Poor service provision is blamed for overuse of antipsychotics in dementia patients

BMJ 2009; 339 doi: (Published 16 November 2009) Cite this as: BMJ 2009;339:b4818
  1. Oona Mashta
  1. 1London

    About 144 000 UK patients with dementia are being given antipsychotic drugs unnecessarily, causing about 1800 deaths a year, a new report says.

    About 820 extra serious adverse events such as stroke each year can be attributed to inappropriate prescribing of antipsychotics, say the report’s authors, led by Sube Banerjee, professor of mental health and ageing at the Institute of Psychiatry, King’s College London.

    Only 36 000 patients may be deriving some benefit from treatment with antipsychotics, says the report on the use of such treatment in people with dementia, which was commissioned by the government.

    Professor Banerjee blamed the overuse of antipsychotics on a system failure.

    The report says, “Part of the reason for health and social care systems not being geared up to dementia is that this recent rapid growth in numbers has not been matched by service changes to accommodate different needs.

    “Just a generation ago there were far fewer cases of dementia and far less that could be done; yet the system has not changed in terms of workforce or training to help primary care to diagnose and treat people with dementia.”

    The government has now agreed to a series of steps the report recommends to drastically reduce the use of antipsychotics over the next three years in England. These include developing local clinical audits of the use of antipsychotic drugs for people with dementia in each of England’s primary care trusts.

    To support primary care in the community and in care homes, each trust should commission a service from specialist older people’s mental health services, the report suggests.

    It also urges the royal colleges of general practitioners and psychiatrists to develop a curriculum to train GPs in the skills needed to manage dementia, which it recognises is a complex problem.

    Better access is also needed to other types of psychological therapies to tackle the causes of agitation and aggression, it says.

    In January the government will appoint a new national clinical director for dementia to drive forward the proposed changes.

    Phil Hope, minister for care services, said, “Excellent examples of practice do exist, but our action plan will help make sure this is the norm, not the exception. Our new clinical director will provide strong leadership, supporting the NHS and social care [services] to safely reduce antipsychotics use and drive up quality.”

    Professor Banerjee believes that if the steps the government has agreed to are followed antipsychotic drug use could be reduced by two thirds over the next three years.

    He said the drugs should be used for a maximum of three months and only when the person represents a risk to themselves or others.

    Jamie Rentoul, the Care Quality Commission’s director of regulation and strategy, said the findings were worrying. He said, “We will be looking at this issue closely by scrutinising how care providers manage medicines and safeguard people. From April 2010 onwards all health and adult social care providers will register with us against a new set of essential quality standards.”

    Steve Field, chairman of the Royal College of General Practitioners, said, “This is an awful situation, but the blame cannot be laid at the door of GPs.

    “Looking after agitated patients can be very distressing for care home staff, and they undoubtedly put pressure on some GPs to prescribe these drugs—but this is not acceptable. GPs know the side effects, and antipsychotic drugs should only ever be used on a short term basis. Even then they should be constantly monitored and reviewed.”

    He said that the quality of care offered by care homes is patchy and that patients everywhere deserved good quality care, with access to experts in the care of elderly people and to alternatives to drug treatment such as talking therapies.


    Cite this as: BMJ 2009;339:b4818


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