1000 Lives + Improving medicines management / Dementia Driver 3 1st May 2012

Multidisciplinary team Team meet every 6 -8 weeks to review progress and agree ongoing actions and interventions. At present group includes: Consultant psychiatrist (Older People, Swansea) Staff grade doctors x 2 (Swansea and Neath Port Talbot) CPNs x 2 (Swansea and NPT) Pharmacists x 3 (from each locality and mental health) Pharmacy technician x 1 (NPT locality) Work plan agreed

Baseline data collection Data was collected from the following: 6 GP practices ( 2 from each locality) Collected in April – May 2011. In addition, a set of 37 case notes from a CMHT in Swansea were audited to collect similar information, between October 2010 and April 2011

Combined Results for common data Number of patients % of patients Number of patients with dementia audited 362 Number of patients with dementia, prescribed an antipsychotic 104 28.7% Number of patients on an antipsychotic, reviewed in last 3 months 50 48.1% Discussion of risk / benefit with patient and/ or carer 3 2.9% Indication for the antipsychotic: Psychotic symptoms (including delusional or paranoid ideas, aggression) 23 22.1% Restless /agitated (including at night) 38 36.5% Unknown 43 41.4%

Pilot Sites 5 ‘pilot ‘ sites have been identified: Site 1: Care Home in Neath Port Talbot Locality Site 2: GP practice in Neath Port Talbot Locality Site 3: Cohort of patients from CMHT Swansea Site 4: Care home in Swansea Locality Site 5: GP Practice in Bridgend Locality: Bridgend all patients in care homes are reviewed by Liaison tea. Plan was to audit patients NOT living in care homes. Run chart identified 1 practice with high ‘low dose’ antipsychotic prescribing, but only 2 patients with dementia , therefore turned out not to be suitable. Looking at another practice for audit work.

Process measures Initial audit done in 3 pilot sites so far, and re-audited in 2 Some results shown in table on next slide Progress will be monitored by re-auditing process measures will be audited every 3/12

Measure Result For how many patients is the following is documented? Site 1 Site 2 Site 3 1. Indication for the antipsychotic 100% 89% 88% 2. A full discussion has taken place with the patient and/or carer about benefits or risks of treatment 53% 11% 3. The clinical need for the antipsychotic has been reviewed in the last 3 months 32% 44% 4. An attempt to reduce the dose or stop the antipsychotic 33% 16% 55% 5. Other approaches have been tried before antipsychotic medication is initiated 68% Compliance with care bundle (all 5 above interventions documented) 0%

Variation across 3 localities Different approaches are being used within each locality Due to different service models in place Brief update for each ......

Antipsychotic Prescribing for Older Adults Dr Robert Colgate Consultant Psychiatrist Bridgend, April 2012

Background Potential problems with antipsychotic medication have been clearly described: Committee on Safety of Medicines (2004) Identified risk of stroke damage Department of Health or “Banerjee” report ‘recommendations (to) reduce the use of these drugs to the level where benefit will outweigh risks (page 6)’ 2009

Bridgend Care Home In-Reach Old Age Liaison Psychiatry service established in late 2009 at Princess of Wales Hospital Multidisciplinary Care Home In Reach team identified ‘drugs of interest’ Antipsychotics, lithium and drugs for dementia Baseline survey of antipsychotic use within the local residential and nursing care homes Rachel to explain how data was collected.

Statistics August 2009: ~ 800 care home residents 36% prescribed antipsychotic medication August 2010 33% prescribed antipsychotic medication August 2011: ~ 850 care home residents 33.5% prescribed antipsychotics (285 individuals)

Examples 75 year man with moderate dementia and previous history of aggression associated with hallucinations. Remains irritable … 75 year woman with mild dementia and history of mild agitation associated with transition into care home setting. Now oversedated …

A Mantra … ? Indiscriminate reduction or discontinuation of antipsychotics is hazardous …

1000 Lives+ Campaign (Wales) Aim: to reduce inappropriate prescribing of antipsychotics in adults with dementia Objective: establish safe reduction strategy Relevant to Driver 3 of Intelligent Targets for dementia and also Medicines Management

A Good Intention … Establish a simple and systematic means of describing the antipsychotic prescription Summarised as … … an antipsychotic statement

Antipsychotic Statement Any decision to alter a prescription of antipsychotic medication should be based on: Knowledge of diagnosis Knowledge of target signs and symptoms Frequency of the target signs and symptoms … so that an assessment of risk can be made

Antipsychotic Statement Optimum management should include follow up in written documentation Specifically when and by whom …

Bridgend Care Home In-Reach Regular monthly care home visits since 2010 Annual survey (August) of antipsychotic prescribing across twenty four care homes Traffic light system of individual reviews Introduction of ‘embedded’ antipsychotic statements in mid 2011 Work in progress to incorporate into Care and Treatment plan documentation Embedded in communication letter for GP

Examples 75 year man with moderate dementia and previous history of aggression associated with hallucinations. Remains irritable … 75 year woman with mild dementia and history of mild agitation associated with transition into care home setting. Now over sedated …

Examples This antipsychotic is prescribed for a diagnosis of dementia with psychotic symptoms, specifically delusional misidentification of care home staff, which are still present The dose should be increased to xxmg and will next be reviewed by the Care Home In Reach team in the care home in one month

Examples The antipsychotic is prescribed for a diagnosis of dementia associated with anxiety and some agitation in September 2011, symptoms which are no longer evident The antipsychotic should be withdrawn now and the situation will be reviewed by telephone contact by the Care Home In Reach team in two weeks

Neath Port Talbot Care Home Liaison Nurse reviews patients in care homes and makes recommendations to medical staff based on her findings Working more closely with locality medicines management team Auditing process measures in 2 pilot sites

Care Home- Neath Port Talbot Process measures audited Patients reviewed regularly by CPN Results showed 100% compliance Continue to audit process measures to ensure these are maintained.

GP Practice- Neath Port Talbot Process measures audited for patients with dementia and on antipsychotic Several patients not reviewed Pharmacist discussed results with consultant Records/ notes checked ? reviews done Communication with GPs identified as an area for improvement 2 patients highlighted as needing a review

NPT Some patients had been reviewed, but if no change to medication was required, evidence of review not communicated to GP practice Info needs to be sent to GPs whether medication changed or not Improvement noted in results

Swansea- CMHT Process measures audited for a cohort of patients Repeated after 3 months Using medication review stamp in patients case notes Perception that practice has changed regarding prescribing of antipsychotics

1000 lives + Dementia Driver 3 Antipsychotics in Dementia Dr Priyadarshini M Rangappagowda, Dr Heledd Jones, Sue Collis, Dr Liz Clarke-Smith Department of Old Age Psychiatry, Gangorch Hospital, Swansea, United Kingdom Introduction The National Institute for Health and Clinical Excellence (NICE) clinical guidelines for dementia include advice on the appropriate use and ongoing monitoring of antipsychotics prescribed for Behavioural and Psychological Symptoms of Dementia (BPSD). The Banerjee report (Nov 2010) states ‘potential benefits (of antipsychotics) are most probably outweighed by their risks overall’. These risks are particularly related to excess cerebrovascular incidents and mortality. Professor Banerjee recommends that reducing the use of antipsychotics in people with dementia should be a priority for the NHS. The Welsh Assembly Government (WAG) have also established Intelligent Targets for Dementia and in particular, driver 3, focuses on reducing ain appropriate use of antipsychotic medications in accordance with NICE dementia guidelines. The Intelligent targets link in with the 1000 lives campaign and a multidisciplinary working group was established in ABMU LHB to work towards driver 3. The 1000 lives campaign emphasises looking at changes in small cycles which can then be rolled out into the wider population.. A Swansea audit earlier in the year of patients with dementia living independently in the community revealed that approximately a third were prescribed antipsychotics and of these 70%had been reviewed on a 3 monthly basis. It was then decided to focus the audit on a smaller sample living in a care home setting. Methods In two Swansea nursing homes, all the patients known to older peoples mental health services suffering from dementia and treated with antipsychotics were identified by manual identification of case records. A review of the clinical records was undertaken measuring against the standards contained in the WAG Intelligent Targets for dementia as detailed below. Results   Two nursing homes No. of patients % of patients For how many patients in the following documented 1 Indication for antipsychotic 8 89 2 Full discussion has taken place with the patient and/or carer about possible benefit or risks of treatment 11 3 The clinical need for the antipsychotic has been reviewed in the last three months 4 44 An attempt to reduce the dose or stop the antipsychotic 5 56 Other approaches have been tried before antipsychotic medication is initiated 33 6 Compliance with care bundle (all 5 above interventions documented) 7 Patients with dementia who have been receiving antipsychotic medication for more than 9 months Measurement summary Discussion The risk versus benefit of prescribing antipsychotics for people with dementia is not routinely discussed with the patient and or carers or that it is not routinely documented. Three monthly reviews in nursing homes of antipsychotic medications are not being carried out or not being documented. Although behavioural approaches are commonly tried, they are probably not being documented. Recommendations Compliance of the recommended review procedure needs to be highlighted amongst the Older peoples mental health services. A review stamp has been developed to assist this process. An educational programme for primary and secondary care staff has been developed and has commenced. Re-audit on a 3 monthly process to monitor improvements. Reference The use of antipsychotic medication for people with dementia: Time for action by A report for the Minister of State for Care Services by Professor Sube Banerjee Audit of antipsychotic prescribing in patients with dementia – May 2011. Welsh Assembly Government 100 lives campaign – Intelligent targets. NICE Clinical guidelines 42 (amended march 2011). 31

Re-audit problems 9 patients in the original cohort 1 patient passed away 8 patients now off listed from caseload

Swansea- Care Home Education sessions by CPN Managing Challenging Behaviour in Dementia ‘Change your life in 53 minutes’ Promising results so far Plans to audit process measures and engage GPs

6 month audit results 6 month audit results of our Challenging behaviour programme at care home Psychotropic Medication prescribing and usage : down 76% Challenging behaviour incidents: down 80% CPN and Medical staff crisis intervention: down 65% Heddfan ward admission: from 6 pa to zero. Data (except medication) is speculative, the biggest differences are staff attitudes and perceptions. The medical staff in agreement with the results, verified by the massive drop they have noticed with unplanned clinical input

Interventions being tested Education on prescribing antipsychotics in dementia for GP’s Use of an antipsychotic review stamp to improve documentation of 3 monthly reviews in patients notes. Standardised consultant letter to GPs in Bridgend, including a section on antipsychotic prescribing and review Use of a patient information leaflet on risks and benefits of using antipsychotics in dementia Use of pain assessment tool to identify pain as cause of agitation

Outcome Measure

Summary Lots of work being undertaken in various parts of ABMU Difficult to capture everything Progress being made in some pilot sites Next steps: to engage care home staff and GP for pilot site in Swansea