I was very pleased to read March 17th’s editorial by Dr.s McCleery and Fox (Antipsychotic prescribing in nursing homes). Partly because it provided a helpful reminder of the clinical risks involved in prescribing antipsychotics for people with Dementia, but, moreover, because they managed to highlight and articulate an ethical conundrum I have found myself faced with on numerous occasions since starting my Psychiatric specialist training 2 years ago.
My first Psychiatry job was an Old Age Psychiatry community post and involved frequent home visits to Care Homes. I was fortunate to have a Consultant who was very conscious of the clinical and ethical challenges around the pharmacological aspects of managing Behavioural and Psychological Symptoms of Dementia (BPSD). But even with that support I frequently struggled with significant pressure from Care Home staff and sometimes relatives to prescribe something to ‘sort things out’.
At the moment, I am experiencing a parallel situation in a community Learning Disability job. Our patient group, many of whom live in Care Homes, are double-disposed towards ‘challenging behaviour’. The indirect route is seen in those patients with Down’s Syndrome who have an increased risk of relatively early-onset Alzheimer’s Disease. But Learning Disabilities can also be directly associated with challenging behaviour – via communicative difficulties, disinhibition, limited alternative coping strategies, etc..
This leaves our clinical population at an increased risk of staff seeking pharmacological ‘answers’ to behavioural and managerial challenges in Care Home/Supported Living environments. This frequently translates into requests for a prescription of something to help ‘calm the patient down’.
In our team, we are lucky enough to have the support of a Challenging Needs Specialist (CNS) whose input we can seek instead of taking the prescription pad option. However, there is only one CNS - and several hundred patients! The prescription pad is therefore sometimes required. Promethazine, via its sedating properties, can sometimes be of benefit, but often it is an anti-psychotic, such as low-dose Risperidone, that is chosen.
Enter the ethical conundrum. The evidence base for antipsychotics in the pharmacological management of ‘challenging behaviour’ is limited, but the placebo effect in staff/carers may be significant. The cerebrovascular and mortality risks associated with antipsychotic use in people with Dementia may not have been explicitly linked to people with Learning Disabilities, but it seems reasonable to think that at least some of the risk ‘translates’ across clinical groups, especially since these groups are overlapping. It would therefore seem prudent to exercise similar caution in antipsychotic prescribing in the Learning Disability setting. But, as McCleery and Fox so rightly point out, the pressure to prescribe remains and the ethical conundrum continues.
A further complication is that a significant proportion of the patients receiving antipsychotics in either of these two clinical populations may not have capacity to make decisions about their treatment/care. Decisions are therefore made on ‘best interests’ grounds. But carers’ assessments of what is in patients’ ‘best interests’ may well be coloured by their own experiences of the stress of struggling to manage ‘challenging behaviour’ in an under-resourced environment. This can push the scales towards the prescription pad with the potential for the attendant risks discussed above. The Doctor can be left wondering who they are prescribing for and who their patient is.
Open discussion with those involved in a person’s care (family, carers, Support Workers, etc.) is the starting point for arriving at a ‘best interests’ decision, but this does not necessarily unburden the Doctor of their sense of ‘needing to do something’. Where non-pharmacological means are not readily and speedily available, the default response may well be medication. And given the current economic climate, it seems all too likely that the processes behind the ‘pressure to prescribe’ will intensify. A tricky time to be a Doctor. Or a person with Dementia or Learning Disabilities! Let us hope that editorials such as McCleery and Fox’s can foster increased reflection on this matter and, ultimately, better care for these vulnerable patient groups.
Dr Samuel Yates
CT2 in Learning Disability Psychiatry
Hounslow and Richmond Community Healthcare
Charing Cross Psychiatry Scheme
Rapid Response:
Re: Antipsychotic prescribing in nursing homes
I was very pleased to read March 17th’s editorial by Dr.s McCleery and Fox (Antipsychotic prescribing in nursing homes). Partly because it provided a helpful reminder of the clinical risks involved in prescribing antipsychotics for people with Dementia, but, moreover, because they managed to highlight and articulate an ethical conundrum I have found myself faced with on numerous occasions since starting my Psychiatric specialist training 2 years ago.
My first Psychiatry job was an Old Age Psychiatry community post and involved frequent home visits to Care Homes. I was fortunate to have a Consultant who was very conscious of the clinical and ethical challenges around the pharmacological aspects of managing Behavioural and Psychological Symptoms of Dementia (BPSD). But even with that support I frequently struggled with significant pressure from Care Home staff and sometimes relatives to prescribe something to ‘sort things out’.
At the moment, I am experiencing a parallel situation in a community Learning Disability job. Our patient group, many of whom live in Care Homes, are double-disposed towards ‘challenging behaviour’. The indirect route is seen in those patients with Down’s Syndrome who have an increased risk of relatively early-onset Alzheimer’s Disease. But Learning Disabilities can also be directly associated with challenging behaviour – via communicative difficulties, disinhibition, limited alternative coping strategies, etc..
This leaves our clinical population at an increased risk of staff seeking pharmacological ‘answers’ to behavioural and managerial challenges in Care Home/Supported Living environments. This frequently translates into requests for a prescription of something to help ‘calm the patient down’.
In our team, we are lucky enough to have the support of a Challenging Needs Specialist (CNS) whose input we can seek instead of taking the prescription pad option. However, there is only one CNS - and several hundred patients! The prescription pad is therefore sometimes required. Promethazine, via its sedating properties, can sometimes be of benefit, but often it is an anti-psychotic, such as low-dose Risperidone, that is chosen.
Enter the ethical conundrum. The evidence base for antipsychotics in the pharmacological management of ‘challenging behaviour’ is limited, but the placebo effect in staff/carers may be significant. The cerebrovascular and mortality risks associated with antipsychotic use in people with Dementia may not have been explicitly linked to people with Learning Disabilities, but it seems reasonable to think that at least some of the risk ‘translates’ across clinical groups, especially since these groups are overlapping. It would therefore seem prudent to exercise similar caution in antipsychotic prescribing in the Learning Disability setting. But, as McCleery and Fox so rightly point out, the pressure to prescribe remains and the ethical conundrum continues.
A further complication is that a significant proportion of the patients receiving antipsychotics in either of these two clinical populations may not have capacity to make decisions about their treatment/care. Decisions are therefore made on ‘best interests’ grounds. But carers’ assessments of what is in patients’ ‘best interests’ may well be coloured by their own experiences of the stress of struggling to manage ‘challenging behaviour’ in an under-resourced environment. This can push the scales towards the prescription pad with the potential for the attendant risks discussed above. The Doctor can be left wondering who they are prescribing for and who their patient is.
Open discussion with those involved in a person’s care (family, carers, Support Workers, etc.) is the starting point for arriving at a ‘best interests’ decision, but this does not necessarily unburden the Doctor of their sense of ‘needing to do something’. Where non-pharmacological means are not readily and speedily available, the default response may well be medication. And given the current economic climate, it seems all too likely that the processes behind the ‘pressure to prescribe’ will intensify. A tricky time to be a Doctor. Or a person with Dementia or Learning Disabilities! Let us hope that editorials such as McCleery and Fox’s can foster increased reflection on this matter and, ultimately, better care for these vulnerable patient groups.
Dr Samuel Yates
CT2 in Learning Disability Psychiatry
Hounslow and Richmond Community Healthcare
Charing Cross Psychiatry Scheme
Competing interests: No competing interests