The Right Prescription
A Call to Action for junior doctors
on the use of antipsychotic drugs
for people with dementia
The numbers
• 750,000 people with dementia in the UK
•
180,000 people with dementia on antipsychotics
• Only 36,000 will derive some benefit from antipsychotics,
but:
– 1800 additional deaths
– 1620 additional CVAs
Perhaps 2/3 of these prescriptions are
unnecessary if appropriate support is available
Non-cognitive symptoms of dementia
Behavioural and psychological symptoms (BPSD) occur in 90% of people
with dementia and may include…
Behavioural disturbances
• Agitation
• Aggression
• Wandering
• Sleep disturbances
• Changes in, or
inappropriate eating
behaviour
• Inappropriate sexual
behaviour
Psychiatric symptoms
• Depression
• Anxiety
• Delusions
• Hallucinations
• Paranoid ideas
• Misidentifications
Ask yourself – how many times have you
seen these symptoms in someone with
dementia? Remember, dementia is not
just having a ‘poor memory’!
Antipsychotics used in dementia
•
These include older antipsychotic drugs (e.g. halopeirdol) or newer medications (e.g.
quetiapine, olanzapine, risperidone, amisulpride, aripiprazole)
•
Side effects: greater in older people - increased stroke risk, increased cardiovascular
risk, Parkinsonian side effects, falls, additional deaths
•
These are class effects, not limited to one particular drug
•
Not licensed for the treatment of agitation (except risperidone)
•
20-30% of people in nursing homes with dementia are on an antipsychotic
•
NHS survey 2007/8: 5.3% of people over 65 are prescribed an antipsychotic
•
These drugs are often inappropriately prescribed to ‘control’ BPSD
Some alternatives to antipsychotics
Simple patient-centred care plans can help prevent and
soothe behavioural and psychological symptoms in
patients with dementia whilst in hospital:
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•
•
•
High quality ward and nursing environment
Availability of appropriate activities for patients with
dementia in hospital
Remember – collateral history is extremely helpful
Your clinical assessment:
– Behavioural assessment – ABC
•
•
•
•
Antecedents
Behaviour
Consequences
– Physical assessment, eg are they in pain?
– Mental state assessment to consider alternative
causes and treatments, eg for depression or sleep
disturbance
– Look at the mnemonic opposite as a guide for
assessing causes of symptoms in people with
dementia
Refer if necessary to Medicine for the Elderly or Old
Age Psychiatry
Think ‘PINCH ME’ to
identify any treatable
causes of symptoms
• Pain
• Infection
• Constipation
• Hydration
• Medication
• Environmental
Where you can make the difference
•
Establish if your patient with dementia has an individual care plan to help
prevent and manage behavioural and psychological symptoms (BPSD)
•
Carry out a full medical assessment to consider other reasons for BPSD
and try other treatments accordingly, eg: think ‘PINCH ME’!
•
Consider non-pharmacological alternatives such as reviewing the
environment before prescribing antipsychotics for BPSD
•
Involve the patient (where possible), the patient’s carer and/or family in
deciding what treatment is best
•
If you do prescribe an antipsychotic:
–
–
–
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Always monitor carefully for side-effects
Always make it time limited for review at discharge, or clearly communicate with the patient’s
GP why it was prescribed and that it needs review
Do not prescribe antipsychotic drugs for longer than 12 weeks without consulting a specialist
doctor
Also consider referral to the care of the elderly team and/or old age psychiatry team
Junior Doctor Call to Action
We commit to carefully considering whether
or not a prescription for antipsychotic
medication is appropriate for someone with
dementia who is in hospital and to reviewing
the prescription on transfer or discharge
from hospital
Junior Doctor Call to Action
Find out more and join us at
www.institute.nhs.uk/HospitalDoctorsC2A
And for a range of professional and patient leaflets and information, visit the
Alzheimer’s society at www.alzheimers.org.uk