This audit was aimed at finding out if the Trust's old age psychiatry services were following NICE guidance in relation to the prescription of antipsychotics in dementia patients.
This example was originally submitted to demonstrate implemention of NICE guideline CG42. This guideline has now been updated and replaced by NG97. The practice outlined in this example has been reviewed and is consistent with the updated NICE guidance. The updated guidance should be referred to if replicating practice described in this example.
Aims and objectives
1). To gather information from in-patient, outpatient and memory assessment service on the prescribing of antipsychotic medication for people with dementia.
2). To establish that non-antipsychotic medications were tried and there was no alternative for dealing with challenging behaviour but only use of antipsychotic medication.
3). To establish all patients had clear indications for treatment with antipsychotics and were reviewed within 3 months.
Reasons for implementing your project
The development of behavioural and psychological problems (e.g. agitation, physical and verbal aggression, wandering, shouting, psychosis and sleep disturbances) is common in dementia. These can cause difficulties which complicate care due to severe distress and there is a risk of harm to themselves and others, and they can occur at any stage of the illness.
In November 2009, The Department of Health published a 61 page report on the use of antipsychotics in dementia named 'Time for Action'. It has eleven recommendations which aimed at reducing the use of antipsychotic drugs for people with dementia and assuring good practice when they are needed. This report attracted much publicity and there was much criticism about the use of antipsychotics in elderly population e.g. 'About 145,000 people with dementia are wrongly being prescribed powerful anti-psychotic medication which causes around 1,800 deaths a year', The Times reported.
The Time for Action report found that up to a quarter of people with dementia in the UK may be on antipsychotics at any time. This equates to 180,000 people with dementia being treated with antipsychotic medication by the NHS.
How did you implement the project
NICE produced an audit tool with certain clinical criteria for the use of medication for non-cognitive symptoms, behaviour that challenges and behaviour control. These emphasized that people with dementia who develop non-cognitive symptoms or behavior that challenges should only be offered a pharmacological intervention in the first instance if they are severely distressed or there is an immediate risk of harm to themselves or others, and target symptoms should be identified, quantified and documented (Recommendations in Section 1.7.of NG97).
This NICE clinical audit tool was produced in response to the report by the All-Party Parliamentary Group on Dementia entitled 'Always a last resort'. The report found that over-prescribing of antipsychotics in care homes is a problem, and recommended local and national audit of the use of antipsychotics for people with dementia in care homes.
*The audit tool has since been replaced by a baseline assessment tool for NG97 which can be found under the tools and resources page of the guideline.
We included all the patients with dementia who were under the care of the MCPCT Older Adult Team (Outpatients, inpatients, and memory assessment clinics) between April 1st 2011 - June 30th 2011.
The domain of the audit included the following items:
1). Documented diagnosis of dementia.
2). Name of the anti-dementia medication.
3). Name and indication of the antipsychotic medication (if prescribed).
4). Place of initiation of the antipsychotic medication.
5). Were other medications tried prior to prescribing antipsychotics.
6). Duration of antipsychotic treatment.
7). Whether antipsychotics have been stopped, and restarted (if applicable).
8). Review of the prescription and by whom.
- The sample included 136 female and 107 male patients (56% and 44% respectively). - 57% were under the care of the South Team where as 435 were under the North team. - 165 patients (67%) had the diagnosis of Alzheimer's dementia.
- Other diagnosis were : - Mild Cognitive Impairment (9%) - Mixed (8%) - Vascular (7%) - Dementia of Lewy-Body (3% - Fronto-Tempral dementia (2%) - Other diagnoses 4%.
- Our sample included 246 patients with the diagnosis of dementia. Twenty eight patients (11%) received an antipsychotic medication during the period in question. The duration of the antipsychotic treatment was less than 3 months in 22 (82%) patients.
- Place of Initiation: of those who were on antipsychotics: 50% were started in the outpatient clinic by the consultant or the trainee psychiatrist. 29% were started by GP. TOPAS was the site of initiation in 14% . 7% were started in the general hospital.
- The indication of the antipsychotic treatment: These were indicated for frank psychotic symptoms in 43% of cases (31% for hallucinations and 12% for delusions). Agitation was the indication in 30%, Physical aggression in 19% and Verbal aggression in 8% of cases. The review of antipsychotic prescription was done by the consultant psychiatrist in 96% of cases and the GP in 4% of cases.
- The duration of the antipsychotic treatment was less than 3 months in 22 (82%) patients. The teams have attempted to stop antipsychotics in 46% of cases within the first 3 months of treatment. No attempt have been made to stop antipsychotics in 45% of cases. Other (non-antipsychotic) medications were tried in 71% of patients prior to prescribing antipsychotics. These were not tried in 29% of cases.
- After prescribing , antipsychotics were stopped in 39% of patients where as 61% continued on the antipsychotics during the three month period in question. Of those in whom antipsychotics were stopped, 45% were restarted again on antipsychotics. Antipsychotics were not restarted in 55% of cases after ceasing prescription.
It is clear that antipsychotics are infrequently used in older adult population with Dementia who are under the care of our teams (only 11%) which is much less than what the Department of Health report's figures.
- They were prescribed for frank psychotic symptoms (delusions and hallucinations) in nearly half the patients (43%) where was they were used for behavioural problems (agitation, aggression) in 57%.
Key learning points
- The older adult psychiatry teams in Milton Keynes Primary Care Trust are compliant with the Department of Health's guidance on the prescription of antipsychotics for dementia patients (Nov 2009).
- Non pharmacological methods of managing these behavioural and psychotic features were tried in 71%.
- There were clear indications for starting the antipsychotic medication and usually for a limited period only.
- Encouraging the use of non pharmacologic methods to manage behavioural symptoms of dementia (distraction techniques, verbal de-escalation, structuring the daily activities) and resorting to medications as last chance.
- It might be possibility Introducing a document related to the antipsychotic prescription documenting (indication, review date, side effects etc) and enclosing it in the document centre on RIO (or as alerts) so as to make tracking these patients easier.
- Re-auditing the data after several months to see if these recommendations have taken place.