1. Audit of the practice of antipsychotic prescribing in dementia patients in care homes in Newport Arpita Chakraborty, Sue Young, Jane Griffin Aneurin Bevan Health Board

2. Introduction National Institute of Clinical Excellence (NICE) in its clinical guideline (2006) sets out effective and appropriate guidance regarding antipsychotic usage. The use of antipsychotics should be a last resort, to be used at times of severe distress or critical need.

3. Introduction Following an enquiry into the prescription of antipsychotic drugs to people with dementia living in care homes, the All-Party Parliamentary Group on Dementia noted that inappropriate and overprescribing was clearly a significant problem (‘Always A Last Resort’ - April 2008).

4. Audit: aim This audit was undertaken to ascertain whether antipsychotic prescribing in EMI care homes in Newport complies with best practice.

5. Audit criteria This audit included all EMI care home patients in Newport who were on antipsychotic medication in November 2009. There were 4 EMI residential homes and 2 EMI nursing homes in the catchment area. Out of a total 137 clients with dementia from all care homes 54 patients (39% of all residents) fulfilled the inclusion criteria. Data were collected by visiting care homes, review of medical case records and treatment charts and were captured on a data capture sheet.

6. Audit Standards Standards were based on NICE – SCIE guideline on Dementia (CG 42): 1.Target BPSD symptoms identified, quantified and documented in all cases. Antipsychotic medication should only be prescribed in severe BPSD. 2.Physical causes should be ruled out in all cases. 3.Comorbid depression should be treated in all cases. 4.Non-pharmacological intervention should be tried prior to initiation of antipsychotic medication. 5.Discussion taken place with carers /nearest relatives in all cases. 6.Medication to be titrated slowly and reviewed three-monthly.

7. Demography MaleFemaleTotal EMI RH32326 EMI NH82028 Total cases 114354

8. Antipsychotic prescription

9. Antipsychotic medication usage Clients with dementia - all care homes RH & NH breakdown

10. BPSD symptoms

11. Audit outcome: Comparison of performance BPSD symptoms - these were identified, quantified and documented in 20% cases. Case records had no documentation that physical causes were excluded although care home staff verbally communicated that this was done in all cases. Co-morbid depression was looked for in 50% of cases and treated when identified.

12. Audit outcome: Comparison of performance All case records lacked documentation of prior non- pharmacological intervention. Percentage of patients on antipsychotic medications nearly doubled in EMI NH (57%) as compared to EMI RH (30%). Informal discussion with carer happened in all cases although not documented. Discussion with nearest relative took place in 2% cases. In 40% cases antipsychotic medication was slowly titrated. None had a three-monthly review.

13. Implementing change and re-audit Prior to initiation of antipsychotics in care home clients a checklist incorporating above standards must be completed and filed in the case records and clients to be reviewed three-monthly. CMHT in-reach service to support dementia care training in care homes (PInS – Proactive Inreach Service). Re-audit after one year following implementation of above change.