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Dementia is emerging as a key issue in health and social care. The number of people with dementia in the UK is forecast to increase by nearly 40% over the next 15 years, from 700,000 to nearly 1,000,000.

Currently two thirds of care home residents have a form of dementia and there is evidence of widespread prescribing of antipsychotics in this setting. Concerns have been raised regarding the appropriateness and safety of prescribing antipsychotic drugs to people with dementia. With a view to addressing these concerns the All-Party Parliamentary Group (APPG) on Dementia has recently (April 2008) published its report, Always a last resort: Inquiry into the prescription of antipsychotic drugs to people with dementia living in care homes. The inquiry requested written evidence from a variety of stakeholder groups including people with dementia, carers, health and social care professionals, care home providers, academics, regulators and trade bodies. The Group also heard evidence from key organisations and individuals in oral evidence sessions held in February 2008. This article summarises the key issues from this timely document.

Use of antipsychotic medication for older people with dementia
There is consensus among professional bodies that for people with dementia over-prescribing of antipsychotics is a problem. Whilst there is limited published research into prevalence, one study of care home residents by Alldred et al 2007 supports this view. The prescribing rate for residents with dementia was 32% compared with 10 % for those without.

The recent Home from Home report (Alzheimer’s Society, 2008) focuses on the quality of care in care homes. The report reveals that care staff identify understanding and managing difficult behaviour as the most difficult part of caring for people with dementia. Ballard et al, 2006 observed that more than half of all people with dementia experience behavioural and psychological symptoms (BPSD) at any one time. The term BPSD includes experiences such as hallucinations and behaviours like agitation, aggression and disinhibition. BPSD are particularly common in people with dementia living in care homes (Margallo-Lana et al, 2001). Evidence suggests that anti-psychotics are often prescribed off-licence as a treatment for BPSD. Whilst some behaviour such as aggression may pose serious risk to individuals and those around them, other symptoms are associated with neither risk nor distress.

These symptoms may have different causes and meaning at the different stages of the disease. There is also an emerging view that BPSD are not only symptoms of the disease but an attempt on the part of the individual to communicate their needs. Such needs may include physical problems, for example infection or deafness, mental distress arising from depression or anxiety or indeed, environmental factors such as inactivity or under-stimulation.

Training, Staffing and Support
Dementia training is not a requirement for care home staff and currently there are inadequate numbers of staff trained to support this population. Under-recognition of the condition and lack of understanding of individual’s needs limit the ability to produce appropriate care plans. Training in areas such as person centred care, understanding challenging behaviour and communicating with people with dementia can provide carers with alternatives to resorting to medication.

Further barriers to the provision of good dementia care include high staff turnover in the social care workforce and poor leadership in care homes. Limited resource is tied up with managing risk with little time for other aspects of care. Improved leadership could help to ensure adequate supervision and standards in clinical practice.

With respect to medical training, the BMA submission to the APPG highlighted deficiencies with regard to postgraduate education for GPs. GPs are often faced with the role of recognising dementia and prescribing to patients with challenging behaviours in care homes. There is evidence that once medication is started, prescriptions are continued because of inadequate management and review. The work by Alldred et al revealed that only a quarter of the care home residents studied received a medication review by the general practitioner in the preceding 12 months. Furthermore, the Home from Home report highlighted that one third of care home managers reported limited or no support from older people’s mental health services and one quarter listed accessing advice from external services as one of the top three challenges in providing good dementia care.

Involvement of people with dementia, carers and advocates
With the introduction of the Mental Capacity Act 2005, decisions should be made in the best interests of people found to be lacking capacity. In order to do so carers or independent advocates should be consulted. There is widespread concern that people with dementia and their carers or advocates are being excluded from this process. In addition the Relatives and Residents’ Association have commented that in many cases no representatives (Independent Mental Capacity Advocates – IMCA) are appointed to act on behalf of individuals lacking capacity. Furthermore, when antipsychotics are prescribed, there is often little or no information regarding the reasons for prescription or the risks and intended benefits.

The Mental Capacity Act recognises in law Advance Decisions to Refuse Treatment. These statements enable individuals to refuse in advance, specific medical treatments. Consideration of such directives together with consultation with carers and advocates would help to ensure that the wishes of the person with dementia are taken into account.

Appropriate prescribing
There is consensus amongst voluntary agencies and professional bodies that prescription of antipsychotic medications to people with dementia is appropriate in specific situations. This is consistent with the clinical guidelines published by the National Institute for Health and Clinical Excellence and Social Care Institute for Excellence (NICE-SCIE, 2007). The guideline states that antipsychotic drugs should only be used in the first instance, if an individual is severely distressed or if there is immediate risk of harm to others. In less severe cases non-pharmacological interventions must be pursued before medication is considered. The BMA has commented that the use of antipsychotics for BPSD should be considered a form of restraint and therefore can only be justified in exceptional circumstances for the shortest possible time.

Evidence from placebo controlled trials in Patients with Alzheimer’s disease, supports a modest but significant effect for the treatment of aggression over 6-12 weeks. There are a limited number of trials that have run beyond 12 weeks and these demonstrate no benefits for aggression or other behavioural symptoms over 6-12 months (Schneider et al 2006). Work soon to be published by the Alzheimer’s Research Trust shows that for most people with Alzheimer’s disease, withdrawal of antipsychotics tends to improve functional and cognitive status.

Trials have highlighted the potential for serious adverse events when antipsychotics are prescribed for people with dementia. In 2005 the Food and Drug Administration publicised a doubling in the risk of mortality for this group. This followed recommendations by the Committee on Safety of Medicines (2004) that recognised the increased risk of stroke (up to 3 times) in people with dementia and cerebrovascular risk factors treated on olanzapine and risperidone. The APPG report also highlights the need to consider the loss of quality of life, which ensues from patients experiencing side effects to antipsychotic medication.

Appropriate prescribing of antipsychotics to patients with dementia should include a risk benefit analysis and there should be adequate documentation regarding the symptoms being targeted. The NICE-SCIE guideline recommends their use to be time limited and regularly reviewed (every three months or sooner if clinically indicated). The APPG concludes that currently there is widespread over-prescribing, often in cases where there are only mild behavioural symptoms and prescriptions are continued for prolonged periods in the absence of benefit. Given that guidelines are now available there should be regular audit around prescribing of antipsychotics in care homes.

Alternatives to antipsychotics
There is agreement that in order to provide good care to people with dementia, the condition needs to be recognised and diagnosed. Care plans need to be person-centred taking into account the individual’s wishes, lifestyle, culture and aspirations. The care plan should state the interventions that are appropriate and effective for that person. The environment in which care is provided should be rich and stimulating in order to facilitate a reduction in challenging behaviour.

The NICE-SCIE guidelines (2007) recommend various non-pharmacological interventions that should be considered prior to medication. These include aromatherapy, multi-sensory stimulation, music and dance therapy or massage. The evidence for these treatments is not high level but suggests beneficial effects. In addition there has been little concern regarding the safety of such therapies. A Cochrane review on psychological interventions is currently underway and should provide useful commentary.

It is important to note that if these approaches are to replace inappropriate prescribing then it is imperative that training of health and social care staff needs to take place. It has been suggested that training be linked to career structure to encourage retention of appropriately skilled staff. The Alzheimer’s society has recommended the development of national standards for dementia care training for care home staff. In their submissions the British Geriatrics Society and the Royal College of Psychiatrists both support further training for GPs on the management of people with dementia. Furthermore, care staff require effective support from external services via general practitioners and community mental health services. The support should be pro-active and regular.

At the commissioning level local authorities may have a role in improving standards by incorporating good care into service contracts.

Overall recommendations of the APPG
In conclusion the group recommends for an action plan to reduce the number of prescriptions of antipsychotic medication to be included within the forthcoming National Dementia Strategy for England (due for completion later this year). The action plan proposed is as follows:

1. Mandatory dementia training for care home staff.
2. Effective support for care homes from external services including GPs and Community Mental Health Services.
3. Inclusion of the use of antipsychotics in Mental Capacity Act Training for care home staff.
4. Introduction of protocols for the prescribing, monitoring and review of antipsychotic medication for people with dementia.
5. Compulsory regulation and audit of antipsychotic prescribing for people with dementia.

Whilst it remains to be seen how completely these recommendations are embodied in the National Dementia Strategy, there are clear learning points that can easily be incorporated into our everyday medical practice:

• Documentation of risk benefit analysis in antipsychotic prescribing to people with dementia.
• t Documentation of the symptoms being targeted by pharmacological interventions.
• Time limited use of antipsychotics to 3 months or less.
• Regular review of prescriptions and clarity as to who will review.
• At the first instance consider (and promote) behavioural and non-pharmacological interventions, which should be person-centred and tailored to the individual.

With respect to service development there are significant opportunities. The deficits in the support and training available to care home staff lend themselves to the provision of better and more regular ‘in reach’ services provided by PCTs or old age psychiatric services.

Having put the spotlight on prescribing in care homes, it is clear that over-prescribing of antipsychotics is both complex and multifactorial requiring a marked and sustained change in culture and approach from health and social care staff.

Sandie Metcalfe
Specialist Registrar in Psychiatry
Martin Curtice
Consultant in Old Age Psychiatry
Birmingham & Solihull Mental Health Trust

BGS Newsletter, Aug 2008
Issue 17 ISSN 1748-6343 17