Antipsychotic prescribing in nursing homesBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e1093 (Published 23 February 2012) Cite this as: BMJ 2012;344:e1093
- 1Oxford Health NHS Foundation Trust, The Fiennes’ Centre, Banbury OX16 9BF, UK
- 2Health Centre, Coker Close, Bicester, UK
Warnings about an increased risk of death in patients with dementia who receive atypical antipsychotics were first issued in 2004-5, after the publication of a meta-analysis of data from placebo controlled randomised controlled trials.1 2 In 2008 analysis of databases led to similar warnings for older typical antipsychotics. At the time, inconclusive evidence suggested that the risk of death was greater for typical than for atypical antipsychotics.3 The linked paper by Huybrechts and colleagues (doi:10.1136/bmj.e977) adds to the evidence on differential risk.4 Using risperidone—the antipsychotic most widely prescribed for patients with dementia—as the comparator, they report an increased risk of mortality in nursing home residents taking haloperidol and a decreased risk in those prescribed quetiapine. Causation is not definitively proved but seems highly probable given the strength of the association that unmeasured confounders would need to have with both the use of haloperidol (or quetiapine) and mortality to account for the result.
Information on risk must be weighed against the potential benefits of a drug. Although meta-analyses have shown a small benefit for haloperidol on aggression in dementia there is no evidence that the benefit is greater than that for risperidone,5 which seemed to be less harmful in the current study. This strengthens the argument for avoiding haloperidol on safety grounds. In contrast, there is no high quality evidence that quetiapine is effective for treating neuropsychiatric symptoms in dementia,6 7 and the results of the current study should not support its use.
The use of any antipsychotic in dementia is undesirable given the increased risk of death and the many other adverse effects of these drugs, in addition to their limited efficacy against target behavioural and psychological symptoms.7 Evidence on comparative safety must be evaluated in this light, but it is nevertheless important to extend our knowledge of the comparative efficacy and safety of antipsychotics for two reasons.
Firstly, although guidelines universally agree that the first line treatment for behavioural and psychological symptoms in dementia should be non-drug based, they also—in the absence of evidence for greater efficacy of other drugs—recommend the careful use of antipsychotics in the treatment of agitation, aggression, or psychosis that fails to respond to other measures and that reaches various severity thresholds, typically severe distress or serious risk to self or others.8 9 Secondly, despite widely disseminated guidance aimed at limiting their use, antipsychotics are still widely prescribed to older people with dementia or in institutional care. Although published data typically lag behind what is happening in practice by several years, as an example, analysis of a primary care database covering England and Wales for 2008-9 found that 18.2% of patients in care homes were prescribed antipsychotic drugs. Among patients with a recorded diagnosis of dementia, 10.1% in the community and 30.2% in care homes received such drugs.10 Clearly, doctors find compelling reasons to prescribe antipsychotics to patients with dementia, reasons that are unlikely to be found in the evidence base alone.
Few clinical problems place doctors in as tangled a web of clinical evidence, social policy, and ethical concerns as how to manage behavioural problems in patients with dementia. Many studies are now describing the demographic and institutional factors associated with the prescribing of antipsychotics. A complementary approach is to try to understand prescribing practice at the level of physician behaviour. A small qualitative study among psychiatrists in the north of England into prescribing for behavioural and psychological symptoms in dementia, although local, identifies themes with which many primary care doctors and psychiatrists will identify.11 These include feeling pressurised to prescribe, believing that non-drug based approaches are unfeasible because of lack of resources and difficulties of implementation, and perceiving a failure at the societal level to provide the environment and resources needed for high quality innovative care. These could be seen as negative attitudes; equally, they may reflect the reality of the situations in which most dementia care occurs. Where care homes or community care services are inadequate and local clinical resources cannot compensate for them, doctors face genuine dilemmas about how to respond to distressed patients, relatives, and carers, often in ethically complex situations that involve a variety of risks. It is probably fair to say that many doctors think that the evidence based guidelines are not adequate for the day to day reality of practice.
Future research should be pragmatic. It should focus on identifying the key components of non-drug based interventions and on establishing the service structures that can deliver them as simply and efficiently as possible. Although international comparisons may be useful, much research of this nature will need to look for solutions that are compatible with local conditions. More locally based explanatory research into prescribing patterns will help inform service development. Continued debate on the ethical framework of dementia care, such as recent discussions on the usefulness of a palliative care model, should be encouraged.12
Cite this as: BMJ 2012;344:e1093
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; JMcC has acted as a local investigator for Lilly; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.