University of Birmingham Impact of deprivation, dementia prevalence and regional demography on prescribing of antidementia drugs in England Vohra, Neha; Hadi, Muhammad Abdul; Khanal, Saval; Kurmi, Om P; Paudyal, Vibhu DOI: 10.1111/bcp.14782 License: Creative Commons: Attribution (CC BY) Document Version Publisher's PDF, also known as Version of record Citation for published version (Harvard): Vohra, N, Hadi, MA, Khanal, S, Kurmi, OP & Paudyal, V 2021, 'Impact of deprivation, dementia prevalence and regional demography on prescribing of antidementia drugs in England: A time trend analysis', British Journal of Clinical Pharmacology. https://doi.org/10.1111/bcp.14782 Link to publication on Research at Birmingham portal General rights Unless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or the copyright holders. 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Take down policy While the University of Birmingham exercises care and attention in making items available there are rare occasions when an item has been uploaded in error or has been deemed to be commercially or otherwise sensitive. If you believe that this is the case for this document, please contact [email protected] providing details and we will remove access to the work immediately and investigate. Download date: 24. Sep. 2021 Received: 2 July 2020 Revised: 19 January 2021 Accepted: 12 February 2021 DOI: 10.1111/bcp.14782 ORIGINAL ARTICLE Impact of deprivation, dementia prevalence and regional demography on prescribing of antidementia drugs in England: A time trend analysis Neha Vohra1 | Muhammad Abdul Hadi1 | Saval Khanal2 | Om P. Kurmi3 | Vibhu Paudyal1 1Institute of Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK Aim: This study aimed to examine trends in prescribing of antidementia drugs 2Behavioral Science Group, Warwick Business in primary care in England between 2009 and 2019, and investigate the impact School, University of Warwick, Coventry, CV4 7AL, UK of deprivation, regional demography and disease prevalence on prescribing 3Faculty of Health and Life Sciences, Coventry practices. University, CV1 5FB, UK Methods: Analysis of publicly available government data from various sources per- Correspondence taining to primary care prescribing and demographics was conducted. All primary care Vibhu Paudyal, PhD, School of Pharmacy, prescription data pertaining to antidementia drugs in England between 2009 and University of Birmingham, College of Medical and Dental Sciences, Birmingham, B15 2TT, 2019 were extracted and adjusted for inflation and population changes. Data across UK. English clinical commissioning regions were compared to explore the Email: [email protected] association between prescribing trend, deprivation, regional demography and Funding information dementia prevalence. University of Birmingham Results: The number of prescription items for antidementia drugs in England increased by approximately 3-fold (195.4%) from 24 items/1000 population in 2009 to 70.9 items/1000 population in 2019. In 2019, the least-deprived areas had approximately twice the rate of prescribing of antidementia drugs compared to the most-deprived areas (median [IQR] values of 46.7 [36.6-64.8] vs 91.23 [76.2-95.1] items/1000 population, respectively). In the multivariable analysis, the number of prescription items showed an inverse relationship with deprivation (coefficient −0.046, 95% CI −0.47 to −0.045) after adjustment for number of populations aged 65+ years and prevalence of dementia. Conclusions: The 3-fold rise in the number of prescription items for antidementia drugs in the study period reflects the policy emphasis on early diagnosis and treatment of dementia. Higher rates of prescribing in the least-deprived areas may be reflective of better and early diagnoses and access to treatments. Such inequality in access to the treatments needs to be investigated further. Principal investigator statement: The principal investigator for this study is Dr Vibhu Paudyal. This study involves analyses of publicly available government data from various sources pertaining to primary care prescribing and demographics. Hence, participants were not subjected to intervention as part of the research. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2021 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society. Brit Jnl Clinical Pharma. 2021;1–9. wileyonlinelibrary.com/journal/bcp 1 2 VOHRA ET AL. KEYWORDS acetylcholinesterase inhibitor, antipsychotic drugs, dementia, N-methyl-D-aspartate receptor antagonist, prescription patterns 1 | INTRODUCTION What is already known about this subject Globally, there are over 47 million people living with dementia, with this figure set to reach 135.46 million by 2050.1 As of 2019, a total of • There has been increasing policy emphasis on early diag- 472 890 people in England have a coded diagnosis of dementia.2 noses and management of dementia in primary care. The National Institute of Clinical Excellence (NICE) guideline on • Evaluation of prescribing practices in dementia has Dementia in England recommends acetylcholinesterase (AChE) inhibi- predominantly focused on minimising the potentially tors (donepezil, galantamine and rivastigmine) as monotherapies for inappropriate use of antipsychotics for the treatment of the management of mild-to-moderate Alzheimer's disease (AD).3 The noncognitive symptoms. NICE guideline recommends that the N-methyl-D-aspartate (NMDA) • The link between policy changes, prescribing practices, receptor antagonist, memantine, be used to treat moderate AD in deprivation and disease prevalence remains poorly patients who are intolerant or have a contraindication to AChE inhibi- understood. tors. Memantine is also recommended to be used in patients with an established diagnosis of AD when AChE inhibitors are already being What this study adds used. The NICE guidelines also recommend AChE inhibitors for the treatment of non-Alzheimer's dementia, but they do not have UK • In the last 10 years, there has been a nearly 3-fold rise marketing authorisation for this purpose and therefore must be pre- (195.4%) in the number of prescription items for scribed off-label.3 antidementia drugs, potentially reflecting the impact of In addition to AChE inhibitors and memantine, antipsychotics are policy emphases on early diagnosis and treatment. recommended for the management of noncognitive symptoms of • Least-deprived areas demonstrate up to twice the rate of dementia. These symptoms of dementia include agitation, aggression, prescriptions compared to most-deprived areas. distress and psychosis. In the UK, risperidone and haloperidol are the • Results indicate better and early diagnoses and access to only antipsychotics with a UK marketing authorisation to treat non- antidementia drugs in affluent areas compared to cognitive symptoms associated with dementia.3 deprived areas and this warrants further research. In the last decade, there has been an increased emphasis on the diagnoses and management of dementia in primary care, prior to any psychiatric referrals. The National Dementia Strategy (NDS), published in 2009 in England, emphasised the need to improve public and pro- targeted interventions to identify linked comorbidities and reduce fessional awareness and understanding of dementia and early diagno- health inequalities. The aim of this study was to analyse the trends in sis and treatment.4 The Quality and Outcomes Framework (QoF) is a prescribing of antidementia drugs in primary care in England from voluntary annual reward and incentive programme for all English gen- 2009 to 2019 and to investigate the impact of deprivation and eral practices. It incorporates better diagnosis and management of regional demography on prescribing practices. dementia, including a follow-up care plan in primary care as one of the key quality indicators.5 Evaluation of prescribing practices in dementia has predominantly 2 | METHODS focused on minimising the potentially inappropriate use of antipsy- chotics to treat noncognitive symptoms6–9 as overprescribing of anti- 2.1 | Ethical consideration psychotics can contribute to cardiovascular morbidity and mortality mainly caused by stroke and ischaemic heart diseases; the drugs This study represents a secondary analysis of the information therefore should only be prescribed where patients are severely dis- retrieved from publicly available anonymised datasets and does not tressed and