There has been no sustained reduction in the prescribing of antipsychotics to dementia patients in UK care homes, despite government efforts to do so, according to researchers.
The Department of Health’s 2009 national dementia strategy recommended a review of the use of antipsychotics in light of potential serious side effects.
“Antipsychotics increase the risk of stroke, falls and even death”
The Banerjee report, commissioned by the DH as part of its work on the strategy, concluded that antipsychotics had a “substantial clinical risk” associated with them and that their overuse “must not be allowed to continue”.
But a new study by Coventry University and City University of London has found there were no marked change in care home practice regarding the drugs in the years immediately following the strategy’s launch.
Although originally developed for schizophrenia or psychosis, the study found “off-label” antipsychotic prescribing to treat the behavioural and psychological symptoms of dementia was common in care homes.
The research, published today in the medical journal BMJ Open, examined prescribing data between 2009 and 2012 from over 600 care homes across the country.
“Care homes remain the forgotten sector in UK policy debate around the use of antipsychotics”
The study authors concluded that there was no significant decline in antipsychotic prescribing rates over the four-year period, although dosages were usually acceptable.
They also judged the length of treatment to be “excessive” in over 77% of cases by 2012, up from 69.7% in 2009 – meaning it exceeded not only the recommended six-week course, but also the maximum advised treatment length of 12 weeks.
In addition, the findings indicated that older first-generation antipsychotics, such as haloperidol and chlorpromazine, were still being used extensively, with no measurable shift to safer second-generation antipsychotics like risperidone – despite it being recommended in the dementia strategy.
Other trends identified by the study include a link to the homes’ locations and local primary care arrangements.
Care homes in the highest 20% for antipsychotic prescribing were more likely to be located in a deprived area, while those in the lowest prescribing 20% were more likely to be served by a single GP practice.
Care homes failing to cut antipsychotic use
The single practice trend could indicate that those homes benefit from a consistent message that is absent from homes served by multiple practices, suggested the researchers.
Professor Ala Szczepura, from Coventry University, said care homes remained the “forgotten sector” in debates on the use of antipsychotics due to a lack of systematic monitoring of prescribing data.
“Our study has not only identified a failure of the national dementia strategy to produce a sustained decrease in use of antipsychotics, it’s also shown large regional variations and has found evidence indicating that their use is higher in care homes in deprived neighbourhoods,” she said.
She added that it was clear that a “significant change is required in prescription culture and management of vulnerable people with dementia”.
Clive Bowman, visiting professor at City who contributed to the study, said the dementia strategy had “failed to have a sustained effect” on the excessive prescription of antipsychotics in care homes.
Care homes failing to cut antipsychotic use
“This is unacceptable, clear standards are required regarding the use of these drugs and a designated responsibility for monitoring medicines and their usage mandated,” he said.
“New technology can do this in real time, allow public scrutiny and free professional time to promote best practise,” noted Professor Bowman.
George McNamara, head of policy at the charity the Alzheimer’s Society, described the continued reliance on antipsychotics to manage the behavioural symptoms of dementia as “deeply worrying”.
“Around 90% of people with dementia experience symptoms that affect their behaviour causing aggression, agitation, or even delusions and hallucinations,” he said. “Prescribing antipsychotics treats the person with dementia as the problem rather than the root cause of their behaviour.
“Antipsychotics increase the risk of stroke, falls and even death – it’s shocking that the evidence continues to be flatly ignored,” he added.
Researchers from the University of Warwick, Lancaster University, the University of East Anglia and technology company Invatech Health also contributed to the study.