Authors' replyBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7047.1669 (Published 29 June 1996) Cite this as: BMJ 1996;312:1669
- Alice Mcgrath,
- Graham A Jackson
- Senior registrar in child and adolescent psychiatry Knightswood Hospital, Glasgow G13 2XJ
- Senior registrar in old age psychiatry Hairmyres Hospital, East Kilbride
EDITOR,—Like McAllister-Williams and Ferrier, and Tarbuck, we were also concerned about the media coverage of our recent article. We feel this matter was treated with an air of hysteria not justified by the content of our paper. We too would be concerned about the introduction of legislation to control neuroleptic prescribing, and at no point in our article do we advocate this.
Various authors (McAllister-Williams and Ferrier, and Thacker and Jones) have questioned our methodology and interpretation. Our selection of homes was geographical. It was simply a survey of prescribing levels using the only available (American) guidelines, which roughly mirror recommendations in the British National Formulary.
Cameron et al state that 90% of their patients have disturbed behaviour. This may reflect staff tolerance of behaviour rather than showing a need for medication. Their commonly reported problems (agitation and nocturnal restlessness) could be akathisia, a common side effect.
However, the most important issue is whether neuroleptics should be used. Studies have shown that neuroleptics have limited effects—18% benefit compared with placebo.1 These studies were too short, at 6 weeks, to show ongoing benefit or to show side effects which develop later, such as tardive dyskinesia, Parkinsonism, and akathisia. Discontinuation studies, after the American legislation, suggest that there is often no need for ongoing medication.2 Some commonly used neuroleptics have a high incidence of cholinergic effects, which may aggravate confusion and lead to many other side effects.
Documentation of behaviour problems should, indeed, be routine within long term care settings. As Tobiansky and Blanchard point out, environmental factors, physical problems, and staff tolerance must be addressed before medication is considered. Should drugs with considerable morbidity and, indeed, mortality3 4 be used simply because a patient is noisy, as suggested by Cameron?
If neuroleptics must be used, then it should be for as short a period as possible. We must remain aware of the potential for side effects, often not attributed to the drugs, when patients are being managed in non-hospital settings.
We hope that our article will contribute to the debate regarding neuroleptic prescribing in elderly people and, by raising various issues, help lead to more appropriate use.
We believe, along with Tarbuck, and Tobiansky and Blanchard, that the way to improve on prescribing levels in nursing homes is through education and training of staff and the primary care team. Drug use should not be the first choice in the management of behavioural difficulties.
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