misperceptions or hallucinations) and the prevalence of schizophrenia in people over the age of 65 is low (probably around one per cent).
Dangerous side-effects
Drugs like thioridazine and chlorpromazine were widely prescribed for dementia in the 1970s and 1980s but the severe side-effects of these medications prompted the prescription of newer, less harmful antipsychotic drugs such as risperidone and olanzapine. Te most common side-effects are cardiac (prolongation of the QT interval) and extrapyramidal Parkinsonian signs and symptoms.
In 2002, the Canadian Healthcare system identified excess mortality in patients treated with risperidone, which was confirmed a year later by the US Food and Drug Administration (FDA) and followed by a warning the next year from the European Medicines Agency for olanzapine and the UK Medicines and Healthcare Products Regulatory Agency (MHRA) for both drugs. Te FDA extended the warning to the drug aripiprazole in 2005 and in the same year identified a 1.7 times increase in mortality for all the novel neuroleptics. In November 2009 an independent report by Professor Sube Banerjee (Time for Action) commissioned by the Department of Health estimated that 1,800 deaths and 1,600 strokes were prompted by the prescription of these medications in the UK. Tis toll is in addition to the well-documented deleterious effects they have on cognitive function and also their contribution to precipitation of falls. With these recognised dangers, there is significantly increased awareness of the need for caution in the prescription of antipsychotic drugs in people with dementia.
Alternatives to antipsychotics Te evidence base for alternatives to antipsychotic drugs is somewhat patchy. A range of complimentary treatments are oſten cited as being effective in dementia care and while small studies oſten do show significant benefits for interventions such as bright light therapy and aromatherapy, generally the results are disappointing and insufficient to recommend their wholesale introduction into practice (a quick scan of the Cochrane database attests to this).
Alternative drugs are often prescribed and a variety have been suggested to be of help, such as clonazepam for people with a specific REM sleep disorder often seen in people with dementia, or memantine which appears to have some beneficial effects on dementia patients who have behavioural disturbances. Other medications with a patchy evidence-base include trazadone, clomethiazole and propranolol (sometimes used in people post-head-injury to control agitation). Antidepressants such as citalopram have been used with some benefit. Reverting to older neuroleptics showing an evidence-base for less harm is not justified as they are likely to have a similar side-effect profile to the newer agents.
Raising awareness
Te Department of Health in England has embarked on a series of strategies to promote awareness and encouragement for
SUMMER 2011
reduction in the use of antipsychotic medications in dementia care. Tese priorities are being mirrored in the devolved nations. A care pathway is being developed which should be of help to people in primary care and others, emphasising the need to look at preventative strategies (early awareness, the opportunities for non-pharmacological interventions), the importance of person-centred care in the management of individuals with dementia and the key role that short-term medication, including antipsychotics, can play.
A series of audits is being conducted to gain high-quality information, and some specific audits, such as the Royal College of Psychiatrists Prescribing Observatory for Mental Health-UK (POMH-UK), should play a key role in driving down the use of neuropletic medications, even if just by raising the threshold whereby a prescription is given. Te Dementia Action Alliance (DAA) - which includes the Alzheimer’s Society and the Department of Health – recently announced that it wants all prescriptions for antipsychotics to be clinically reviewed by the end of March 2012. Jeremy Hughes, Chief Executive of the Alzheimer's Society, said: “It is essential we bring an end to this chemical cosh and empower people with dementia and carers with the information they need to ensure they are not prescribed these drugs inappropriately.”
Some local measures
Tere have also been some notable local initiatives that have proved successful. In 2010 the Orders of St Johns Trust initiated a policy of requesting information on which of its care home residents had medication reviews completed by a GP over a two-month period. If reviews had not taken place, the home was asked how the issue would be addressed. Te policy has resulted in a 16.6 per cent reduction in antipsychotic drug prescribing over a six-month period.
In Cornwall, health officials have developed a Dementia and Medications STAR Campaign. STAR (Stop, Tink, Assess, Review) is a county wide, multi-agency educational toolkit aimed at reducing the use of inappropriate medication in people with dementia. It was developed by the local PCT, Royal CornwallHospitals Trust and Cornwall Care. It provides information regarding behavioural and psychological symptoms of dementia (BPSD), explanations of contributing factors and alternative strategies to medication. It also promotes a three- monthly checklist to review, monitor and reduce prescribing. Such initiatives replicated across the UK should help bring about a change in attitude and practice in dementia care at a time when the older population is expanding year on year. For more information on the DAA initiative go to
www.tinyurl.com/6guz5lu
nProfessor Alistair Burns is National Clinical Director for Dementia (England) at the Department of Health, Professor of Old Age Psychiatry, University of Manchester and Honorary Consultant Psychiatrist at the Manchester Mental Health and Social Care Trust
13
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24