21^st April 2017

Re: Health, Social Care and Sport Committee Consultation – Use of anti-psychotic medication in care homes

The Dementia Services Development Centre at Bangor University is well-placed to advise the committee on the research evidence regarding this issue. Professor Bob Woods, the DSDC director was a member of the NICE-SCIE Guideline Development Group, which produced the current guidelines for the management of dementia, published in 2006, which emphasise that anti-psychotic medication should only be used as a last resort, in situations of extreme distress, and that use should be short-term with regular reviews. He authored the 1000 Lives Plus ‘How to’ guide for the NHS in Wales on dementia care, which includes recommended actions to reduce the inappropriate use of anti-psychotic medication.

From 2010-2016, Professor Woods has been a co-investigator on a major programme grant, funded by NIHR, “An Optimized Non Pharmacological Intervention to Improve Mental Health, Quality of Life and Health amongst People with Dementia in Care Homes”, led by Jane Fossey (Oxford) and Clive Ballard (Exeter). Fossey and Ballard had previously shown that training care home staff in person-centred care, combined with review of anti-psychotic medication led to a dramatic decrease in use of medication (British Medical Journal, 2006, 332(7544), pp.756-761). This approach has subsequently been implemented further by the Alzheimer’s Society, who funded the original research, as the FITS programme, with good results (Brooker et al., 2016, Aging & Mental Health, 20(7), pp.709-718).

Publications from the initial phase of the WHELD programme (Ballard et al., 2015, American Journal of Psychiatry (on-line) doi: 10.1176/appi.ajp.2015.15010130) examined a variety of approaches in 16 care homes in England, involving 277 residents. The findings showed that simply reviewing anti-psychotic medication could be detrimental (in terms of both mortality and neuropsychiatric symptoms), unless combined with a psychosocial intervention (of greater intensity than the person-centred care that was the focus of the FITS programme). They identified that rates of use had fallen in care homes since their 2006 study, and so even greater care is needed in order to ensure that alternative approaches are available, involving increased social activities or exercise, for example.

Results from the full WHELD study, involving over 1006 people living with dementia in 70 care homes are not yet fully published, but the indications are that the combination of psychosocial intervention and anti-psychotic review is successful in reducing agitation and is associated with less use of anti-psychotics and other medication (Ballard & Fossey, 2016, Alzheimer's & Dementia: The Journal of the Alzheimer's Association, 12(7), p.P599).

In conclusion the research evidence is clear – staff must be trained and supported in delivering psychosocial interventions – tailored to the individual’s interests and preferences – in combination with regular review (with a view to reduction) of anti-psychotic medication. The WHELD training model, which trains and supports dementia WHELD champions in each care home, appeared to be effective.

Copies of the papers referred to above can be made available to the Committee on request.

Yours sincerely,

Bob Woods

Professor of Clinical Psychology of Older People

Director, DSDC Wales