Powys-wide, Primary care audit Rhiannon Davies, Powys tHB Medicines Management Team Prescribing of Antipsychotic Medication in Patients with Dementia

 Dementia is a family name for a number of disorders. All have in common a loss of memory and other intellectual functions and a reduction in the persons ability to care for himself/herself, often accompanied by emotional changes and disturbances in behaviour  The most common form of dementia is Alzheimer’s disease, accounts for around 60% of all cases; two other most common dementias are Vascular Dementia and Dementia with Lewy bodies. These account for 15–20% of cases each.

 Behaviours that challenge are a major cause of distress to patients and their carers, and a frequent reason for transfer to nursing home care  People with dementia who develop non- cognitive symptoms or behaviours that challenge should be offered drug treatment ahead of non-drug interventions only if they are severely distressed or there is immediate risk to themselves or others  Benefits of antipsychotics are small and offset by an increased risk of cerebrovascular events and death, but can be used after full discussion of the risks/benefits with the person with dementia and/or their carers, and with frequent reviews

Background  In 2004, CSM published guidance highlighting the effects of regular use of Antipsychotics in elderly patients with dementia.  Nov 2006, NICE/SCIE issued guidelines (CG42). on the management of patients with dementia. Included a chapter on ‘interventions for non-cognitive symptoms and behaviour that challenges’  April 2008, the All Party Parliamentary Group on Dementia produced ‘Always a last Resort’

Banerjee report, Time for Action, Nov 2009  Unacceptable level of people dying as a result of prescribing antipsychotics  Clear evidence that they are currently being over prescribed  Alternative, non-pharmacological approaches to dealing with anxiety and behavioural problems should be used first-line  Recommendations for prioritisation, improvements in leadership, audit, training of staff and improvements in services offered to people with dementia were accepted by the Secretary of State for Health in November 2009.

What’s happening in Wales  National Dementia Action Plan for Wales  1000 Lives Plus - Improving Dementia Care.  1000 Lives plus Driver- Reducing inappropriate use of antipsychotic medications in accordance with NICE/SCIE guidelines

Aim of the audit:  To establish whether antipsychotics are being prescribed for the treatment of behavioural and psychological symptoms of dementia (BPSD) within the existing guidelines.  NICE/SCIE guidance: “antipsychotic drugs should only be prescribed when a person is a risk to themselves or others, and where all other methods have been tried. This should be for a short period of three months only, whilst a care plan is put in place”.

Audit: inclusions and exclusions  Inclusions: All patients over the age of 65 diagnosed with dementia who have been prescribed an antipsychotic in the past 12 months  Exclusions: Patients with a diagnosis of schizophrenia or other psychosis

Audit criteria: NICE/SCIE  Anti-psychotics should only be considered for severe non-cognitive symptoms  Target symptoms have been identified, quantified and documented and regularly assessed  Benefits of treatment have been discussed and recorded with patient or carer  Treatment is time-limited and regularly reviewed

Search Criteria  Patient ID  Residence - Residential home, Nursing home, own home  Diagnosis  Anti-dementia medication prescribed  Name and dose of Antipsychotic medication prescribed and date started  Who initiated?  Record of challenging behaviour?

Search Criteria  Documented record of severe stress or immediate risk of harm to themselves or others?  If no record of challenging behaviour, reason initiated (name)?  Benefits and risks of treatment discussed and recorded?  Evidence of review/assessment every 3 months?  Who is reviewing/managing the patients care routinely?

 June 2010, all medical practices in Powys asked to audit their prescribing of antipsychotics for patients with dementia.  To date, responses have been received from 12 of the 17 Practices (88 patients).  Data to patient level has been received from 10 of these (70 patients).  Patient numbers highest around those practices with Community EMI beds (Brecon, Llandrindod and Builth Wells).

Powys recorded diagnosis

TotalPercent Patients on antipsychotics88 Initiated by GP2123.9% Initiated by specialist5663.6% Number in Care homes6675.0% Record of challenging behaviour7484.1% Record of stress or harm3539.8% Risks benefits discussed1618.2% Patients on antipsychotics >3m8697.7% Regular review of treatment4652.3% last review by GP5865.9% last review by 2 care3337.5%

 Average length of treatment 786 days (2.15 years); Min treatment length 2 days, Max treatment length 2225 days (6.10 years)  Only 9 patients concurrently taking medication for dementia.  1 patient has dementia with Lewy bodies and is taking Haloperidol 3mg BD, despite increased safety concerns about using these drugs in this type of dementia.

 35 patients (of 70 analysed) had regular reviews. Of these, 12 were managed by GPs (irrespective of who initiated treatment). Average treatment length days  35 also had no regular review. Of these, 25 were managed solely by GPs. Average treatment length days

 27 patients were reviewed by a mixture of GPs, CPNs and Consultants: Average Treatment length days (min days, max days)  37 reviewed by GP only: Average Treatment length days (min days, max )  Unclear who is reviewing 6 patients: Average treatment length days (min 2.00 days, max days)

 Despite advice going back to 2004, antipsychotics continue to be prescribed for patients with dementia outside of guidelines.  Less clear whether these are prescribed as a “last resort”, although it does seem that prescribing is not short term (but we didn’t measure the number of patients with dementia who only received short courses).  Half of patients (35 of 70) audited do not have a regular review, and of these most (25) are managed solely by a GP.  When care is shared between GPs and CMHT / consultants, reviews appear to be more frequent.  Need also to identify if patients have care plans?  Do patients / GPs have access to the “alternative methods of managing behavioural problems” mentioned in the report: if not, will this evidence provide the spur for developing these services?

 Dementia management will form part of the GPs Quality and Outcomes Framework (QOF) for 20011/12  Presentation to be made at next Primary Care Drugs and Therapeutics Committee To discuss the outcomes To discuss and identify where the issues lie To identify what support GPs require in implementing the Guidelines To identify what other measures need to be put in place to improve the quality of care of this vulnerable patient group.

Good Practice: Brecon Medical Practice  First undertook Audit: Nov 2009  Re-audited in June 2010, Next re-audit scheduled July 2011  41 patients were included in one or both of the audits (41 in first and 32 in second)  Comparing data: 9 patients’ doses had been reduced and 2 had stopped  Care home GP devised staff template for monitoring behavioural and psychological symptoms of dementia, ongoing use.