1. Antipsychotic use in patients with dementia – How are we doing? Project Team Dr Seema Gupta, Consultant OPMH YGC, Audit Lead Elizabeth Bond, MH pharmacist YGC Dr James Bright, Staff Grade OPMH YGC Richard Moore, Staff Nurse WMH Dr Petra Gutting, Consultant OPMH YG David Patel, Audit Facilitator YGC September 2015

2. Background Dementia and BPSD  More than 90% exhibit BPSD  Major cause of carer stress  May lead to placement breakdown  Stepped approach to management needed  Antipsychotics are a last resort

3. What are BPSD?   BPSD is an umbrella term for a group of non cognitive symptoms that may include: 1. Agitation / Aggression 2. Persistent and distressing psychosis 3. Mood disorder

4. When are antipsychotics used for patients with dementia? Non cognitive or behavioural and psychological symptoms of dementia (BPSD): Non cognitive or behavioural and psychological symptoms of dementia (BPSD): Extreme / Severe distress Extreme / Severe distress Not responding to personalised care Not responding to personalised care At risk of harm to self / others At risk of harm to self / others

5. Antipsychotics in dementia Risk vs Benefits (Drouillard, 2013)  Benefits Reduced aggression / harm / distress Reduced aggression / harm / distress (NNT 5 to14)  Risks Parkinsonism / somnolence / confusion / falls / peripheral oedema (NNH 10 to 20) Parkinsonism / somnolence / confusion / falls / peripheral oedema (NNH 10 to 20) CVA (NNH 70) CVA (NNH 70) Mortality (NNH 100) Mortality (NNH 100)

6. Why Audit?  Recent Reports Trusted to Care – ‘prescription of antipsychotics without appropriate assessment ‘ (Cote wards) Trusted to Care – ‘prescription of antipsychotics without appropriate assessment ‘ (Cote wards) Ockendon ‘oversedation’ (OPMH ward) Ockendon ‘oversedation’ (OPMH ward) MHLD 100 day plan MHLD 100 day plan  BCUHB Response BPSD Management checklist (2011) BPSD Management checklist (2011) BCUHB guideline – management of challenging behaviour in dementia (OPMH March 2015) BCUHB guideline – management of challenging behaviour in dementia (OPMH March 2015)

7. Criterion for Audit  All patients with dementia should only be prescribed antipsychotics within agreed NICE CG42 (Dementia)

8. Audit Standards (NICE CG42 Dementia ) 1. People with dementia have a comprehensive assessment of underlying causes of behaviour that challenges. 2. Antipsychotics are only prescribed after non drug options have been tried. 3. There has been a documentation of discussion with the patient / carers about benefits and risks to treatment.

9. Audit Standards ctd (NICE CG42 Dementia ) 4. Target symptoms for antipsychotic treatment are identified and documented. 5. Antipsychotic medication is reviewed within 3 months of initiation. 6. Evidence that target symptoms, cognition and side effects are regularly assessed (at least every 3 months) in conjunction with antipsychotic medication.

10. Methods  Proforma developed by Audit department.  The patient population was selected: Patients prescribed antipsychotic on Patients prescribed antipsychotic on OPMH Dementia wards across 3 sites  Data collectors identified by Project lead  Data collected on agreed day across 3 sites

12. Results

17. Standard 1.

18. Standard 2.

19. Standard 3.

20. Standard 4.

21. Subgroup analysis: Duration of treatment> 6 months (N=6) 

22. Standard 5.

23. Standard 6.

24. Standard 7.

25. Summary - Key findings  NICE Standards for antipsychotic prescribing in dementia were not being met on inpatient wards  Main Deficiencies: Documentation of discussion risk/benefit Documentation of discussion risk/benefit Target symptoms and side effect monitoring Target symptoms and side effect monitoring Continuation of treatment beyond 3 months despite stable symptoms Continuation of treatment beyond 3 months despite stable symptoms

26. Limitations  Small study size  Incomplete data recording  Point prevalence /snapshot audit  Limited population  Lack of detail around non drug interventions or symptoms to determine appropriateness of antipsychotic or symptoms to determine appropriateness of antipsychotic

27. Recommendation  Disseminate findings to OPMH teams  Extend audit to inpatient general wards  Implementation of BCUHB guideline documentation  Re-audit in 6 months (POMH-UK audit 2016)

28. References 1. Drug & Therapeutic Bulletin (2007) How safe are antipsychotics in dementia? Vol 45;11 2. NICE CG 42 (2006) Dementia. Supporting people with dementia and their carers in health and social care. www.nice.nhs.uk www.nice.nhs.uk 3. Duff G. (2004) Atypical antipsychotics and stroke. MHRA www.mhra.gov.uk www.mhra.gov.uk 4. Baker M. (2008) Response to antipsychotic enquiry: Call for evidence into the prescription of antipsychotic drugs to people with dementia living in care homes. RCGP. http://www.rcgp.org.uk/pdf/feb%2008%20- response%20to%20antipsychotics%20inquiry%20-%20web.pdf http://www.rcgp.org.uk/pdf/feb%2008%20- response%20to%20antipsychotics%20inquiry%20-%20web.pdfhttp://www.rcgp.org.uk/pdf/feb%2008%20- response%20to%20antipsychotics%20inquiry%20-%20web.pdf 5. All Party Parliamentary Group (2008) Always a last resort. All Party Parliamentary Group (APPG) report on Dementia; http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=322 http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=322 6. Drouillard, N., Mithani, A., Chan, P. (2013) Therapeutic approaches in the management of behavioural and psychological symptoms of dementia in the elderly BCMJ, 55(2) 90-95.