More recently, there has been increasing evidence questioning the safety of the use of antipsychotics for the treatments of BPSD. These of such drugs has been shown to increase the risk of falls, accidents, strokes and death, in addition to other side effects associated with the use of antipsychotics.
NICE guidance on dementia states that antipsychotic drugs should not be used for mild to moderate non-cognitive symptoms in dementia because the increased risk of cerebrovascular events and death.
Antipsychotics should only be considered for severe non-cognitive symptoms or behaviours where there is immediate risk of harm to the person with dementia or others and when:
• Risks and benefits have been fully discussed including the assessment of risk factors for stroke and the possible increased risk of stroke/transient ischemic attack and possible adverse effects on cognition.
• Changes in cognition are regularly assessed and recorded.
• Target symptoms have been identified, quantified and documented, and changes are regularly assessed and recorded.
• Co-morbid conditions such as depression have been considered.
• The drug is chosen after an individual risk benefit analysis.
• The dose is started low and titrated upwards carefully.
• Treatment is time limited and regularly reviewed (every three months or according to clinical need).
In response to the Banerjee report, the Department of Health introduced a target of reducing the use of antipsychotics by two-thirds within the revised national dementia strategy.
Within BSMHFT, we have developed prescribing guidance for the treatment of BPSD as well as an overall guideline for the treatment of BPSD which includes psychological therapies. Several staff training sessions have also been provided.
Pharmacy services have also audited the use of antipsychotics in dementia within inpatient services on a regular basis since August 2010. Since the first audit, there has been a 40 per cent reduction in the use of antipsychotics in patients with dementia within inpatient wards in BMHFT.
With regular audit and feedback, we have also observed improved documentation, medication review and the review of antipsychotics inpatients with dementia. There has also been an overall dose reduction among patients who have remained on antipsychotic treatment.
Earlier this year, the trust participated in the national Prescribing Observatory for Mental Health (POMH-UK) audit on the prescribing of antipsychotics for people with dementia. This showed that the trust’s use of antipsychotics in patients with dementia was in line with the national average.
The trust performed well on the documentation of indications, factors that affect symptoms of BPSD and medication reviews for long term patients. The audits also showed the trust can improve on the documentation of the risk benefits analysis for the use of antipsychotics in dementia and to take account more fully of the potential adverse effects from antipsychotics in patients with dementia.
Having made significant improvements to the use of antipsychotics in dementia within inpatient services, we will be focusing on the prescribing of antipsychotics in dementia within our older adults CMHTs in the coming year, providing more pharmacy input to facilitate this. This will further contribute to improvement already made in inpatient areas and support the wider improvement in the use of antipsychotics in dementia across the community.
Other activities which will support the overall reduction in inappropriate use of antipsychotics in dementia include:
- Training for prescribers in the use of antipsychotics in dementia.
- The training of care home staff and domiciliary care staff in the treatment of symptoms of BPSD.
- Critical medication review of patients with dementia who are taking antipsychotics focusing on the following:
- The target symptoms and indications for antipsychotics in patients with dementia and BPSD.
- Careful assessment of the risk of stroke and stroke or transient ischemic attacks.
- The impact on cognition in these patients.
- An assessment of the adverse effects experienced by patients on antipsychotics.
- The dose of antipsychotic.
- Concomitant use of other psychotropic agents which may contribute to adverse effects or increase the risk of falls / accidents.
Most importantly, before prescribing antipsychotics, should be the consideration of non-pharmacological treatments in the treatment of BPSD including the treatment of any causative physical disorders such as pain, UTI, constipation, optimisation of hearing and aids and glasses, music therapy, more daytime activities and improvements to the care environment.
Update by:
Nigel Barnes, director of pharmacy and medicines management
