Practice Change Page

Don’t use antipsychotics routinely to treat agitation and aggression in people with dementia

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6420 (Published 03 November 2014) Cite this as: BMJ 2014;349:g6420

Re: Don’t use antipsychotics routinely to treat agitation and aggression in people with dementia

I welcome this “change page”. [1]

The authors describe the routine prescription, off-label, of antipsychotics to our most vulnerable elderly. At a recent international conference one presentation referred to the estimate that “2/3rds of current UK prescriptions for antipsychotics in people with dementia are inappropriate”.[2] These reports remind us that those living with dementia are often considered to lack “capacity” and their voice is easily lost.

My previous correspondence to the BMJ has demonstrated my view that our profession should not be “educated” by commerce or industry. [3]

In 1999, as a doctor in training, I was handed a document by my trainer. This I was told was “the way forward”. The document had an acronym: “BPSD”. I had not heard of “BPSD”. I learned that this acronym stood for “Behavioural & Psychological Symptoms in Dementia”. I accepted it with little thought. The comprehensive BPSD document was produced by Pharma: though at the time, and for almost a decade thereafter, I was not aware of this fact.

I am aware that a number of NHS guidelines are in existence for the treatment of “BPSD”. [4] Haloperidol, in lowest possible dose, is generally the drug recommended. My concerns over prescribing of antipsychotic drugs like Haloperidol in a frail elderly population, led me to raise a petition for a “Sunshine Act” with the Scottish Government. [5]

It has been my experience that marketing activity by the pharmaceutical industry, and also “education” by key opinion leaders paid for by the pharmaceutical industry, have in the past encouraged the off-label use of antipsychotic drugs. Until we acknowledge this mechanism, we risk losing the opportunity to minimise the harm of such an approach.

References:
[1] Ballard,, Burns & Corbett. Change Page [PRACTICE] Don’t use antipsychotics routinely to treat agitation and aggression in people with dementia. BMJ 2014;349:g6420 Published 3 Nov 2014

[2] Saad, K. UK Chair ALCOVE Steering Group. Presentation to Alzheimer’s Europe Conference, Glasgow, 21 Oct 2014 “Preventing behavioural problems reducing inappropriate use of antipsychotics in dementia”

[3] Gordon, P, J. Letters: Drug industry sponsorship BMJ 2011;343:d7375. Published 15 Nov 2011 and Letters Clinical guidelines BMJ 2014;348:f7699 Published 6 Jan 2014
[4] Acute Hospital Guidelines and pathways: NHS Lothian and NHS Forth Valley
[5] Gordon, P, J. PE01493: A Sunshine Act for Scotland http://www.scottish.parliament.uk/GettingInvolved/Petitions/sunshineact

Competing interests: No competing interests

07 November 2014
Peter, J Gordon
Psychiatrist for Older Adults
Locum for NHS
St John's Hospital, NHS West Lothian