Antipsychotic prescribing for people with dementia

Vijay Bhatia 
Eureka Place, Ashford

Purpose

Audit report prepared for the Memory Service National Accreditation Programme (MSNAP), Royal College of Psychiatrists (1).

Aim

To audit the case notes for the use of antipsychotic drugs in people with dementia and to compare with the standards of MSNAP.

Background/rationale

British National Formulary (2) guidance on prescribing antipsychotic medication for the elderly:

The balance of risks and benefit should be considered before prescribing antipsychotic drugs for elderly patients. In elderly patients with dementia, antipsychotic drugs are associated with a small increased risk of mortality and an increased risk of stroke or are particularly susceptible to postural hypotension and to hyper- and hypothermia in hot or cold weather.

It is recommended that:

  • Antipsychotic drugs should not be used in elderly patients to treat mild to moderate psychotic symptoms.
  • Initial doses of antipsychotic drugs in elderly patients should be reduced (to half the adult dose or less), taking into account factors such as the patient’s weight, co-morbidity, and concomitant medication.
  • Treatment should be reviewed regularly.’

The Department of Health (DoH) report, written by Professor Sube Banerjee (3): ‘The use of antipsychotic medication for people with dementia: Time for action’ was published in November 2009. It highlighted a need to ensure that antipsychotic drugs are only prescribed to people with dementia when necessary.

The National Dementia and Antipsychotic Prescribing Audit (4) is commissioned by the DoH and delivered through the Health and Social Care Information Centre:  ‘The use of antipsychotic medication can lead to serious side effects for people with dementia. The Government has made a commitment to reduce the inappropriate prescribing of antipsychotic medication for people with dementia.  The audit collects information from GP practices on the prescribing of antipsychotic drugs for people with dementia.

The audit aims to:

  • Provide publicly available information on the current prescribing of antipsychotic medication for people with dementia.
  • Provide information to support the Government’s commitment to reduce the inappropriate prescribing of antipsychotic medication.
  • Help GP practices identify where services can be improved.

The Memory Service National Accreditation Programme (1) has set standards for the use of antipsychotic drugs for people with dementia and advises that local audit of the prescription of antipsychotic drugs for dementia should be evidenced for Memory Service National Accreditation.

Methodology

Standards were taken from the Memory Service National Accreditation Programme:

‘MSNAP Standard 5.2 – Antipsychotics are only prescribed as a last resort, after a thorough assessment of risk factors, and their use is reviewed regularly.

MSNAP Standard 5.2.1 – People with dementia who develop psychotic symptoms or behaviour that challenges are only offered antipsychotic medication when the severity and associated risks are high and when other options have been considered and excluded.

MSNAP Standard 5.2.2 – Where antipsychotic medication is given, this prescription is recorded and a single, named individual is responsible for undertaking a review. When stabilised on medication, review should take place at least every 3 months.’

Sample:

Time frame: 1st June 2015 to 30th June 2015.

Sample Frame: All clients seen by the Consultant Psychiatrist Dr Andrew during the month of June 2015.  These patients include patients reviewed in the outpatient clinic and during home visit to client homes, residential and care homes, but excludes inpatients under Dr Andrew’s care on Cranmer ward St Martins Hospital Canterbury.

Electronic patient records (RiO) were audited to identify clients on antipsychotic medication. Further examination involved identifying the diagnosis and, in particular, whether a patient has a diagnosis of dementia. Any client who has a diagnosis of dementia and was found to be on antipsychotic medication had their case notes further examined to record their last review date. Letters to the general practitioner were reviewed to identify the reasons for use of antipsychotic medication and justify that other alternatives have been examined or tried. Their last review was recorded to identify clients for the purpose to see if the standard of the MSNAP has been achieved regarding review once every 3 months.

Clients reviewed by other medical practitioners in Ashford CMHSOP were not included in this audit and will be subject of a further separate audit.

Exclusions: Clients who are inpatients on acute psychiatric units.

Results

Total number of case records audited: 61

Total number of clients on antipsychotics with any diagnosis: 7

Total number of clients on antipsychotics with functional diagnosis: 5

Total number of clients on antipsychotics diagnosed with dementia: 2

Total number of clients on antipsychotics who have a diagnosis of dementia and have been reviewed in the last 3 months: 0

Discussion

People with dementia can have psychotic symptoms and challenging behaviours and would need management. The guidelines and standards stipulate that antipsychotics should be used as a last resort due to its potential side effects on mortality and incidents of stroke leaving them with disability. The aim is to consider other alternatives in the management of psychotic and challenging behaviours in patients with dementia.

This audit has highlighted that, although antipsychotics are used only in 2 cases, their last review was not in the last 3 months.

Limitations

This audit sample is selected from the diary of one clinician only and during one month period only. This audit may not represent all relevant clients.

Recommendations/Action Plan

  • Clients identified in the audit not meeting the required standard will be reviewed.
  • The same audit will be conducted for clients seen by the other 3 medical practitioners in Ashford CMHSOP in the month of June 2015.
  • A re-audit will be conducted in 2015
  • Review of clinicians’ caseloads to ensure that required standards are met for all clients with dementia who receive antipsychotic medication.

References

  1. Hodge S, Hailey E, Orrell M. Memory Services National Accreditation Programme (MSNAP) Standards for Memory Services. London: Royal College of Psychiatrists. 2014.
  2. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press <http://www.medicinescomplete.com> [Last accessed on 02/08/17]
  3. Banerjee S. The use of antipsychotic medication for people with dementia: Time for action. London: Department of Health. 2009 Nov:5.
  4. Department of Health: National Dementia and Antipsychotic Prescribing Audit National Summary Report 17/07/12 https://www.digital.nhs.uk/catalogue/PUB06624 [last accessed on 02/08/17]