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Old Age Psychiatry, Holly House, St Mary’s Hospital, Greenhill Road, Armley, Leeds LS12 3QE, email: soyinka{at}mailcity.com
Humber Mental Health Teaching NHS Trust, Hull
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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To review the quality of information and advice contained in correspondence from old age psychiatrists to general practitioners (GPs) regarding the prescription of antipsychotic drugs for the management of behavioural and psychological symptoms of dementia. Discharge summaries (n=22) and subsequent out-patient review letters were examined and compared with evidence-based guidelines in two phases of an audit cycle; first in 2002 and latterly in 2005.
RESULTS
Practice was below acceptable standards during both phases of the audit cycle, with an actual drop in the quality of explicit advice given to GPs in 2005, despite national publicity about the issues and guidance from the Royal College of Psychiatrists.
CLINICAL IMPLICATIONS
The prescription of antipsychotic drugs is associated with an adverse prognosis for people with dementia. As such, it is imperative that such treatment is regularly reviewed and time limited. Old age psychiatrists need to ensure that this message is communicated to their primary care colleagues.
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Introduction |
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Until relatively recently, old age psychiatrists had considered ‘atypical’ antipsychotics to have a more favourable side-effect profile than the older ‘typical’ drugs in their patient group. However, in March 2004, the Committee on Safety of Medicines reported an apparent two- to threefold increase in the risk of cerebrovascular events in people with dementia prescribed olanzapine or risperidone, and recommended that these drugs should not be used in this group (message from Professor Gordon Duff, Chairman, Committee on Safety of Medicines; CEM/CMO/2004/1). In response to this advice, a joint guidance note was issued by the Faculty of the Psychiatry of Old Age of the Royal College of Psychiatrists, and other stakeholders, including the Alzheimer’s Society and was updated in 2005 (Royal College of Psychiatrists, 2005). This guidance supports the use of antipsychotic drugs for particular behavioural and psychological symptoms, when the problem is severe and when the individual or others may be placed at serious risk as a result of their symptoms. Emphasis is placed on the need to adequately document the reasoning and discussions involved in the decision to prescribe. Further, there is a recommendation that drug treatment is time-limited, with supporting evidence that antipsychotics can be withdrawn successfully in people who have been relatively free from symptoms for 3 months (Ballard et al, 2004).
Old age psychiatrists have a key role in ensuring that this message is understood by other prescribers, including general practitioners (GPs). Communication of clear guidance between secondary and primary care is therefore essential.
This audit examined the quality of information conveyed from secondary care to primary care in the Hull and East Riding area, when psychiatric in-patients with behavioural and psychological symptoms of dementia, who had been prescribed antipsychotics, were discharged to local residential/nursing homes. A first phase of the audit had taken place in 2002 when poor standards had been identified, and had led to a highlighting of the associated issues at a trust-wide level, including the education of junior doctors (Inasu et al, 2004). This report completes the audit cycle.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The initial phase of the audit had taken place in 2002, and therefore pre-dated the recommendations. Hence, slightly different criteria had been used. (The previous standards had stipulated that once the maintenance dose of antipsychotic drug was achieved, there should be a review at least once every 12 months rather than the 3 months now recommended). Nevertheless, very poor standards had been highlighted (see Table 1).
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Table 1 details the findings when agreed standards were applied to discharge summaries and subsequent correspondence to GPs. Comparison of the 2002 and 2005 figures shows that standards had not improved since the first phase of the audit cycle in 2002. Indeed, there had been decline in the quality of advice that had been given to GPs regarding the need to review the prescription of antipsychotic. This seemingly occurred despite the heightened publicity surrounding the issue and despite the presence of clear guidelines.
Of equal interest is the marked alteration in the balance of prescribing typical or atypical antipsychotic drugs, with the prescription of typical drugs increasing from 7% in 2002 to 50% in 2005 (see Table 2). This, presumably, is a consequence of the guidance from the Committee on Safety of Medicines regarding olanzapine and risperidone.
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Although not within the scope of the audit, an incidental finding was that a number of patients had been discharged on a benzodiazepine, again without appropriate advice being given on the need for review and monitoring.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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This audit revealed poor standards of practice in this regard, despite the issue of antipsychotic prescribing being highlighted, both locally, by the results of the first phase of the audit cycle, and nationally, by the publicity surrounding the Committee on Safety of Medicines guidance on risperidone and olanzapine in 2004 (message from Professor Gordon Duff, Chairman, Committee on Safety of Medicines; CEM/CMO/2004/1), and the subsequent launch of the Faculty of the Psychiatry of Old Age guidance (Royal College of Psychiatrists, 2005). There was no apparent change in the frequency of prescribing of antipsychotics for older people with behavioural and psychological symptoms of dementia during the audit period, but there was a shift towards prescribing the older ‘typical’ drugs. Such ‘typical’ drugs are associated with an increase in disabling side-effects in older people with dementia, including extra-pyramidal and anticholinergic problems, as well as potential worsening of confusion. Moreover, there is a mounting evidence base to suggest that they are likely to increase the risk of cerebrovascular events and death to the same order as their ‘atypical’ cousins (Gill et al, 2005; Schneider et al, 2005; Wang et al, 2005). It is unlikely that practice within the Humber Mental Health Teaching Trust differs greatly from other old age psychiatry services. Therefore, we assume that the issues can be generalised to many other areas in the country.
Despite the emphasis in this audit on drug treatments, it is clearly important for non-pharmacological management to be considered as first-line treatment. Where available, aromatherapy, reality orientation, validation therapy and recreational activity should be considered as treatment options (Douglas et al, 2004). Despite their widespread use, drug treatments only have a modest supporting evidence base in the management of the behavioural and psychological symptoms of dementia (Sink et al, 2005). Although this audit concerned the management of people who required in-patient care, and are therefore more likely to represent the more severe end of the spectrum, it does confirm the continued and concerning trend of ‘medicalising’ the behavioural and psychological symptoms by the prescription of drug treatments. More than half of those with dementia were discharged in receipt of an antipsychotic drug, at a time when concern about the effects of such prescribing had received significant publicity.
Following the introduction of the National Service Framework for Mental Health, and the new General Medical Services contract, registers of people with severe and enduring mental health problems are being developed in primary care. Until recently, these have not addressed the needs of people with dementia, a situation reinforced by the initial exclusion of dementia from the Quality and Outcomes Frameworks (QOF) contained in the contract. However, from April 2006, following successful lobbying by the Alzheimer’s Society, dementia care became one of nine new areas introduced into the QOF. It is now a target for GP practices to produce a register of all patients diagnosed with dementia, and for a review of their care to take place at least every 15 months. Although the time frame is far from ideal, this does provide a tremendous opportunity to ensure that such a review includes a consideration of the appropriateness of medication, including antipsychotic drugs, based on the evidence-based guidelines (Royal College of Psychiatrists, 2005). Secondary care services have a clear educational role in this regard. It is also important that old age psychiatrists follow good practice models in their written communications with primary care. Indeed, it is time for psychiatrists to grasp the issue and practice what we preach.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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BALLARD, C. G., THOMAS, A., FOSSEY, J., et al (2004) A 3-month randomized, placebo-controlled, neuroleptic discontinuation study in 100 people with dementia: the Neuropsychiatric Inventory median cut off is a predictor of clinical outcome. Journal of Clinical Psychiatry, 65, 114 -119.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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