Letters Antipsychotics in nursing homes

Pressure to prescribe antipsychotic drugs in learning disability too

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2455 (Published 02 April 2012) Cite this as: BMJ 2012;344:e2455
  1. Samuel Yates, CT2 in learning disability psychiatry1
  1. 1Hounslow and Richmond Community Healthcare, Hounslow TW5 0LW, UK
  1. samuelyates{at}doctors.org.uk

My first specialist job in community old age psychiatry entailed frequent visits to nursing homes. Fortunately, my consultant was conscious of the clinical and ethical challenges of managing the behavioural and psychological symptoms of dementia, but even with such support I was often pressured by care home staff and sometimes relatives to prescribe something to “sort things out.”1

My current job in community learning disability has similar challenges. Many patients live in care homes and are doubly disposed towards challenging behaviour—for example, patients with Down’s syndrome have an increased risk of relatively early onset Alzheimer’s disease, and learning disabilities may also be directly associated with challenging behaviour. They are thus at risk of staff seeking pharmacological answers to behavioural and managerial challenges. This frequently translates into requests for a prescription of something to help “calm the patient down.”

Fortunately, in our team we have the support of a challenging needs specialist. However, there is only one specialist for several hundred patients so prescription is sometimes required. Promethazine may be helpful because of its sedating properties, but often a low dose antipsychotic drug such as risperidone is chosen.

The evidence base for antipsychotics in challenging behaviour is limited, but the placebo effect in staff and carers may be large. Some of the risks associated with their use are likely to apply across patient groups—to patients with learning disabilities as well as those with dementia.

A further complication is that prescription is often decided on the grounds of a patient’s best interests, and carers’ assessments may be coloured by their experiences of struggling to manage challenging behaviour in an under-resourced environment. The doctor can be left wondering for whom they are prescribing and who is their patient.

Notes

Cite this as: BMJ 2012;344:e2455

Footnotes

  • Competing interests: None declared.

References