Welcome to the Right Care
webinar programme
Now that you have joined in you will notice you are on mute.
If you have any questions throughout the webinar please write them in
the Q&A section located in the below right panel. There will be
opportunity to have your questions answered at the end.
We will take you off mute when your question is being answered so you
have the opportunity to speak to the panel.
If you would like to chat to other colleagues you can do so by typing in
the chat section. There is a drop down menu which will allow you to
select who you would like to send the message to.
This webex event will be recorded.
The pharmacist contribution to
the care of people with dementia
across health & social care
Denise Taylor, Anne Child,
Jonathan Mason
Speakers

Chair: Dr Denise Taylor Senior Lecturer,
University of Bath and President of CMHP
D.A.Taylor@bath.ac.uk
Speaker 1: Anne Child, Head of Pharmaceutical
Care & Clinical Standards, Avante Care &
Support
Anne.Child@avantepartnership.org.uk
Speaker 2: Jonathan Mason, Clinical Adviser
(Medicines) at NHS England London Region
Jonathan.Mason@nhs.net
Our Objectives
Scene setting
- Getting medicines right for people with dementia
- CMHP, CPPE & Royal Pharmaceutical Society
- Royal College of Psychiatrists
- Local research & need for proactive medicines
optimisation in dementia
 Pharmacist contributions to ensuring appropriate
medicines use in people with dementia
 NHS England Perspective
 Q&A Time

Dementia
“ a syndrome consisting of
progressive impairment in two or
more areas of cognition:
(memory; language; visuospatial &
perceptual ability; thinking &
problem-solving; personality)
sufficient to interfere with work,
social function or relationships”
Local & National
Getting medicines right for people with
dementia
CMHP, CPPE & Royal Pharmaceutical Society
Royal College of Psychiatrists - liaison
Secondary Care Prescribing of Antipsychotics
Prescribing Antipsychotics for
Older People with Dementia




CSM 2004 warning: stroke increased by over 3fold with risperidone or olanzapine and more
than doubled with any other atypical
antipsychotic agent.
Two epidemiological studies in 2005 showed
typicals had similar risk pattern
Prime Ministers Challenge – reduce by 2011
Audit 2012 – success story or….
Patient ID
ANTIPSYCHOTIC RISK ASESSMENT IN DEMENTIA
(AID - Assess, Investigate and Deliver best care)
DELIVER BEST CARE
1
ASSESS
Does the patient have dementia with psychosis or
exhibits severe physical aggression?
3
Complete a Capacity Assessment for informed consent to the treatment.
If lacking proceed under “Best Interest” guidance (see Mental Capacity
Act)
•Treat factors which worsen symptoms e.g. delirium & pain
•Treat underlying thrombo-embolic risk factors , dehydration, causes of
sedation e.g. medication and infection
YES
NO - do not
prescribe an
antipsychotic
•Maximise mobility
•Consider VTE prophylaxis
•Review the need for an antipsychotic on a regular basis, initially daily
•Review the need for their continuing use prior to discharge
2
INVESTIGATE
Look for factors which worsen symptoms & risk
factors for thrombo-embolism (CVA, DVT, PE, MI)
Delirium (see NICE CG103 – Delirium)
Pain
Dehydration
Sedation
Infection
Immobility
VTE risk assessment
When completed
Date:
•If prescribed post discharge arrange a post-discharge review as soon as
possible by primary care or specialist mental health services
• Do not give an antipsychotic to a patient with Parkinson’s disease or
Lewy Body dementia without advice from a psychiatrist or specialist
physician experienced in their use. Do not use the drugs stated below
Start with the lowest dose possible for clinical effect. Use oral
risperidone (max 2mg daily) or when oral administration is not possible
intra-muscular haloperidol (max 3mg daily).
Do not use anticholinergic medication routinely for problematic side
effect as they cause delirium in dementia as do other drugs with
anticholinergic side effects. Reduce the dose or stop the antipsychotic
Discuss with the patient & their relative/carer the risks and benefits of
their use. 1 in 3 people will benefit. 1 in 100 will experience a CVA
& 1 in 100 will die as a result of their use
Pharmacists Role




Look for underlying causes; ensure these are
treated effectively
Look for underlying medication precipitants;
withdraw if appropriate
Ensure smallest effective dose used of nonanticholinergic AP (risperidone); monitor for
effect
Ensure withdrawn if ineffective or symptoms
resolve
Possible care pathway for AD management in patients with behavioural symptoms
Diagnosis of Alzheimer’s
disease
No
Does the patient have
challenging behavioural
symptoms?
Yes
Consider psychological
and alternative therapies
Yes
Has there been a
sufficient response?
No
Monitor
Pharmacological
options
Professor Clive Ballard
Short-term
management
Longer-term
management
Rationale for Nonpharmacological interventions

Liaison Services (eg. Ballard et al 2002)

Clinical Psychologist (eg. Bird et al
2007/2009)

Staff training (Fossey et al 2006, Chenoweth
et al 2009)
Social Interaction (Cohen-Mansfield et al 1997,
2007, Ballard et al 2009)
Aromatherapy, herbal remedies and food
supplements
Study
Intervention
Design
Number
Outcome
Holmes et al
2002
Lavender
aromatherapy
Double blind
crossover, 10 days
n=15, NH severe
dementia
Significant
improvement in
agitation (p=0.02)
Smallwood et al
2001
Lavender
aromatherapy
and massage
Single blind RCT 2
weeks
aromatherapy +
massage v massage
only
n=21 In patients
severe dementia
34% improvement in
motor agitation
(p=0.056) with
aromatherapy
+massage
Ballard et al
2002
Melissa
aromatherapy
Double blind RCT 4
weeks
n=72, NH severe
dementia
Significant
improvement in CMAI
(p<0.0001)
Burns et al
2008/9
Melissa
aromatherapy
Double blind 12
weeks
n=100 ESSENCE
AD
To be completed
october 2008
Akhondzadeh et
al 2003
Oral Melissa
Single blind RCT
n=30
Agitation in 5% active
v 40% placebo
(p=0.03)
Freund-Levi et
al 2008
Oral omega-3
supplements
Double blind RCT
n=174
No overall effect, but
significant reduction of
agitation with apoE4
Recommendations for shortterm antipsychotic use
Non pharmacological Interventions and
alternative pharmacological treatments need to
be available
 Severity criteria need to be in place for the
prescribing of Antipsychotics to people with
dementia
 Relatives should receive full explanation
 Monitoring should be mandatory
 Treatment should not be continued beyond 12
weeks except in extreme circumstances - and
this should be policed

Neuropsychiatric symptoms in AD:
Potential alternative therapies
Sodium valproate*
Meta-analysis (Lonergan et al 2008): Low doses ineffective, higher
doses poor tolerability
Carbamazepine*
2 small 4-6 week RCT focusing on agitation/aggression, both with positive
outcomes (Tariot et al 1998, Olin et al 201). Meta-analysis shows significant
benefit on CGIC and BPSD (Ballard et al 2009). New Norwegian study this week
trend to improvement of agitation. Hollis 2007 – no  mortality.
Gabapentin*
Systematic review (Kim et al 2008): few small case series only
Trazadone*
Meta-analysis (Martinon-Torres et al 2008): 2 trials, 1 parallel group, 1 cross-over.
Insufficient evidence to recommend as a treatment
Citalopram*
Two promising RCT, 1 v placebo, 1 v risperidone
Memantine
Meta analysis suggests significant benefit for “behaviour” (2.76 points on NPI –
McShane et al 2008). Promising post hoc pooled analysis (Wilcock et al 2008)
Cholinesterase
inhibitors
Ineffective over 12 weeks (Howard et al 2007 –CALM-AD). Meta-analyses and
pooled analyses suggest 1.5-2 point advantage on total NPI over 6 months (Trinh
et al 2003)
* Not licensed for treatment of AD
Assessment Tools
Assessing cognition in older
People: a practical toolkit
for health professionals
.
http://www.alzheimers.org.uk/cognitiveassessment
Recent Research

-
Pharmacist input
concomitant medication
swallowing difficulties
compliance issues
repeat prescribing problems, and
lack of proactive information provision
Potential Pharmacist Input





Medicines management issues
Concomitant medication
Medicines use reviews
Progression, and at any stage
Proactive provision of information
See the RPS Practice Guidance for dementia
http://www.rpharms.com/public-health-resources/mental-health.asp?
Medicine Management Issues






Counselling points
All medication
Cautions
Side Effects
Assessing Efficacy
Withdrawal Issues – all medication
Concomitant Medication





Check for anticholinergic load e.g oxybutynin;
antidepressants; thioridazine;
Check for adverse CNS effects e.g. Long acting
benzodiazepines, barbiturates; opiates; dopaminergics
Check need for antipsychotics – risperidone only licensed
agent in aggression
Any agent potentially causing confusion e.g. LA
hypoglycaemics; NSAID’s H2 antagonists e.g. cimetidine
Ensure all CV and diabetic risks treated appropriately
Medicines Use Reviews
http://www.pm-modules.co.uk/pm_modules/dem_pm0713.pdf


-


Appropriate titration
Check for side effects
Cholinergic
Cardiovascular
Cramps
compliance issues and repeat
prescribing problems
Other medicines – question everything
Compliance (Secondary
Adherence) issues
Large numbers of medicines
 Interactions or side effects
 Timing
 Remembering
 Strain on main carer/PWD living on own
 Repeat prescribing issues
- stock, labelling issues, equal quantities of all
medicines, formulation

Progression





Swallowing difficulties
Behaviour
Dietary intake and fluid
Bowels
Palliation
Proactive Information

On diagnosis
-
signposting to support groups & social service
support

Lifestyle changes to keep healthy
-
healthy body is a healthy brain

On receiving a medicine for dementia
-
AE, compliance issues, concomitant medicines

Social, ethical and legal issues
- Advance Directives, wills, Power of Attorney etc
 Care & end of life issues
Social Care & Support







CPN monitoring
Psychiatric care support programme
Care & patient
counselling/support/stimulation
Day hospital services
Social worker assessment
Respite care
End of Life Care – hospice?
Why is this Important?



Prolonged stress leads to poorer
health outcomes for both carer and
PWD and then institutionalisation
Better quality of life for people if
better adherence to their medicines
Carers more supported in coping
with supervisory medicines role
Public Health and Dementia?
Lifestyle changes which
improve cognitive
reserve
Better and continuing
education & occupation
Physical activity and
exercise
Midlife obesity
Alcohol intake
Smoking cessation
?improved social
networking
Improved treatment or
prevention of certain
medical conditions
Stroke prevention
Diabetes control,
midlife hypertension,
Midlife
hypercholesterolaemia
Midlife fitness levels
QUALITY OUTCOMES FOR
INDIVIDUALS WITH DEMENTIA
Anne Child
Head of Pharmaceutical Care and Clinical Standards
Avante Care and Support
HERE WE ARE! - WHERE ARE WE



?
Challenges faced in delivering quality
outcomes for residents with dementia
Dementia is in itself a complex condition
requiring a MDT approach
Residents are often living with more than two
other LTC that need close monitoring and coordinated management across specialisms
There is a need to meet health and social care
needs in order to promote overall well being
IMPROVED INTEGRATION
HOW THIS WOULD HELP WITH MUR !
Access to specialist input in home
environment - GPs can access support
i.e. ask consultants:
Is there a pathway where pharmacists
could tap into specialist pharmacists and
thus improve residents outcomes?
Continued





This could be used post review to enhance
recommendations - more MDT working
Facilitate medicines optimisation and or
facilitate withdrawal of low dose
antipsychotics
how many community pharmacist would
feel confident to initiate withdrawals?
Improve professional understanding
Help with management and positive care
planning for residents
Example of medication review outcomes
POSITIVE CARE PLANNING I.E. LBD



Pharmacist Input could be focused on the
individual, not the drug profile:
Increase staff awareness to drug
sensitivity of individuals with this diagnosis
Increase risk of postural hypotension and
falls, target this area in MURs
Reduction in psychotropic medication by
management of disease manifestations
Advanced care planning

Adequate information for individuals and their
relatives to support decision making

Some areas have this well managed see PEACE
pathway Kings College for last months of life

Medway has the my wish register
APPROPRIATE USE OF LOW
DOSE ANTIPSYCHOTICS



In practice at home level we apply best
practice
Watchful waiting - Psychosocial
interventions - In some residents we have
found it is appropriate to use this form of
medication in line with the Banerjee report
Regular review
OTHER HEALTH CARE PROFESSIONALS
Avante is lucky enough to have:


An Admiral Nurse who works with
individuals, families and staff to improve
understanding and manage expectations
of care
A Health and Wellbeing specialist who
oversees nutrition and hydration
MORE THAN THE DRUGS
OUTCOME LINKED



Reducing avoidable hospital admissions
linked to medication, falls, nutrition and
hydration
Personalisation of care and improved
expectations
Living well with dementia as opposed to
suffering from dementia
Jonathan Mason
Clinical Adviser (Medicines) at NHS
England London Region
‘Why dementia matters to me, and why it
should matter to Pharmacy’
Conclusions





Dementia is a complex and life changing
condition
It affects spouses, partners, families and
communities
Needs are multiple and varied
Medicines can play an important role in
delaying progression and Improving behaviours
Pharmaceutical Care for people with dementia
and their carers needs to be proactive
Questions
Today we have briefly looked at how
pharmacists are and can help support
people living with dementia
in any care sector.
We would value your questions or
comments
Dementia Action Alliance.
If you would like to join DAA for support in
your practice in dementia please join here:
http://www.dementiaaction.org.uk/join_the_a
lliance
There are further resources after the the
next slide
Thank you
The Dementia Action Alliance will send you an invitation to join our
Linkedin network over the coming weeks.
For today’s slides and any other resources from past webinar events
please visit: http://www.dementiaaction.org.uk/rightcarewebinars
Alzheimer's Society

Assessing cognition in older people: a
practical toolkit for health professionals.
http://www.alzheimers.org.uk/cognitiveassessment

Reducing the use of antipsychotic drugs: A
guide to the treatment and care of
behavioural and psychological symptoms of
dementia
http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=1133
Mortality risks: typical and
atypical antipsychotics
Risks
Typical
Atypical
References
Death
++
+
Ballard, Rochon, Gill,
Schneeweis,
Schneider, Wang
Stroke
+(+)
+(+)
Gill, Hermann, Rochon,
Kleijer, Douglas
Heart
death
+
+
Ray, Wang
Pneumonia
+
++
Knol
DAT/CB
Responses to atypical
antipsychotics






Response** based on CGIC score at 12 weeks:
32% Olanzapine group
26% Quetiapine group
29% Risperidone group
21% placebo group
Overall comparison: p=0.22
** A response was defined as continued treatment with the original phase 1 study drug and at
least minimal improvement on the CGIC. DAT/CB
Schneider L et al. NEJM 2006; 355:1525-38.
Differential Survival
Differences in the survival rates in the DART-AD trial
Survival rate on placebo
Survival rate on a antipsychotic
80%
70%
60%
50%
40%
30%
20%
10%
0%
24
36
42
Survival rate on placebo
71%
59%
53%
Survival rate on a antipsychotic
46%
30%
26%
Number of months
Ballard C et al. Lancet Neurol 2009; 8(2):151-7.
Psychotropic drugs and BPSD
40-60% people with dementia in NH are taking antipsychotics1
Drugs
None
(n=13)
Delusions
(n=28)
Agitation
(n=72)
Depression
(n=35)
Neuroleptics
4 (31%)
13 (46%)
38 (72%)
16 (46%)
Benzodiazepines
0 (0%)
4 (14%)
10 (14%)
5 (14%)
Antidepressants
2 (15)
6 (21%)
17 (24%)
13 (37%)
Other psych
1 (8%)
1 (4%)
3 (4%)
0 (0%)
Table adapted from Ballard et al 2001
Stopping antipsychotics:
Impact on QoL
Follow-up
n=42
Social
Withdrawal
Daytime
sleep
Type 1
Behaviours
Wellbeing
CMAI
Baseline (sd)
FITS (sd)
Control
(sd)
Evaluation
(Baseline v
Follow-up)
6.64 (8.96)
-5.24 (13.56)
-1.29 (5.42)
T 2.1
p=0.04
-20.69 (23.24)
-6.20 (24.58)
-1.29
(24.38)
T 1.1
p=0.27
+34.74 (19.53) +13.44
(23.73)
+1.47
(24.29)
T 2.3
p=0.03
0.65 (0.69)
+0.34 (0.59)
+0.15 (0.98) T 2.2
p=0.03
42.88 (14.57)
+0.75 (22.35)
+5.29
(12.74)
DAT/CB
T 0.83
p=0.41
Further Information- general








Mental Health Resources http://www.rpharms.com/supporttools/mental-health-resources.asp
Pharmaceutical care Guidance in Mental health
http://www.rpharms.com/public-health-issues/mental-health.asp
Alzheimer’s Society http://alzheimers.org.uk/
College of mental health pharmacy http://www.cmhp.org.uk
CPPE Focal Point on Dementia
http://www.cppe.ac.uk/learning/Details.asp?TemplateID=Dementia%2
DW%2D01&Format=W&ID=174&EventID=CPPE Mental health
http://www.cppe.ac.uk/learning/programmes.asp?format=e&ID=47&the
me=11
CPPE http://www.thelearningpharmacy.com/
Taylor D.A. Medicines Use Reviews in Dementia. CPD Module.
Pharmacy Magazine June 2013.
Living with Dementia
Living with dementia
http://www.youtube.com/watch?v=WR74FEyc9KY&feat
ure=related
Communication
http://www.healthtalkonline.org/Nerves_and_brain/Carer
s_of_people_with_dementia/People/Interview/839/Ca
tegory/144/Clip/4016/dementiacommunication#dementia-communication
Dementia Video Clips
Alz Pt 1 of 4
http://www.youtube.com/watch?v=_OD0z0u93sw&feature=channel
Alz Pt 2 of 4
http://www.youtube.com/watch?v=VHxdAYmMfK4&feature=channel
Stan 3 of 4
http://www.youtube.com/watch?v=yykeknxMozk&feature=channel
Mum 4 of 4
http://www.youtube.com/watch?v=nl9xqm_9KbE&NR=1
Living with dementia
http://www.youtube.com/watch?v=WR74FEyc9KY&feature=related
Dementia tour (what its like to live with dementia)
http://www.youtube.com/watch?v=3hROU6f5TUQ
Carer Views on Medication

Over-sedated
http://www.healthtalkonline.org/Nerves_and_brain/Carers_of_peopl
e_with_dementia/People/Interview/833/Category/160/Clip/3519/
dementia#dementia

Problem in giving medication
http://www.healthtalkonline.org/Nerves_and_brain/Carers_of_peopl
e_with_dementia/People/Interview/830/Category/102/Clip/3693/
dementia-medication#dementia-medication

Availability of medication
http://www.healthtalkonline.org/Nerves_and_brain/Carers_of_peopl
e_with_dementia/Topic/2075/