Audit of psychotropic medication prescribing in EMI nursing homes in Monmouthshire Dr Pauline Ruth Dr Rui Zheng Dr Arpita Chakraborty Dr Usman Mansoor

Literature search  Dementia and BPSD are common in care homes.  Various psychotropic drugs are commonly used, despite weak evidence of efficacy.  40% of prescriptions for residents in nursing homes may be inappropriate.  21% received a recent prescription of antipsychotics in England and Wales. (Shah et al 2011)  elderly residents in care homes without severe mental illness receive antipsychotics. (Shah et al 2011)  Benzodiazepine use in nursing homes is another major concern % in Australian NHs (Westbury et al 2010)

Literature search What will help?  Davidsson et al 2011: Medication reviews conducted by MDTs can reduce the number of drugs and the number of drug related problems  Forsetlund et al 2011: Educational outreach On-site education given alone or as part of an intervention package Pharmacist medication review

In Monmouthshire  4 EMI nursing homes: 154 residents  4 EMI residential homes

Audit aims  To ascertain whether psychotropic medication prescribing in EMI nursing homes is in keeping with NICE/SCIE guidelines. Includes: antipsychotics, antidementia drugs, antidepressants, mood stabilizers, and benzodiazepines.  To ascertain the level of awareness of staff at the nursing homes re monitoring BPSD and side effects of psychotropic medication.

Audit Standards

Audit standards: In dementia patients with BPSD Standards were based on NICE-SCIE guidelines on Dementia (CG42):  Standard 1: Non-pharmacological interventions should be offered as first line in all cases.  Standard 2: Target symptoms should be identified, quantified and documented in all cases.  Standard 3: If patients are prescribed antipsychotics there should be documentation of severe distress or of immediate risk of harm to themselves or others.  Standard 4: The risks of starting antipsychotics should be discussed with the person and/or carers and this discussion clearly documented.  Standard 5: The dose should be low initially and then titrated upwards if needed.  Standard 6: This should be time limited and reviewed every 3 months.

Audit standards: In patients on antidementia drugs Standards were based on NICE-SCIE guidelines on Dementia (CG42):  Standard 1: Only specialists should initiate treatment.  Standard 2: Patients who continue on treatment should be reviewed six monthly.  Standard 3: Treatment should be reviewed by the specialist team.

Audit standards: In patients on lithium  Standards were based on NICE guidelines on bipolar disorder (CG38):  Standard 1: Lithium level should be checked every 3 months in all patients.  Standard 2: U&Es, TFTs should be checked every 6 months in all patients.  Standard 3: All patients on lithium should have a lithium monitoring card.

Audit standards: In patients on benzodiazepines Standards were based on Drug Misuse and Dependence – UK Guidelines on Clinical Management (Department of Health):  Standard 1: All benzodiazepine prescribing should have a clear end date or be part of a gradually reducing regime.  Standard 2: Only one benzodiazepine should be prescribed at a time.  Standard 3: Dose should be below 30mg Diazepam equivalent.  Standard 4: If standards not met, there should be documentation in the notes giving clinical reason why.

Audit standards: In all patients  Standard 1: Glucose and blood pressure should be checked annually.  Standard 2: Lipids should be checked annually.

Methodology  4 EMI nursing homes in Monmouthshire to be visited.  Medication charts to be reviewed.  All patients on psychotropic medication will be included.  Clinical notes in CMHT to be reviewed.  Primary care to be contacted with the help of community pharmacist.  Nursing home care records to be reviewed and staff to be interviewed.

Results from the pilot station

Diagnosis

Psychotropic Medication

Responsibility

What do we aim to achieve?  Clearer monitoring agreements between primary and secondary care  Better adherence to prescribing standards  Better training and increased awareness of staff at nursing homes  Person-centred record of psychotropic prescribing and monitoring focusing on side effects staff might look for  To create a more standardized model of inreach services