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Research

Reducing antipsychotic drugs in care homes

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The risks of antipsychotic drugs to people with dementia are well known. A review by pharmacists with care home staff led to the drugs being reduced or discontinued

Abstract

Antipsychotic medication should be used in people with dementia only when there is an identified need and the benefits outweigh the risks. An audit-based service provided by pharmacists, working with nursing and care staff in residential homes, resulted in antipsychotic doses reductions of 20% and drug discontinuation in 17% of residents with dementia.

Citation: Prentice A, Wright D (2014) Reducing antipsychotic drugs in care homes. Nursing Times; 110: 22, 12-15.

Authors: Aileen Prentice is Boots Care Services operations manager, Boots UK; David Wright is professor of pharmacy practice, School of Pharmacy, University of East Anglia.

Introduction

Prescribing and medicines management in care homes, which is largely the responsibility of nurses, care staff and GPs, needs improvement (Alldred et al, 2013). One of the main areas of concern is the inappropriate use of antipsychotic medication (Parsons et al, 2012); an estimated 180,000 people with dementia are treated with antipsychotic medication in the UK every year (Banerjee, 2009). The care home population is frail and susceptible to the side-effects of antipsychotics (Box 1).

Box 1. Side-effects of antipsychotics

  • Sedation
  • Postural hypotension
  • Extrapyramidal symptoms such as restlessness
  • Muscle twitching
  • Parkinsonian symptoms
  • Tardive dyskinesia (permanent involuntary movements)
  • Cardiovascular accidents 

It has been estimated that the use of antipsychotic medication in patients with dementia - who represent at least 60% of the care home population in the UK - equates to 1,620 cerebrovascular adverse events and 1,800 deaths per year on top of those that would be expected (Banerjee, 2009). Antipsychotics make a significant contribution to what is known as the “anticholinergic burden” of prescribed medication ­- the cumulative effect of using multiple medications with these properties at the same time - which is related to increased mortality (Fox et al,  2011).

Within the US, legislation was introduced to reduce antipsychotic prescribing in care homes (US Federal Government, 1987). Homes are required to employ an independent consultant pharmacist to undertake regular review of antipsychotic medication, with the aim of reducing or discontinuing drugs. Evidence suggests this has been effective (Gurvich and Cunningham, 2000).

Within most care homes in the UK, nursing and care staff and GPs provide care and manage medicines, with occasional visits from an independent pharmacist from a primary care organisation to review prescribing, and monthly inter-actions with a community pharmacy to supply the medicines.

While an independent pharmacist working closely with nursing and care staff has been shown to realise significant medicine acquisition cost savings and improve residents’ quality of life, the impact on longer-term outcomes is largely unknown (Alldred et al, 2013).

One study based in northern England, using a pharmacist employed by a medical practice with a close working relationship with GPs and care and nursing staff, demonstrated a significant reduction in falls after a pharmacist-conducted clinical medication review (Zermansky et al, 2006). In another study, where a specially trained pharmacist focused on antipsychotic use in people with dementia, a 25% reduction in antipsychotic prescribing was achieved (Child et al, 2012).

New legislation to improve antipsychotic prescribing in the UK is unlikely, so we need practical and sustainable models of care to address concerns regarding antipsychotic prescribing.

Government plans for community pharmacies include greater involvement in the management of long-term conditions (Department of Health, 2008). In addition to care and nursing staff and GPs, community pharmacists in primary care are ideally located to review monthly prescriptions for residents in care homes.

The national audit of care homes

Our national pharmacy chain services a large number of care homes across the UK.

Care home leadership teams had expressed a need for support in better managing the medicines of their residents, with antipsychotic prescribing identified as a priority area.

It is an NHS contract requirement for community pharmacists to undertake at least two audits per year (Pharmacy Services Negotiating Committee, 2013). We therefore carried out an audit of antipsychotic medication between July 2010 and June 2012 with homes that were customers of our company and that had requested the service. The homes were run by national chains of care homes and were located in England, Scotland and Wales.

Preparation for the audit

Community pharmacists were trained to provide the audit-based service using online training packages and attendance at an Alzheimer’s train the trainer session. This session increased their knowledge and enabled them to deliver a two-hour dementia awareness session to care staff in the care homes.

Using patient medication records held nationally by the community pharmacy company, pharmacists undertook a clinical assessment of antipsychotic prescriptions for individual residents to establish possible reasons for starting the medication, the duration of the prescription and any interactions.

A blank audit form, GP information letter, consent letter and explanation of the process were sent to home managers. They were asked to identify residents who were prescribed at least one antipsychotic medication, and who were either diagnosed with dementia or suspected of having dementia. If there was no suspected or confirmed diagnosis of dementia, and the resident was taking the medication for other medical conditions such as schizophrenia or bipolar disorder, they were not included in the audit.

The homes sent consent letters to the relatives of those residents identified as potentially suitable for the audit as well as an introductory letter to their GPs.

The audit process

Pre-audit joint strategy

Before discussing individual residents, the audit-trained community pharmacists worked with the professionals responsible for patient care at each home to create an joint strategy for the use of antipsychotic medication in line with national guidance (National Institute for Health and Care Excellence, 2006).

Pre-visit work

Before the audit visit, care home managers were asked to collate the following information for all relevant residents:

  • Date of admission;
  • Date medication started;
  • Medical conditions;
  • Recent changes;
  • Monitoring;
  • History of falls and fractures.

Individual assessments to determine the presence of symptoms that required treatment with an antipsychotic were undertaken.

Audit visit

During the audit visit, pharmacists recommended antipsychotic medication reviews for residents who had not received a review within the last three to six months, or where there was evidence of side-effects or no current symptoms of behavioural and psychological symptoms of dementia (BPSD).

Pharmacists and home staff discussed guidelines from NICE (2006). Then, for each resident, a risk versus benefits discussion took place, with a particular focus on falls and cardiovascular accidents.

Where it was deemed necessary, the pharmacists recommended that staff should discuss titrated withdrawal of antipsychotic medication during the review. The audit pharmacist also discussed with the home staff the information that would be provided and discussed with the GP or psychiatrist during the review. This could include a description of other ways of managing BPSD, and how the resident’s needs were being met after admission to the care home, including how the need for medication may have changed.

The audit visit was seen as helpful in facilitating a conversation between home staff and their GP to challenge prescriptions. A document was provided to the home to enable them to request an anti-psychotic medication review from the GP. Homes decided whether to use the form or to make more informal direct requests.

Follow-up

Pharmacists telephoned or revisited the homes twice, two to four months after the audit visit, to ascertain the impact of their recommendations.

Data governance and ethics

No resident-identifiable data was removed from any care home. All databases contained unique reference numbers, which could be identified only within care homes or community pharmacies providing the service and were stored on password-protected computers.

As this was a service evaluation, which falls under the remit of clinical audit, ethical approval was not sought. All homes provided written consent to participate. The community pharmacists providing the service were employed by the company responsible for the regular provision of medicines to the residents so the review of prescribing was within their remit.

Results of the audit

Data was analysed from 463 homes, which received a service from four audit-trained community pharmacists on behalf of 350 company stores.

A total of 3,165 residents receiving antipsychotic medication were reviewed, of whom 1,300 (41.1%) had a recorded diagnosis of dementia; 1,180 reviews were started in 2010, 1,078 in 2011 and 901 in 2012. For six reviews, the year of initiation was not recorded.

Of the 3,165 residents reviewed, 2,341 (74%) demonstrated symptoms that may necessitate antipsychotic treatment. In 236 (7.5%) residents, antipsychotic medication was prescribed for BPSD, while a further 250 (7.9%) residents had been prescribed antipsychotic medication for another condition and had subsequently developed dementia.

By the first visit 147 (4.6%) of residents were deceased and a further 119 (3.8%) had died by the end of the follow-up visit.

Types of antipsychotic medication prescribed

Table 1 provides a summary of the anti-psychotic drugs prescribed for the residents reviewed. In 87 instances, a resident was prescribed more than one antipsychotic concurrently and, in two cases, the name of the antipsychotic drug reviewed was not recorded. Quetiapine represented 42% of prescriptions, risperidone 16.8% and haloperidol 12.2%.

Reviews of medication

A total of 1,772 (56.0%) residents had had a recorded review of their antipsychotic medication within the previous three months, 465 (14.7%) within the previous six months and 228 (7.2%) in the previous 12 months.

Residents’ antipsychotic prescriptions were reviewed when:

  • They were currently receiving another antipsychotic;
  • They were demonstrating side-effects from their medication;
  • The risks of antipsychotic medication were deemed to outweigh the benefits;
  • There was no evidence of symptoms;
  • There was no evidence of review.

Fig 1 shows the numbers of prescriptions in which these criteria for questioning were found. Risks were deemed to outweigh benefits for 1,840 (58%) of prescriptions, while there was no evidence of symptoms for 824 prescriptions (26%).

Actions resulting from the audit

Table 2 shows the actions taken as a result of the audit process. A total of 653 patients out of 3,165 (20%) had their dose reduced while 548 (17%) had their prescription discontinued.

Just over half of dose reductions were made before the audit visit, while the majority of discontinuations resulted from the audit visit. There were a large number of anecdotal stories of significant success as a result of this audit.

Discussion

This large-scale audit found that in care home residents receiving antipsychotic medication, 26% did not have any symptoms that necessitated regular antipsychotic medication, and in 58% of cases the risk of the medication was deemed to outweigh the benefit. This relatively simple audit-based service resulted in over 20% of residents having their antipsychotic dose reduced and more than 17% having antipsychotic medication discontinued.

With the known side-effects of antipsychotic medication, including sedation, and an increased risk of falls and cardiovascular events, this service is likely to have improved the quality of life of a large number of care home residents.

The results suggest that nurses working in care homes should regularly question prescriptions for antipsychotic medication. This would ideally be done in partnership with the GP and community pharmacist.

It is not possible to determine what would have happened without this service. It is reasonable to assume that the regular reviews recorded as being undertaken would have led to some antipsychotics being reduced or stopped. However, it is unlikely that the large reduction seen in such a relatively short period of time would have occurred without active intervention by the community pharmacists.

The level of recorded regular antipsychotic medication review was high, so it is perhaps surprising that so many medicines were still considered suitable for stopping or reducing as part of the audit process. This may, however, demonstrate the value of using a third party to instigate such reviews, as in the US model (US Federal Government, 1987) since this provides a fresh perspective that is not clouded by historical practice. It may also provide support for less frequent independent reviews rather than regular in-house reviews. It would, however, also seem sensible for nurses in care homes for older people to review local practice to ensure that antipsychotic medication review is undertaken effectively.

The changes to prescribing at different time points of the project demonstrates the value of developing a care home strategy jointly, collecting information on each resident and holding interprofessional meetings to discuss individual prescriptions. The development of a joint strategy for antipsychotic prescribing was effective in reducing antipsychotic use, while the visits to discuss individual residents’ prescriptions had a greater impact on therapy discontinuation.

Although in 58% of cases, the risk of antipsychotic medication was deemed to outweigh the prescription, it would be unreasonable to expect all these prescriptions to be discontinued, as such decisions must be taken with care and all factors require consideration.

The reductions in antipsychotic prescribing seen in this audit are similar to those found in other studies (Westbury et al, 2012; Patterson et al, 2010).

Quetiapine was found to be the most commonly prescribed antipsychotic for BPSD, which is an unlicensed use. Risperidone, the only licensed therapy, was used in fewer than one in six residents. The preference for quetiapine requires further exploration, as national guidance states that unlicensed use of medicines should only become necessary if the clinical need cannot be met by licensed medicines (Joint Formulary Committee, 2013). It would therefore be appropriate for prescriptions for quetiapine to be questioned.

While this audit-based service focused on strategies to manage the use of antipsychotic medication once prescribed, an additional emphasis by nurses, carers and GPs at the initiation of antipsychotic medication in patients with dementia in care homes on risk scoring, drug selection, effectiveness monitoring and review is perhaps also required.

The audit was designed to encourage conversations between nurses, care home staff and GPs about antipsychotic medication. The pharmacists reported that it appeared to empower the nursing and care staff to feel more confident with GPs. It also made nursing and care staff reflect on current practice, taking time out of the “day job” to review patient care and prescribing.

The audit team also reported, perhaps unsurprisingly, that engagement of the care homes involved was the key to success. Where the leadership team focused on positive outcomes for patients, we had more engagement and enthusiasm throughout the audit process. Furthermore, in homes with more stable employee populations, more of the actions seemed to be followed though, which ultimately influenced patient outcomes.

Conclusion

This is a simple audit in an important area of practice that has potential for providing significant improvements in patient care.

A large number of medicines were discontinued or stopped as a result of this service, which will in many cases have immediately improved quality of life.

The results suggest that nurses and carers in care homes for older people should question, at the point of initiation, whether antipsychotic therapy is required and ensure the most appropriate drug is selected. At antipsychotic medication reviews, they should be aware that this should always be undertaken from the perspective of discontinuing or reducing therapy, rather than simply confirming that the therapy is working and not causing any harm. Working with suitably trained pharmacists provides the opportunity for an independent perspective on the appropriateness of and need for therapy.

Key points

  • At least 60% of people living in care and nursing homes in the UK have dementia
  • The use of antipsychotic medication in people with dementia is widespread, and causes an additional 1,800 deaths per year
  • Antipsychotic drugs contribute to the anticholinergic burden, which is associated with increased mortality
  • Quetiapine is commonly prescribed for behavioural and psychological symptoms, but its use is unlicensed
  • Working with pharmacists can make nurses more confident in questioning the appropriateness of antipsychotics
  • Declaration of interest: corresponding author Aileen Prentice is employed by Boots UK, which funded this work. 
  • 3 Comments

Readers' comments (3)

  • I would like to ask the nurses who work in the nursing homes, don't you find more psicotic attacks when reducing the antipsicotic drugs? Aren't patients more difficult to manage without their treatments?

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  • This article brought back memories of my uni days as a student when I had to write essays. I remember one of my male lecturers asking me what state of mind was I in when I wrote an essay. I suppose I would have been in a psychotic state as I always had anxiety writing essays and it is one of my weakest points. Finding it hard to put words on paper in a succint manner conveying information to answer the essay question. I also did not proof read my essays.
    Someone forgot to proof read this article. Table 1 on page 14 titled "Antibiotics prescribed to residents" lists antipsychotic drugs and no antibiotic drugs.

    I remember my mental health clinical practical in a community based and hospital setting giving out depot injections testing my pushing strength. Some of those depot injections were really hard to push through the syringe.

    I know some antipsychotic medication would can lead to hypotension which can increase the potential for the elderly to fall and hurt themselves. What other therapies are available for those with dementia who display psychotic behaviour?

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  • replace anti psychotics with staff who can provide adequate care and surveillance of patients.

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