Antipsychotic prescribing patterns in care homes and relationship with dementia

AIMS AND METHOD

To determine the prescribing patterns for antipsychotics incare homes for the elderly, a cross-sectional study was carriedout using data from the intervention group of a randomisedcontrolled trial of medication review in care homes.

RESULTS

Of 331 residents studied, 67 (20%) were prescribed an antipsychotic(70% atypical); 57 of these (85%) did not have a diagnosisof a psychotic disorder. The antipsychotic prescribing ratewas 32% (46 out of 146) for those with dementia and 10% (17out of 174) for those without dementia. A quarter (82 out of331) had received a medication review by the general practitionerin the preceding 12 months.

CLINICAL IMPLICATIONS

One-fifth of residents were prescribed an antipsychotic withlittle evidence of review. Systems should ensure residents’treatment is reviewed regularly.

Introduction

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Introduction

The use of antipsychotics by care home residents has been ofconcern for many years. In the USA, the prescription of antipsychoticsto up to 55% of nursing home residents led to the introduction,in the Omnibus Reconciliation Act 1987, of legal restrictionson the use of these drugs (Lee et al, 2004). In the UK, antipsychoticprescribing rates to care home residents ranging from 24 to28% have been reported (McGrath & Jackson, 1996; Passmore et al, 1996;Oborne et al, 2002; Fahey et al, 2003). Many of the residentsof these homes have Alzheimer’s disease or other formsof dementia, and treatment of behavioural and psychologicalsymptoms of dementia may be one reason for use of these drugs.However, there is only limited evidence for their efficacy for behavioural and psychological symptoms despite the widespreaduse (Schneider et al, 1990; Drugs and Therapeutics Bulletin, 2003;Lee et al, 2004). A recent systematic review concluded thatfurther evidence is required before these drugs can be endorsed (Lee et al, 2004).

Antipsychotics are associated with significant harm, includingan increased risk of falls (Evans, 2003) and long-term cognitivedecline (Wisniewski et al, 1994; McShane et al, 1997). Afterconcerns about cardiac safety, the Committee on Safety of Medicinesplaced restrictions on the prescribing of thioridazine andsertindole; droperidol was discontinued by the manufacturer (Medicines and Healthcare Products Regulatory Agency, 1999, 2000, 2001). An increased risk of ischaemic stroke has beenassociated with atypical antipsychotic use in elderly patientswith dementia (Medicines and Healthcare Products Regulatory Agency, 2004),and this led the Committee on Safety of Medicines to issueguidance that risperidone and olanzapine should not be usedfor treating behavioural symptoms of dementia. A more recentstudy suggests that the risk of ischaemic stroke is similarfor both atypical and conventional antipsychotics (Gill et al, 2005). Furthermore, typical antipsychotics have been associated witha higher risk of death in the elderly compared with atypicals (Wang et al, 2005).

Prior to its restriction, thioridazine was the most commonlyused antipsychotic in UK care settings, accounting for 51-74%of prescriptions (McGrath & Jackson, 1996; Oborne et al, 2002). To our knowledge the prescribing of antipsychotics in UK carehomes has not been studied since thioridazine was restricted.The aim of this study was to determine the prescribing patternsof antipsychotics in care homes for the elderly since the restrictionson thioridazine.

Method

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Method

A cross-sectional study was carried out in 65 care homes forolder people in Leeds (nursing, residential and mixed carehomes). Baseline data were used from the intervention groupof a randomised controlled trial of a clinical medication reviewof elderly care home residents against usual care (ISRCTN45416155;Zermansky et al, 2006).

Approval was obtained from the local National Health Serviceresearch ethics committee. We approached all care homes inthe Leeds area with six or more residents aged 65 and over,seeking to include all residents taking one or more medicineson a long-term basis. We excluded those who were in another clinical trial or who were terminally ill. We excluded individualsat the general practitioner’s (GP’s) request. Weobtained informed consent from those able to grant it and assentfrom the nearest relative from those with impaired capacity.

Data collection
Clinical data were collected from GP records from 59 practicesbetween April 2002 and July 2003. Details of repeat medicineswere recorded for each participant. Typical and atypical antipsychoticswere defined as listed in the British National Formulary, section4.2.1 (British Medical Association & Royal Pharmaceutical Society of Great Britain, 2005).

All participants were assessed for physical dependency usingthe Barthel Index (Wade & Collins, 1988) and cognitiveability using the Standardised Mini-Mental State Examination(SMMSE; Molloy & Standish, 1997).

Results

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Results

Prescription data were obtained for the 331 residents in 13nursing, 38 residential and 14 mixed care homes who were randomisedto the intervention group. Care home size ranged from 6 to128 residents. Different types of homes, for example owner-operated,local authority-owned, medium-sized groups and large chains,were represented. Of the 331 residents, clinical data were availablefor 320 (97%). Medical records were unavailable for 11 residents owing to death or misplacement of records. Table 1 details residents’ characteristics. There were 146 residents(44%) who had a documented diagnosis of dementia and 249 outof 331 residents (75%) had some degree of cognitive impairment(SMMSE score <23); 24 residents (7%) had a documented historyof a psychotic disorder; 82 residents (25%) had a documentedmedication review by the GP in the previous 12 months.

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Table 1. Residents' characteristics (n=331)

Table 2 details antipsychotic prescribing. Out of 331, 67 residents(20%) were prescribed an antipsychotic, with 47 (14%) and 20(6%) prescribed an atypical and typical antipsychotic respectively.Of the 67 residents prescribed an antipsychotic, 10 (15%) hada documented diagnosis of a psychotic disorder and 46 (68.7%)had a diagnosis of dementia.

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Table 2. Antipsychotic prescribing according to type and diagnosis

Of the 146 residents with a diagnosis of dementia, 46 (32%)were prescribed an antipsychotic (typical 13 (9%); atypical33 (22%)). Only 7 of those prescribed an antipsychotic (10%)had a documented diagnosis of psychotic disorder, although15 out of 146 of the residents with dementia (10%) had a diagnosisof a psychotic disorder.

In contrast, of the 174 residents without a documented diagnosisof dementia, 17 (10%) were prescribed an antipsychotic (typical7 (4%); atypical 10 (6%)). Again out of 174, 9 of the residentswithout dementia (5%) had a diagnosis of a psychotic disorder,but only 3 of these were receiving an antipsychotic. It isnot clear why antipsychotics were prescribed to the other 6residents. For the 11 residents for whom diagnostic informationwas not available, 4 were prescribed an antipsychotic (allatypical).

The most commonly prescribed antipsychotic was risperidone (meandose 1 mg), which accounted for 57% of antipsychotic use (Table 3).

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Table 3. Antipsychotic prescribing by drug and documented diagnosis

Discussion

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Discussion

To our knowledge, this is the first study of antipsychotic prescribingin UK care homes since the restrictions on thioridazine usein 2000. The results show that in a sample of residents aged65 and over, from 65 care homes, one-fifth were prescribedan antipsychotic. This figure is slightly lower than previousUK studies, which reported antipsychotic prescribing rates of24 to 28% (McGrath & Jackson, 1996; Passmore et al, 1996;Oborne et al, 2002; Fahey et al, 2003). In a recent studyin two Canadian long-term care facilities, 21.5% of residentsin one facility and 31.3% in the other were prescribed an antipsychotic(Hagen et al, 2005). The corresponding figure in a sample of51 nursing homes in Australia was 24.5% (Snowden et al, 2006).In our study, almost one-third of residents with a diagnosisof dementia were receiving an antipsychotic. Of those prescribedan anti-psychotic, 15% had a documented diagnosis of a psychotic disorder and it is therefore reasonable to assume that 85%were receiving antipsychotics for unlicensed indications.

In our sample, risperidone had replaced thioridazine as themost commonly prescribed agent and demonstrated a shift fromtypical to atypical antipsychotic use. The mean dose of risperidoneused was 1 mg daily. It seems likely that risperidone becamethe standard choice of antipsychotic for use in care homesafter the restrictions imposed on thioridazine, without any reduction in the overall rate of prescribing. It is possiblethat since the safety concerns about risperidone and olanzapinehave come to light, other antipsychotics may have taken theirplace. Given the reports that these concerns may be applicableto all antipsychotics (Gill et al, 2005; Wang et al, 2005),it would seem desirable to reduce the frequency of antipsychoticprescribing for residents of care homes, particularly as themajority of residents in this study had evidence of cognitiveimpairment.

This study was conducted in a randomised sample of approximately10% of care home residents in Leeds. It included homes of arange of size and type, and covered inner city, suburban andrural areas. However, the results may not be generalisableto care home residents in other locations.

The UK National Service Framework for Older People requiresan annual review of all medicines and a 6-monthly review forthose on four or more medicines (Department of Health, 2001).However, in this study, only one-quarter of patients had a documentedmedication review by their GP within the previous 12 months. Antipsychotics can be withdrawn in up to one-half of patientswith no adverse effects on behaviour and functioning (Avorn et al, 1992;Schmidt et al, 1998), and alternative strategies are effectivein reducing agitation in people with dementia (Ballard et al, 2002; Holmes et al, 2002). Practices should therefore use the medicationreview markers on electronic records to ensure that all patientsand their treatment are reviewed regularly and the review documented.The reviewer should always consider whether it might be appropriateto withdraw medication. Reviews should be conducted by clinicianswith an interest in the management of dementia.

Behavioural approaches may be the treatment of choice for thebehavioural and psychological symptoms of dementia, but maynot be practical for very disturbed behaviour. Furthermore,such expertise and resources are limited in the care home setting.Antipsychotics may therefore be prescribed in desperation inthe face of challenging behaviour. However, there is little evidence of the value of antipsychotics in this situation.Furthermore, since this survey, studies have suggested thatthey may be harmful to physical health (Medicines and Healthcare Products Regulatory Agency, 2004;Gill et al, 2005; Wang et al, 2005).

Acknowledgments

We thank the other members of the trial team, Professor NickFreemantle and Dr Joanne Eastlaugh, Department of Primary Careand General Practice, University of Birmingham, Mrs Susan Thorntonand Mrs Denise Buttress, School of Healthcare, University ofLeeds. The study was funded by The Health Foundation.

References

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