Quality statement 3: Use of antipsychotic medication for people who are distressed

Quality statement

Adults with delirium in hospital or long-term care who are distressed or are a risk to themselves or others are not prescribed antipsychotic medication unless de-escalation techniques are ineffective or inappropriate.

Rationale

Antipsychotic medication is associated with a number of adverse effects. Therefore it should only be considered as a short-term treatment option for delirium if a person is distressed or is a risk to themselves or others and de-escalation techniques have failed or are inappropriate. Antipsychotic medication may be inappropriate in a variety of circumstances; for example, if reversible causes such as pain or urinary retention have not been treated or excluded, if barriers to communication have not been overcome, or for people with specific conditions such as Parkinson's disease or dementia with Lewy bodies.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with delirium in hospital or long-term care who are distressed or are a risk to themselves or others are not prescribed antipsychotic medication unless de-escalation techniques are ineffective or inappropriate.

Data source: Local data collection.

Process

Proportion of adults with delirium in hospital or long-term care who have been prescribed antipsychotic medication who were distressed or a risk to themselves or others and for whom de-escalation techniques were ineffective or inappropriate.

Numerator – the number in the denominator who were distressed or a risk to themselves or others and for whom de-escalation techniques were ineffective or inappropriate.

Denominator – the number of adults with delirium in hospital or long-term care who have been prescribed antipsychotic medication.

Data source: Local antipsychotic prescribing audits.

Outcome

Antipsychotic medication prescribing rates.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, residential care homes, nursing homes, GPs) ensure that there are procedures and protocols in place to monitor the use of antipsychotic medication in adults with delirium, to ensure that this is only considered as a treatment option for delirium when the person is distressed or a risk to themselves or others and de-escalation techniques are ineffective or inappropriate.

Healthcare professionals ensure that they do not prescribe antipsychotic medication for adults with delirium who are distressed or a risk to themselves or others unless de-escalation techniques are ineffective or inappropriate.

Commissioners (such as clinical commissioning groups [CCGs], local authorities, NHS England area teams) ensure that staff in hospitals and long-term care homes are trained in de-escalation techniques if appropriate, monitor antipsychotic medication prescribing rates for adults with delirium, and support providers to develop, monitor and improve procedures and protocols to monitor this prescribing.

What the quality statement means for patients, service users and carers

Adults in hospital or in a residential care home or nursing home who have delirium are not given antipsychotic medication (which can be used to treat people who experience hallucinations or delusions) unless they are very distressed or are thought to be a risk to themselves or others, and if other ways of calming them down have not worked or are not suitable.

Source guidance

  • Delirium (NICE clinical guideline 103), recommendation 1.6.4 (key priority for implementation).

Definitions of terms used in this quality statement

Long-term care

Residential care provided in a home that may include skilled nursing care and help with everyday activities. This includes nursing homes and residential homes. [NICE clinical guideline 103, full guideline, glossary of terms]

Antipsychotic medication for adults with delirium

Short-term (usually for 1 week or less) use of appropriate antipsychotic medication, starting at the lowest clinically appropriate dose and titrating cautiously according to symptoms, should be considered for adults with delirium who are distressed or considered a risk to themselves or others when de-escalation techniques have been ineffective or are inappropriate. [Adapted from NICE clinical guideline 103, recommendation 1.6.4]

Antipsychotic drugs should be avoided, or used with caution if they are needed, in people with conditions such as Parkinson's disease or dementia with Lewy bodies. [Adapted from NICE clinical guideline 103, recommendation 1.6.5]

De-escalation techniques

Communication approaches that can help solve problems and reduce the likelihood or impact of confrontation. This includes verbal and non-verbal communication such as signs, symbols, pictures, writing, objects of reference, human and technical aids, eye contact, body language and touch. [Adapted from Skills for Care's National minimum training standards for healthcare support workers and adult social care workers in England, standard 5.5: Dealing with confrontation and difficult situations]

Equality and diversity considerations

A learning disability specialist nurse should be involved in treating the symptoms of delirium in adults with a learning disability, to ensure that the person's specific needs are taken into account.