Patients, methods, and results

We visited 28 nursing homes in the south of Glasgow and examined the medicine dispensing sheets of all 909 residents. We identified those taking neuroleptics regularly and collected information on the drugs and dosages prescribed. We interviewed a senior member of nursing staff in each home to collect information on age, sex, psychiatric diagnosis, and why the drug was being used. We applied the guidelines of the American legislation to decide whether the drug was being used appropriately.

The guidelines state that the use of a neuroleptic is appropriate for (a) psychotic disorders and (b) organic mental syndromes associated with specific psychotic and non-psychotic behaviours that present a danger to the resident or others or that interfere with the ability of families or staff to provide care for the resident. Behaviours for which neuroleptic treatment is considered inappropriate are wandering, poor self care, restlessness, impaired memory, anxiety, insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, depression without psychosis, uncooperativeness, and agitation that is not dangerous. Neuroleptics should be prescribed for use as required only in appropriate conditions and for up to five days.

Table 1 shows the neuroleptic drugs prescribed. Of the 909 residents, 217 were taking neuroleptics regularly, of whom eight were taking more than one. Prescription of antipsychotic drugs was appropriate according to the American guidelines in only 27 (12%) of the residents. The 190 others had been prescribed the drugs for inappropriate reasons, most commonly for mild aggression and agitation, wandering, uncooperativeness, and insomnia.

Comment

Our finding that 24% of residents of nursing homes in south Glasgow were receiving regular antipsychotics is consistent with reported prevalences of 17%-30% in the United States before the legislation was passed. These high rates were the spur to introduce the legislation.

Most residents receiving neuroleptics in our study (88%) could be deemed to be receiving them inappropriately according to the American guidelines. Therefore implementing similar guidelines in Britain would affect the prescribing rate of these drugs in nursing homes. In addition, 4% of the residents taking antipsychotics were prescribed more than one antipsychotic drug and over a third (78, 36%) were taking amounts equivalent to more than 50 mg thioridazine daily.

The number of patients being prescribed potentially inappropriate and large doses of neuroleptics gives us cause for concern. None of these drugs is without hazard, and long term use has problems, including an increased risk of fractured neck of femur,2 increased constipation,3 and impaired cognitive function,4 as well as the more generally recognised problems of akathisia, drug induced parkinsonism, and tardive dyskinesia. Several neurotransmitter systems in elderly people are particularly susceptible to these drugs—for example, thioridazine is a particularly potent anticholinergic agent. The neuroleptic malignant syndrome is a potentially fatal reaction of all neuroleptics.

With the closure of large institutions and long stay hospital beds, residents of nursing homes are becoming a frailer and more dependent population, with a high incidence of coexistent illnesses and therefore an increased susceptibility to the side effects of neuroleptics. In addition, several American studies have shown little, if any, deterioration in behaviour after cutting down or stopping these drugs.5 One large study showed that antipsychotics could be stopped in 45% of residents with dementia alone and in 25% of those with a psychiatric diagnosis.5