Reducing Antipsychotic Drugs in Care Homes

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Keywords: Antipsychotic medication/ Nursing Practice Dementia/Care homes Research ●This article has been double-blind Medicines management peer reviewed 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 Reducing antipsychotic drugs in care homes

In this article... 5 key Risks of antipsychotic medication points At least 60% of Reasons for reducing or discontinuing antipsychotics 1people living in The nurse’s role in medication review care and nursing homes in the UK have dementia Authors Aileen Prentice is Boots Care multiple medications with these properties The use of Services operations manager, Boots UK; at the same time – which is related to 2antipsychotic David Wright is professor of pharmacy increased mortality (Fox et al, 2011). medication in practice, School of Pharmacy, University Within the US, legislation was intro- people with of East Anglia. duced to reduce antipsychotic prescribing dementia is Abstract Prentice A, Wright D (2014) in care homes (US Federal Government, widespread, and Reducing antipsychotic drugs in care 1987). Homes are required to employ an causes an homes. Nursing Times; 110: 22, 12-15. independent consultant pharmacist to additional 1,800 Antipsychotic medication should be used undertake regular review of antipsychotic deaths per year in people with dementia only when there medication, with the aim of reducing or Antipsychotic is an identified need and the benefits discontinuing drugs. Evidence suggests 3drugs outweigh the risks. An audit-based service this has been effective (Gurvich and Cun- contribute to the provided by pharmacists, working with ningham, 2000). anticholinergic nursing and care staff in residential homes, Within most care homes in the UK, burden, which is resulted in antipsychotic doses reductions nursing and care staff and GPs provide associated with of 20% and drug discontinuation in 17% of care and manage medicines, with occa- increased mortality residents with dementia. sional visits from an independent pharma- Quetiapine is cist from a primary care organisation to 4commonly rescribing and medicines man- review prescribing, and monthly inter- prescribed for agement in care homes, which is actions with a community pharmacy to behavioural and largely the responsibility of supply the medicines. psychological Pnurses, care staff and GPs, needs While an independent pharmacist symptoms, but its improvement (Alldred et al, 2013). One of working closely with nursing and care use is unlicensed the main areas of concern is the inappro- staff has been shown to realise significant Working with priate use of antipsychotic medication medicine acquisition cost savings and 5pharmacists (Parsons et al, 2012); an estimated 180,000 improve residents’ quality of life, the can make nurses people with dementia are treated with impact on longer-term outcomes is largely more confident in antipsychotic medication in the UK every unknown (Alldred et al, 2013). questioning the year (Banerjee, 2009). The care home popu- One study based in northern England, appropriateness of lation is frail and susceptible to the side- using a pharmacist employed by a medical antipsychotics effects of antipsychotics (Box 1). practice with a close working relationship It has been estimated that the use of with GPs and care and nursing staff, dem- antipsychotic medication in patients with onstrated a significant reduction in falls dementia – who represent at least 60% of after a pharmacist-conducted clinical the care home population in the UK – medication review (Zermansky et al, 2006). equates to 1,620 cerebrovascular adverse In another study, where a specially trained events and 1,800 deaths per year on top of pharmacist focused on antipsychotic use those that would be expected (Banerjee, in people with dementia, a 25% reduction 2009). Antipsychotics make a significant in antipsychotic prescribing was achieved contribution to what is known as the (Child et al, 2012). “anticholinergic burden” of prescribed New legislation to improve antipsy- Quetiapine was the antipsychotic most

Alamy medication – the cumulative effect of using chotic prescribing in the UK is unlikely, so often prescribed, in an unlicensed use

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we need practical and sustainable models Box 1. Side-effects of took place, with a particular focus on falls of care to address concerns regarding antipsychotics and cardiovascular accidents. antipsychotic prescribing. Where it was deemed necessary, the Government plans for community pharmacists recommended that staff pharmacies include greater involvement ● Sedation should discuss titrated withdrawal of in the management of long-term condi- ● Postural hypotension antipsychotic medication during the tions (Department of Health, 2008). In ● Extrapyramidal symptoms such as review. The audit pharmacist also dis- addition to care and nursing staff and GPs, restlessness cussed with the home staff the informa- community pharmacists in primary care ● Muscle twitching tion that would be provided and discussed are ideally located to review monthly pre- ● Parkinsonian symptoms with the GP or psychiatrist during the scriptions for residents in care homes. ● Tardive dyskinesia (permanent review. This could include a description involuntary movements) of other ways of managing BPSD, and The national audit of care homes ● Cardiovascular accidents how the resident’s needs were being met Our national pharmacy chain services a after admission to the care home, large number of care homes across the UK. including how the need for medication Care home leadership teams had confirmed diagnosis of dementia, and the may have changed. expressed a need for support in better resident was taking the medication for The audit visit was seen as helpful managing the medicines of their residents, other medical conditions such as schizo- in facilitating a conversation between with antipsychotic prescribing identified phrenia or bipolar disorder, they were not home staff and their GP to challenge pre- as a priority area. included in the audit. scriptions. A document was provided to It is an NHS contract requirement for The homes sent consent letters to the the home to enable them to request an community pharmacists to undertake at relatives of those residents identified as anti-psychotic medication review from least two audits per year (Pharmacy Ser- potentially suitable for the audit as well as the GP. Homes decided whether to use vices Negotiating Committee, 2013). We an introductory letter to their GPs. the form or to make more informal therefore carried out an audit of antipsy- direct requests. chotic medication between July 2010 and The audit process June 2012 with homes that were customers Pre-audit joint strategy Follow-up of our company and that had requested the Before discussing individual residents, the Pharmacists telephoned or revisited the service. The homes were run by national audit-trained community pharmacists homes twice, two to four months after the chains of care homes and were located in worked with the professionals responsible audit visit, to ascertain the impact of their England, Scotland and Wales. for patient care at each home to create an recommendations. joint strategy for the use of antipsychotic || ||| || | | | | 26% medication in line with national guidance Data governance and ethics | |

| Percentage of residents | | (National Institute for Health and Care No resident-identifiable data was removed

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| receiving antipsychotic |

| FACT Excellence, 2006). from any care home. All databases con-

| | drugs despite having |

| | no symptoms tained unique reference numbers, which Pre-visit work could be identified only within care homes Before the audit visit, care home managers or community pharmacies providing the Preparation for the audit were asked to collate the following infor- service and were stored on password- Community pharmacists were trained to mation for all relevant residents: protected computers. provide the audit-based service using » Date of admission; As this was a service evaluation, which online training packages and attendance at » Date medication started; falls under the remit of clinical audit, eth- an Alzheimer’s train the trainer session. » Medical conditions; ical approval was not sought. All homes This session increased their knowledge » Recent changes; provided written consent to participate. and enabled them to deliver a two-hour » Monitoring; The community pharmacists providing dementia awareness session to care staff in » History of falls and fractures. the service were employed by the company the care homes. Individual assessments to determine responsible for the regular provision of Using patient medication records held the presence of symptoms that required medicines to the residents so the review of nationally by the community pharmacy treatment with an antipsychotic were prescribing was within their remit. company, pharmacists undertook a clin- undertaken. ical assessment of antipsychotic prescrip- Results of the audit tions for individual residents to establish Audit visit Data was analysed from 463 homes, which possible reasons for starting the medica- During the audit visit, pharmacists recom- received a service from four audit-trained tion, the duration of the prescription and mended antipsychotic medication reviews community pharmacists on behalf of 350 any interactions. for residents who had not received a review company stores. A blank audit form, GP information within the last three to six months, or A total of 3,165 residents receiving letter, consent letter and explanation of the where there was evidence of side-effects or antipsychotic medication were reviewed, process were sent to home managers. They no current symptoms of behavioural and of whom 1,300 (41.1%) had a recorded diag- were asked to identify residents who were psychological symptoms of dementia nosis of dementia; 1,180 reviews were prescribed at least one antipsychotic med- (BPSD). started in 2010, 1,078 in 2011 and 901 in ication, and who were either diagnosed Pharmacists and home staff discussed 2012. For six reviews, the year of initiation with dementia or suspected of having guidelines from NICE (2006). Then, for each was not recorded. dementia. If there was no suspected or resident, a risk versus benefits discussion Of the 3,165 residents reviewed, 2,341

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Table 1. Antibiotics prescribed to residents Actions resulting from the audit Table 2 shows the actions taken as a result Drug name Number of Percentage of of the audit process. A total of 653 patients prescriptions prescriptions out of 3,165 (20%) had their dose reduced while 548 (17%) had their prescription dis- Flupentixol decanoate 2 0.06 continued. Perphenazine 2 0.06 Just over half of dose reductions were Unknown 2 0.06 made before the audit visit, while the majority of discontinuations resulted Levomepromazine 4 0.12 from the audit visit. There were a large Pericyazine 5 0.15 number of anecdotal stories of significant Prochlorperazine 6 0.18 success as a result of this audit.

Benperidol 7 0.22 Discussion Flupentixol 10 0.31 This large-scale audit found that in care Zuclopenthixol 19 0.58 home residents receiving antipsychotic medication, 26% did not have any symp- Trifluoperazine 30 0.92 toms that necessitated regular antipsy- Sulpiride 31 0.95 chotic medication, and in 58% of cases the Chlorpromazine hydrochloride 41 1.26 risk of the medication was deemed to outweigh the benefit. This relatively simple Aripiprazole 52 1.6 audit-based service resulted in over 20% of Olanzapine 207 6.37 residents having their antipsychotic dose Promazine hydrochloride 235 7.23 reduced and more than 17% having antipsychotic medication discontinued. Amisulpride 288 8.86 With the known side-effects of antipsy- Haloperidol 396 12.18 chotic medication, including sedation, Risperidone 548 16.85 and an increased risk of falls and cardiovascular events, this service is likely to Quetiapine 1,366 42 have improved the quality of life of a large Total 3,252 100 number of care home residents. The results suggest that nurses working (74%) demonstrated symptoms that may Reviews of medication in care homes should regularly question necessitate antipsychotic treatment. In 236 A total of 1,772 (56.0%) residents had had prescriptions for antipsychotic medica- (7.5%) residents, antipsychotic medication a recorded review of their antipsychotic tion. This would ideally be done in was prescribed for BPSD, while a further medication within the previous three partnership with the GP and community 250 (7.9%) residents had been prescribed months, 465 (14.7%) within the previous pharmacist. antipsychotic medication for another con- six months and 228 (7.2%) in the previous It is not possible to determine what dition and had subsequently developed 12 months. would have happened without this service. dementia. Residents’ antipsychotic prescriptions It is reasonable to assume that the regular By the first visit 147 (4.6%) of residents were reviewed when: reviews recorded as being undertaken were deceased and a further 119 (3.8%) had » They were currently receiving another would have led to some antipsychotics died by the end of the follow-up visit. antipsychotic; being reduced or stopped. However, it is » They were demonstrating side-effects unlikely that the large reduction seen in Types of antipsychotic medication from their medication; such a relatively short period of time prescribed » The risks of antipsychotic medication would have occurred without active inter- Table 1 provides a summary of the anti- were deemed to outweigh the benefits; vention by the community pharmacists. psychotic drugs prescribed for the resi- » There was no evidence of symptoms; The level of recorded regular antipsy- dents reviewed. In 87 instances, a resident » There was no evidence of review. chotic medication review was high, so it is was prescribed more than one antipsy- Fig 1 shows the numbers of prescrip- perhaps surprising that so many medi- chotic concurrently and, in two cases, the tions in which these criteria for ques- cines were still considered suitable for name of the antipsychotic drug reviewed tioning were found. Risks were deemed to stopping or reducing as part of the audit was not recorded. Quetiapine represented outweigh benefits for 1,840 (58%) of pre- process. This may, however, demonstrate 42% of prescriptions, risperidone 16.8% scriptions, while there was no evidence of the value of using a third party to instigate and haloperidol 12.2%. symptoms for 824 prescriptions (26%). such reviews, as in the US model (US

Table 2. Changes to antipsychotic medication

Time Pre-audit Pre-visit Three months Six months after Total planning work after audit visit audit visit Number of dose reductions 327 (10.3%) 14 (0.4%) 228 (7.2%) 84 (2.7%) 653 (20.6%) Number of prescriptions discontinued 120 (3.8%) 2 (0.1%) 286 (9.0%) 140 (4.4%) 548 (17.3%)

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Federal Government, 1987) since this pro- Fig 1. Prescriptions queried vides a fresh perspective that is not clouded by historical practice. It may also provide support for less frequent inde- Another antipsychotic currently pendent reviews rather than regular in- prescribed (n=88) house reviews. It would, however, also seem sensible for nurses in care homes for Demonstrating side-eects from antipsychotic medication (n=345) older people to review local practice to ensure that antipsychotic medication Risk deemed to outweigh beneﬁts review is undertaken effectively. (n=1,840) The changes to prescribing at different time points of the project demonstrates No evidence of symptoms the value of developing a care home (n=824) strategy jointly, collecting information on each resident and holding interprofes- No evidence of review sional meetings to discuss individual pre- (n=614) scriptions. The development of a joint strategy for antipsychotic prescribing was 0 10 20 30 40 50 60 effective in reducing antipsychotic use, All prescriptions (%) while the visits to discuss individual residents’ prescriptions had a greater impact on therapy discontinuation. the “day job” to review patient care and References Although in 58% of cases, the risk of prescribing. Alldred D et al (2011) Interventions to optimise the prescribing for older people in care homes (protocol). antipsychotic medication was deemed to The audit team also reported, perhaps Cochrane Database of Systematic Reviews; Issue 4. outweigh the prescription, it would be unsurprisingly, that engagement of the tinyurl.com/Cochrane-older-prescribing unreasonable to expect all these prescrip- care homes involved was the key to suc- Banerjee S (2009) The Use of Antipsychotic tions to be discontinued, as such decisions cess. Where the leadership team focused Medication for People With Dementia. Time for Action. London: Department of Health. tinyurl. must be taken with care and all factors on positive outcomes for patients, we had com/RCPysch-antipsychotic-dementia require consideration. more engagement and enthusiasm Child A et al (2012) A pharmacy led programme to The reductions in antipsychotic pre- throughout the audit process. Further- review anti-psychotic prescribing for people with dementia. BMC Psychiatry; 12: 155. scribing seen in this audit are similar to more, in homes with more stable employee Department of Health (2008) Pharmacy in those found in other studies (Westbury et populations, more of the actions seemed England. Building on Strengths – Delivering the al, 2012; Patterson et al, 2010). to be followed though, which ultimately Future. London: DH. Fox C et al (2011) Anticholinergic medication use Quetiapine was found to be the most influenced patient outcomes. and cognitive impairment in the older population: commonly prescribed antipsychotic for the Medical Research Council cognitive function BPSD, which is an unlicensed use. Risperi- Conclusion and ageing study. Journal of the American done, the only licensed therapy, was used This is a simple audit in an important area Geriatrics Society; 59: 8, 1477-1483. Gurvich T, Cunningham J (2000) Appropriate use in fewer than one in six residents. The pref- of practice that has potential for providing of psychotropic drugs in nursing homes. American erence for quetiapine requires further significant improvements in patient care. Family Physician; 61: 5, 1437-1446. exploration, as national guidance states A large number of medicines were dis- Joint Formulary Committee (2013) General guidance: guidance on prescribing. British National that unlicensed use of medicines should continued or stopped as a result of this ser- Formulary. www.bnf.org only become necessary if the clinical need vice, which will in many cases have imme- National Institute for Health and Care Excellence cannot be met by licensed medicines (Joint diately improved quality of life. (2006) Dementia: Supporting People with Formulary Committee, 2013). It would The results suggest that nurses and Dementia and their Carers in Health and Social Care. www.nice.org.uk/CG42 therefore be appropriate for prescriptions carers in care homes for older people Parsons C et al (2012) Potentially inappropriate for quetiapine to be questioned. should question, at the point of initiation, prescribing in older people with dementia in care While this audit-based service focused whether antipsychotic therapy is required homes: a retrospective analysis. Drugs and Aging; 29: 2, 143-155. on strategies to manage the use of antipsy- and ensure the most appropriate drug is Patterson S et al (2010) An evaluation of an chotic medication once prescribed, an selected. At antipsychotic medication adapted US model of pharmaceutical care to additional emphasis by nurses, carers and reviews, they should be aware that this improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood GPs at the initiation of antipsychotic med- should always be undertaken from the Northern Ireland study). Journal of the American ication in patients with dementia in care perspective of discontinuing or reducing Geriatric Society; 58: 1, 44-53. homes on risk scoring, drug selection, therapy, rather than simply confirming Pharmacy Services Negotiating Committee (2013) effectiveness monitoring and review is that the therapy is working and not Community Pharmacy Contractual Framework. www.psnc.org.uk/contract perhaps also required. causing any harm. Working with suitably US Federal Government (1987) Omnibus Budget The audit was designed to encourage trained pharmacists provides the opportu- Reconciliation Act of 1987: Subtitle C, Nursing conversations between nurses, care home nity for an independent perspective on Home Reform Westbury J et al (2011) A 12-month follow-up study staff and GPs about antipsychotic medica- the appropriateness of and need for of “RedUSe”: a trial aimed at reducing antipsychotic tion. The pharmacists reported that it therapy. NT and benzodiazepine use in nursing homes. appeared to empower the nursing and International Psychogeriatrics; 23: 8, 1260-1269. care staff to feel more confident with GPs. ● Declaration of interest: corresponding Zermansky A et al (2006) Clinical medication review by a pharmacist of elderly people living in It also made nursing and care staff reflect author Aileen Prentice is employed by care homes – randomised controlled trial. Age and on current practice, taking time out of Boots UK, which funded this work. Aging; 35: 6, 586-591.

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