AWTTC response to Health, Social Care and Sport committee consultation: “Use of anti-psychotic medication in care homes”
1. The availability of data on the prescribing of anti-psychotics in care homes, to understand prevalence and patterns of use
Data to inform prevalence and patterns of use of antipsychotics in care homes would need to be captured at patient level. Resources such as CASPA and Medusa which record medicines usage data for Wales would not provide sufficient detail with regards to patient demographics and treatment indication.
The data required to address the questions of prevalence and patterns of use would need to consider the following:
a. Is the patient a care home resident?
b. Is the patient prescribed an antipsychotic?
c. What is the indication for which the antipsychotic is being prescribed?
In addition to use for behavioural symptoms of dementia, antipsychotics may be prescribed for a range of psychiatric illnesses including psychosis (such as schizophrenia), bipolar disorder, and as an adjunct to antidepressants. In order to capture prevalence data for the use of antipsychotics for behavioural symptoms of dementia, use in these other indications would need to be identified and excluded.
None of the data in points a–c above would be available via CASPA or Medusa. Therefore it may be necessary to capture data directly from GP practices, using systems such as Audit Plus or on a national level perhaps from the Secure Anonymised Information Linkage (SAIL) databank co-ordinated via Swansea University.
Feedback from one health board indicates that audit work to identify antipsychotic usage in care homes has taken place in both primary and secondary care as part of the 1000 lives Dementia pathway. However, data was not complete and it was hard to identify patterns of use as data were drawn from GP practices rather than from care homes themselves. An audit based on care home data is in place for 2017. Secondary care audit data is being used to identify variation in prescribing across hospital sites.
2. Prescribing practices, including implementation of clinical guidance and medication reviews
In order to assess prescribing practices and identify whether or not they are in line with clinical guidance, additional data would need to be collected. This could include aspects of the following:
a. If an antipsychotic is prescribed for the treatment of behavioural symptoms of dementia, has a full discussion with the patient and/or carers taken place as described in NICE CG42?
b. Which antipsychotic is prescribed?
Although the antipsychotic risperidone has marketing authorisation for short term use in aggressive behaviour associated with Alzheimer’s dementia, NICE CG42 does not currently recommend a particular antipsychotic for the treatment of behavioural and psychological symptoms of dementia (BPSD). Instead, it states that the choice should be based upon an individual risk-benefit analysis. There are some (albeit observational) data which suggest that the nature of the risk associated with individual antipsychotics may vary (e.g. Gerhard et al 2014; see also Trifiro et al 2014 for review) and that more robust evidence may help to improve patient safety in this regard.
c. What dose of antipsychotic is prescribed?
NICE CG42 states that the dose should be low initially and then be titrated upwards. It has been shown that there is a relationship between antipsychotic dose and risk of mortality with higher doses associated with an increased risk of mortality (Gerhard et al 2014).
d. What is the duration of treatment?
e. Has the ongoing need for treatment been reviewed at regular intervals?
NICE CG42 states that treatment should be time limited and regularly reviewed. A Prescribing Observatory for Mental Health (POMH-UK) audit of UK mental health services conducted in 2011 suggested that the quality and frequency of medication review was an area for improvement (Barnes et al 2012).
As described above, patient level data would be required to answer these questions. Data from the UK suggest a reduction in the mean prevalence of antipsychotic use following a dementia diagnosis from 19.9% in 1995 to 7.4% in 2011 (Martinez 2013).
Feedback from one health board indicates that medication reviews for care home residents are included as an enhanced service in primary care. In some areas pharmacists are supporting medication reviews and undertaking audit and training for care home staff. In secondary care, consultants have agreed health board guidance on prescribing antipsychotics and ongoing audits are in place to monitor compliance. Ongoing audits will be carried out for inpatient units to monitor improvements against action plans. This is supported by the dementia audit group. Guidance on prescribing antipsychotics in dementia will be extended to support primary care reviews.
3. The provision of alternative (non-pharmacological) treatment options
Feedback indicates that training related to non-pharmacological management of behavioural symptoms of dementia is available in at least one of the health boards. All inpatient (secondary care) dementia wards have activities co-ordinators that provide personalised therapy and activities to reduce stress and agitation.
4. Training for health and care staff to support the provision of person-centred care for care home residents living with dementia
Feedback indicates that e-learning material is available for care home staff in at least one of the health boards. Training through Practice Development team includes mental health awareness, falls and dementia. Secondary care liaison nurses provide advice to care home staff, however there is no capacity for secondary care staff to provide training to care home staff.
The provision of a national e-learning package through the NHS Wales e-learning system would seem a useful resource for NHS and care home staff.
5. Identifying best practice, and the effectiveness of initiatives introduced so far to reduce inappropriate prescribing of anti-psychotics
Identification of best practice in primary care could be facilitated through national groups such as the All Wales Prescribing Advisory Group, as well as through prescribing leads and primary care pharmacists at a local level. The All Wales Therapeutics and Toxicology Centre is organising a primary care best practice day in June 2017, which will include a presentation from a secondary care mental health pharmacist with experience of antipsychotic review. Due to the limitations of available routine data described above, monitoring the effectiveness of initiatives to reduce inappropriate prescribing would require capturing information at a patient level (for example through the use of audit or SAIL data).
Feedback from one health board indicates that an indication and review date will be added to every antipsychotic prescription for challenging behaviour in dementia in that area. A proforma to improve communication on discharge and ensure that an indication and review date is included on any transfer of care documentation has been established in secondary care. The effectiveness of this intervention will be monitored through audit. Collaborative working between care homes, GPs, pharmacists, nurses and consultants have demonstrated reduction in inappropriate antipsychotics however the model was not sustainable.
6. The use of anti-psychotic medication for people with dementia in other types of care settings
The appropriate monitoring and review of antipsychotic treatment in patients with dementia should apply to all patients no matter what the care setting.
Feedback from one health board indicates that all of the above measures apply equally to other care settings and the audit of antipsychotic use in dementia will include patients in all care settings. A leaflet will be available in ward settings and offered to carers to raise awareness of the risks and benefits of using antipsychotics in dementia. The provision of this leaflet will be documented in patient records, and consideration given to ways of monitoring service user feedback.