Icgp-education.ie

Antipsychotic prescribing
for dementia patients
Treating the behavioural and psychological symptoms of dementia is a
common example of a difficult prescribing decision, writes Emer Shortall
The NICe guIdelINes oN demeNTIa reCommeNd: "people
with Alzheimer's disease, vascular dementia or mixed
results on prescribing
dementia with mild to moderate non-cognitive symptoms should not be prescribed antipsychotic drugs because Cycle one
Cycle two
of the possible increased risk of cerebrovascular adverse events and death".1 The aim of this audit was to measure the number of No on antipsychotics (APs) patients on antipsychotic medication, the indications for No on APs with a psychiatric initiation, the type of drugs prescribed and how recently diagnosis, eg. schizophrenia the need for the drug had been reviewed. It was hoped to show a reduction in unnecessary prescribing in the second No on APs with review of need for drug in chart in Our practice of three doctors looks after patients in risperidone prescribed St Mary's Hospital in Castleblayney, Co Monaghan a nursing home of 115-130 patients. One doctor from the practice attends the nursing home each day. An audit template was designed using the NICE audit support tool from the NICE olanzapine in mg/day website.2 This template was completed for each patient by chart and drug kardex review in December 2011. quetiapine in mg/day Dr Feargal Leonard, consultant psychiatrist, who also cares for patients in St Mary's Hospital, was consulted before and after the first cycle for input from his team. • 26 patients (67%) were on the medication for more than After the first cycle there was a practice meeting to discuss 12 months and in the case of 13 patients (33%) it was the results, and a policy on antipsychotic prescribing in the unclear how long they had been on the medication nursing home was agreed upon. This included guidelines • 27 (69%) had no reason documented in notes for initia- about starting and discontinuing antipsychotic medication tion, however, many of these patients seem to have been and was based on the NICE guidelines and the best prac- on the drug when they came to St Mary's tice guide from the Alzheimer's Society UK and RCGP.3 • 12 patients (31%) had a reason for drug initiation There was a meeting with the clinical nurse managers of documented. The reasons were agitation, delusions, hal- the nursing home to discuss the results of the first cycle lucinations and schizophrenia and the new policy document. A laminated copy of the • 14 patients (36%) of the patients had a review of drug in policy was given to each doctor and posted on the wall in past year documented in their medical notes.
each ward. The second cycle was completed in May 2012.
Cycle two (see Table 1) • Of 115 patients 24 (21%) of patients were on AP Cycle one (see Table 1) • Of 123 patients 39 (32%) were on antipsychotic (AP) • 20 (83%) patients had a review of the need for the AP • Of these patients nine (23%) had a psychiatric diagnosis • 10 out of 39 patients had had their APs stopped as an indication for the medication, eg. schizophrenia • Three patients had had their AP stopped and then • Of the patients on APs, 28% were on risperidone, 33% restarted because of behavioural problems were on quetiapine and 30% were on olanzapine. The • Two patients had had their dose reduced and then rest of the patients were on haloperidol, amisulpride and • Eight patients had successfully had their dose reduced • 20 (64%) of the patients on APs had a diagnosis of • Four patients on APs had died and one had gone home in dementia documented in their medical notes between the first and second cycle.
Forum December 2012 51
Policy for prescribing antipsychotic medication for dementia*
Policy for prescribing of antipsychotic medication for patients
discontinuation of antipsychotic medication
with dementia in st mary's hospital
If the patient is on a low dose, the drug can be stopped and the Antipsychotics can double the risk of death and triple the risk of patient monitored stroke in people with dementia Examples of ‘low doses': Research suggests if 1,000 patients with dementia were treated with • Olanzapine low dose = 2.5mg antipsychotic medications for 12 weeks there would be: • Risperidone low dose = 0.5mg • An additional 10 deaths • Quetiapine low dose = 50mg • An additional 18 CVAEs If the patient is on a higher dose, taper the dose over one month
1) Antipsychotics should be considered a last resort for the treatment of agitation, wandering, shouting, poor sleep or aggression Step 1: Reduce to half dose for two weeks 2) Before starting any drug treatment, underlying causes for the Step 2: GP review at two weeks behaviour should be considered, eg. infection, depression, pain, medications and environmental factors Step 3: Discontinue immediately after a further two weeks 3) Non-pharmacological treatment should be considered if possible, eg. massage, aromatherapy, multisensory stimulation, animal-assisted therapy, music/dance therapy 4) The drug should be started at a low dose and adjusted as needed 5) The drug should only be continued at the lowest possible dose for the shortest possible time All-Party Parliamentary Group on Dementia. Always a last resort inquiry into the prescription of antipsychotic drugs to people with dementia living in care 6) The reason for initiation and the ‘target symptom' should be homes, April 2008.
recorded in the notes The use of antipsychotic medication for people with dementia: Time for action. A report for the Minister of State for Care Services by Professor Sube 7) The need for continuing the drug should be reviewed three monthly Banerjee 2009.
(eg. when the drug kardex is being rewritten) NICE guidelines on dementia 2006. Optimising treatment and care for people with behavioural and psychological symptoms of dementia. A best practice 8) If the drug dose cannot be reduced or stopped the reason should guide for health and social care professionals. Alzheimer's Society UK.
be recorded in the notes *Adapted from the laminated cards available in St Mary's Hospital to harm (NNH) suggests that 100 people with dementia Percentage increase
would need to be treated to result in one additional death over 6-12 weeks.5 of documented review
A recent editorial in the BMJ stated: "Few clinical prob- lems place doctors in as tangled a web of clinical evidence, social policy, and ethical concerns as how to manage behav- ioural problems in patients with dementia."6 Indeed, treating the behavioural and psychological symptoms of dementia is a common example of a difficult prescribing decision in general practice. Evidence-based guidelines do not always take into account the complexities of a situation involving patient and carer distress and lim- ited resources and staff numbers in a care setting may limit Percentage of patients the non-pharmacological options for treatment. This audit shows that by implementing a policy on initiation % on antipsychotics % with documented review and regular review of antipsychotic medication, prescriptions of need for antipsychotic can be significantly reduced (see Table 3). emer shortall is a third-year gP trainee with the North-east gP
The rate of antipsychotic prescribing of 32% in the first Training scheme, Castleblayney, Co monaghan
cycle is comparable to previous studies in the UK and US where it was found 30% of patients in nursing homes were on antipsychotics.4 With thanks to Dr Mary O'Duffy, Dr Michael Clarke and Risperidone is the only antipsychotic licensed to treat Dr Feargal Leonard. This paper won first prize at the North behavioural and psychological symptoms of dementia East GP Scheme audit meeting June 2012. (BPSD) in Ireland. The European Medicines Agency (EMEA) and UK Medicines and Healthcare products Regulatory References1. Dementia NICE guidelines 2006.
Agency (MHRA) have issued warnings about the increased 2. Dementia: the use of medication for non-cognitive symptoms, behaviour risk of stroke and death and in 2005, the Food and Drug that challenges and behaviour control. NICE audit support tool 2009. 3. Optimising treatment and care for people with behavioural and psycho- Administration (FDA) issued a ‘black box' warning. logical symptoms of dementia. A best practice guide for health and social There is evidence to suggest antipsychotics can help care professionals, Alzheimer's society UK.
4. Time for action, A report for the Minister of State for Care Services by BPSD but the effect is very small. The number needed to Professor Sube Banerjee. treat (NNT) to achieve improvement in one behaviourally 5. Time for action, A report for the Minister of State for Care Services by Professor Sube Banerjee.
disturbed patient range from five to 11. The number needed 6. BMJ editorial 2012;344:e1093 52 Forum December 2012

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