NPT
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Some patients had been reviewed, but if no
change to medication was required, evidence
of review not communicated to GP practice
Info needs to be sent to GPs whether
medication changed or not
Improvement noted in results
Process Measures NPT Practice
100.00%
90.00%
80.00%
% Comliance
70.00%
60.00%
01/09/2011
01/02/2012
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
% patient with % Indication
dementia on documented
antipsychotic
% where
discussion
about risks
and benefits
carried out
%
% Attempt to
% Other
% Has patient
Antispychotic reduce or stop approaches
received
reviewed in antipsychotic tried before antipsychotic
last 3/12
antipsychotic
>9/12
prescribed
Measure
Swansea- CMHT
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Process measures audited for a cohort of
patients
Repeated after 3 months
Using medication review stamp in patients
case notes
Perception that practice has changed
regarding prescribing of antipsychotics
1000 lives + Dementia Driver 3
Antipsychotics in Dementia
Dr Priyadarshini M Rangappagowda, Dr Heledd Jones, Sue Collis, Dr Liz Clarke-Smith
Department of Old Age Psychiatry, Gangorch Hospital, Swansea, United Kingdom
Introduction
The National Institute for Health and Clinical Excellence (NICE) clinical guidelines for dementia include advice on the appropriate use and ongoing monitoring of antipsychotics
prescribed for Behavioural and Psychological Symptoms of Dementia (BPSD). The Banerjee report (Nov 2010) states ‘potential benefits (of antipsychotics) are most probably
outweighed by their risks overall’. These risks are particularly related to excess cerebrovascular incidents and mortality. Professor Banerjee recommends that reducing the use
of antipsychotics in people with dementia should be a priority for the NHS.
The Welsh Assembly Government (WAG) have also established Intelligent Targets for Dementia and in particular, driver 3, focuses on reducing ain appropriate use of
antipsychotic medications in accordance with NICE dementia guidelines. The Intelligent targets link in with the 1000 lives campaign and a multidisciplinary working group was
established in ABMU LHB to work towards driver 3. The 1000 lives campaign emphasises looking at changes in small cycles which can then be rolled out into the wider
population..
A Swansea audit earlier in the year of patients with dementia living independently in the community revealed that approximately a third were prescribed antipsychotics and of
these 70%had been reviewed on a 3 monthly basis.
It was then decided to focus the audit on a smaller sample living in a care home setting.
Methods
In two Swansea nursing homes, all the patients known to older peoples mental health services suffering from dementia and treated with antipsychotics were identified by manual
identification of case records. A review of the clinical records was undertaken measuring against the standards contained in the WAG Intelligent Targets for dementia as detailed
below.
Results
Two nursing homes
No. of patients
% of patients
Indication for antipsychotic
8
89
For how many patients in the following documented
1
2
Full discussion has taken place with the patient and/or carer about possible benefit or risks of treatment
1
11
3
The clinical need for the antipsychotic has been reviewed in the last three months
4
44
4
An attempt to reduce the dose or stop the antipsychotic
5
56
5
Other approaches have been tried before antipsychotic medication is initiated
3
33
6
Compliance with care bundle (all 5 above interventions documented)
0
7
Discussion
Patients with dementia who have been receiving
antipsychotic medication for more than 9 months
•The risk versus benefit of prescribing antipsychotics for people with dementia is not
routinely discussed with the patient and or carers or that it is not routinely
documented.
•Three monthly reviews in nursing homes of antipsychotic medications are not being
carried out or not being documented.
•Although behavioural approaches are commonly tried, they are probably not being
documented.
100
90
80
0
Measurement summary
89
89
8
89
70
60
50
40
30
56
44
33
20
10
0
11
0
Indication
Dis cus s ion
Review
Reduce/Stop
Other
approaches
Com pliance
More than 9
m
Recommendations
Compliance of the recommended review procedure needs to be highlighted amongst the Older peoples mental health services. A review stamp has been developed to assist this
process.
An educational programme for primary and secondary care staff has been developed and has commenced.
Re-audit on a 3 monthly process to monitor improvements.
Reference
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The use of antipsychotic medication for people with dementia: Time for action by A report for the Minister of State for Care Services by Professor Sube Banerjee
Audit of antipsychotic prescribing in patients with dementia – May 2011.
Welsh Assembly Government 100 lives campaign – Intelligent targets.
NICE Clinical guidelines 42 (amended march 2011).
Re-audit problems
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9 patients in the original cohort
1 patient passed away
8 patients now off listed from caseload
Swansea- Care Home
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Education sessions by CPN
Managing Challenging Behaviour in Dementia
‘Change your life in 53 minutes’
Promising results so far
Plans to audit process measures and engage
GPs
6 month audit results
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6 month audit results of our Challenging behaviour programme at
care home
Psychotropic Medication prescribing and usage : down 76%
Challenging behaviour incidents: down 80%
CPN and Medical staff crisis intervention: down 65%
Heddfan ward admission: from 6 pa to zero.
Data (except medication) is speculative, the biggest differences
are staff attitudes and perceptions.
The medical staff in agreement with the results, verified by the
massive drop they have noticed with unplanned clinical input
Interventions being tested
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Education on prescribing antipsychotics in dementia
for GP’s
Use of an antipsychotic review stamp to improve
documentation of 3 monthly reviews in patients notes.
Standardised consultant letter to GPs in Bridgend,
including a section on antipsychotic prescribing and
review
Use of a patient information leaflet on risks and
benefits of using antipsychotics in dementia
Use of pain assessment tool to identify pain as cause
of agitation
Outcome Measure
Summary
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Lots of work being undertaken in various parts
of ABMU
Difficult to capture everything
Progress being made in some pilot sites
Next steps: to engage care home staff and GP
for pilot site in Swansea