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

2. 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)  54000 elderly residents in care homes without severe mental illness receive antipsychotics. (Shah et al 2011)  Benzodiazepine use in nursing homes is another major concern. 15-42% in Australian NHs (Westbury et al 2010)

3. 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

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

5. 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.

6. Audit Standards

7. 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.

8. 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.

9. 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.

10. 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.

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

12. 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.

18. Results from the pilot station

19. Diagnosis

20. Psychotropic Medication

21. Responsibility

22. 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