Poor service provision is blamed for overuse of antipsychotics in dementia patients
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4818 (Published 16 November 2009) Cite this as: BMJ 2009;339:b4818
All rapid responses
The atypical anti- psychotics such as olanzapine and risperidone were
condemned by the FDA as being involved in a higher death rate for those
with dementia. But the conventional first generation anti psychotics,
particularly haloperidol, are implicated in even larger hazard ratios (HR)
(1). All anti- psychotics, old or new, are unsafe for the elderly.
Anti- psychotics were designed for schizophrenia and have no
appropriate receptor profile for Alzheimer's. Schizophrenics may be
worried meanwhile that they are being given drugs damaging those who are
weak and vulnerable. It is part of schizophrenia that its sufferers are
less likely to look after themselves and are in bad health.
Anti- psychotics are not so benign as aspirin and to overprescribe
them is dangerous for the old in nursing homes- or indeed for
schizophrenics in psychiatric units.
REFERENCES:
(1) All- cause mortality associated with atypical and conventional
antipsychotcis among nursing home residenst with dementia: a retrospective
cohort study. Rosa Liperoti et al. J. Clin Psychiatry. 2009:70 (10):1340-
1347
Competing interests:
None declared
Competing interests: No competing interests
The report led by Professor Banerjee is welcome and timely given the
widespread off-label use of antipsychotics to treat behavioural and
psychotic symptoms due to dementia (BPSD).[1] Commissioning specialist
older people’s mental health services to support primary care and care
homes and developing a curriculum to train GPs will go some way to meeting
the proposed targets. However, given the current economic climate and lack
of realistic evidence-based alternatives it seems unlikely that
antipsychotic use will drop to the extent predicted by Professor Banerjee.
The report recommends that “the Improving Access to Psychological
Therapies (IAPT) programme should ensure that resources are made available
for the delivery of therapies to people with dementia and their carers”.
This seems unrealistic given the lack of evidence-based non-
pharmacological methods of treating BPSD. The National Institute for
Health and Clinical Excellence (NICE) guidance on the use of
antipsychotics for BPSD has been heavily criticised for the inclusion of
non-pharmacological measures such as animal-assisted therapy and massage
which lack an evidence base.[2] More emphasis should be placed on the need
for further research in assessing the clinical and cost-effectiveness of
non-pharmacological methods of treating BPSD and of other pharmacological
approaches as an alternative to antipsychotic medication.
Similarly, there is only a strand of the IAPT initiative that focuses
on older people and it has been more focused on adults of a working age.
It seems that the lion's share of the £173m budget for IAPT will not be
ring-fenced as mental health experts had originally believed. Instead the
remaining £100m yet to be allocated will be spent at the discretion of
individual PCTs. Few older people and even fewer people with dementia and
their carers are likely to benefit from the programme as it is currently
designed and delivered.
Furthermore, the report recommends “the need to develop a curriculum
for the development of appropriate skills for care home staff in the non-
pharmacological treatment of behavioural disorder in dementia, including
the deployment of specific therapies with positive impact.” Like many of
us, care home owners have felt the financial strain of the current
economic recession. It is unlikely that they will invest scarce resources
into such developments anytime soon.
Finally, we can learn from the United States where concern about the
overuse of antipsychotics was highlighted over twenty years ago. This led
to the introduction of legislation (Omnibus Reconciliation Act 1987)
requiring all nursing facilities to have a medical director and each
resident having an attending doctor who visits them at specified
intervals. This had a considerable impact on the prescribing of
antipsychotics to residents of nursing homes[3,4] and the government
should consider how these policies could be adopted in the United Kingdom.
References
1. Banerjee S (2009) The use of antipsychotic medication for people
with dementia: Time for action. A report for the Minister of State for
Care Services Department of Health: London
2. Haw C, Yorston G, & Stubbs J (2009) Guidelines on
antipsychotics for dementia: are we losing our mind? Psychiatric Bulletin;
33: 57-60
3. Shorr RI, Fought RL, & Ray WA (1994) Changes in antipsychotic
drug use in nursing homes during implementation of the OBRA-87
regulations. JAMA; 271: 358-62.
4. Semla TP, Palla K, Poddig B, & Brauner DJ (1994) Effect of the
Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing
home residents. J Am Geriatr Soc; 42: 648-52.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
I have been following with great interest the recent revelations in
both medical and non medical publications that anti-psychotic medications
are leading to excess mortality secondary to cardiovascular disease in
patients with dementia. I also read with great interest the fact that this
excess use is being blamed on primary care and General Practitioners.
In june long before these revelations were made widely known, i was
in my second year of GP training and i undertook an audit of drug use in
patients with dementia. Clearly the numbers involved were small but it was
interesting to find that over 90% of patients with dementia on anti-
psychotic medications had been started in secondary care by our local
elderly care psychiatry team NOT by their GP. The vast majority of these
patients remained under secondary care follow up and the majority had been
on these medications for well over 1 year (well beyond the 6 weeks
currently being recommended). Is is right that primary care services are
receiving all the blame? Can i be accountable for a drug i didn't
prescribe?
As a ST3 GP Registrar i do not need more training about how to look
after patients with dementia. I have done my time as an Elderly care and
Psychiatry SHO and most importantly i have spent plenty of time in GP
training. I know that anti-psychotics increase stroke risk but i also know
that nursing home staff and resources, and families are stretched to the
limit. If i could prescribe 1:1 nursing care with overnight sitters, i
would, if i could prescribe cats and dogs for animal therapy, i would, if
i could ensure that the same nurse would be looking after the same patient
everyday, i would.... but i can't. So instead, after careful
consideration, looking at the patient as a whole, taking into account the
likelihood of harm verses benefit for the patient and those around them i
might prescribe anti-psychotic medication. This is not a decision that is
made easily i can assure you.
Please don't waste more money and resources teaching hard working GPs
how to look after patients with dementia, please tackle the problem and
use resources where they will have the biggest impact.
Competing interests:
None declared
Competing interests: No competing interests
We welcome Professor Sube Banerjee's recent publication of his report
(1) for the Minister of State for Care Services which draws attention to
the risks associated with the use of antipsychotic drugs in the management
of Behavioural and Psychotic Symptoms in Dementia (BPSD).
We are surprised that the report and the Government's response(2)
make no reference to the Mental Capacity Act 2005(3) and its associated
Code of Practice(4) . We presume most patients with dementia who are
prescribed antipsychotic medication for BPSD will have been assessed as
lacking capacity to make this treatment choice. The Mental Capacity Act
provides the legal authority for those who act in connection with
treatment and care for those who lack capacity to make decisions about
their care. In order for such treatment to be lawful, the staff
responsible for its administration (the prescriber and the carer giving
the medication) must have a 'reasonable belief' that they are acting in
the patient's best interests. Section 4 of the Act sets out who must be
consulted and what factors should be taken into account when deciding on
best interests (further guidance being given in the Code).
The latest evidence suggests the prescription of anti-psychotic
medication for these patients may fall within the remit of section 37 MCA
Serious Medical Treatment (what is proposed is likely to have serious
consequences for the patient. 'Serious consequences' are those which
could have a serious impact on the patient, either from the effects of the
treatment itself or its wider implications. An Independent Mental Capacity
Advocate must be instructed, and then consulted, for people lacking
capacity who have no-one else to support them (other than paid staff),
whenever an NHS body is proposing to provide serious medical treatment.
Prescribers clearly need to adhere to a framework of assessment,
consultation, prescribing and review to demonstrate that medical treatment
for BPSD is in a patient's best interests and therefore lawful.
We hope that the scientific and ethical arguments, along with the
legal requirements, will ensure prescribers and carers review the
appropriate management of these marginalised and vulnerable patients.
1 Banerjee S (2009) The use of antipsychotic medication for people
with dementia: Time for action. A report for the Minister of State for
Care Services Department of Health: London
2 Department of Health (2009) Government response to Professor Sube
Banerjee's report on the prescribing of anti-psychotic drugs to people
with dementia. Department of Health: London
3 2005 c.9
4 Department for Constitutional Affairs (2007) Mental Capacity Act
2005 Code of Practice. London: TSO
Competing interests:
None declared
Competing interests: No competing interests
Due to their frailty, isolation, and loneliness, the elderly have increased needs
for sympathy, support, and reassurance. Sadly, it’s all too easy to disregard
these needs by silencing the elderly with antipsychotics. This practice is not
only
unethical but also dangerous and should be stopped. Hospital administrators,
medical directors, nursing supervisors, pharmacists, and family should be alert
to this all-too-common scenario and intervene when necessary. The elderly
need many advocates, and we can all function on their behalf.
Competing interests:
None declared
Competing interests: No competing interests
Care of people with dementia: report on the use of antipsychotics
This is an important report. Its eleven recommendations are sensible
and should be implemented. It is best seen as a component of a planned and
sustained campaign to improve care for people with dementia.
Sadly it was launched through the media with scaremonger headlines
suggesting careless, murderous prescribing of lethal medication by
ignorant doctors (GPs) in cahoots with other dumb and insensitive care
professionals.
It may be difficult to get behind and beyond those headline sound-bites to
the real messages: these ask for better and more generously sponsored
services for people with dementia at home but particularly in Care Homes
or Hospitals.
The report has many features of a sales brochure:
It correctly identifies the likely total number of people with
dementia but offers an estimate of their experience of Behavioural and
Psychological Symptoms (BPSD) which is unreasonably high (60-80% point
prevalence – even within a series known to psychiatric services, the
prevalence is much less (1)). Receiving a diagnosis of dementia is
troubling enough, being told you have a 60% chance of having such
additional symptoms at any one time is alarming – and untrue.
Quotations from carers are cited – all with bad experiences.
The meat of the material is to declare that:
‘The systems that we have in place to manage behavioural problems in
dementia have grown up by chance rather than by planning or
commissioning’, that the first response by professionals is to turn to
medication and that the medication they prescribe has ‘minimal efficacy’
and may cause death or stroke disease.
The estimates of additional deaths and strokes were in every headline.
The facts show that this country has addressed the matter of care for
people with dementia and other mental disorders of late life thoughtfully
and creatively for more than half a century. Medicine has established
specialities of Geriatric Medicine and Old Age Psychiatry; other care
professions have similarly recognised their responsibilities in the field.
A number of charities have grown up in support of aspects of the cause and
series of reports, advice, planning documents and directives can be
identified (2).
That’s not to say that all is well – there is much to be desired, but
people work within the constraints of what is possible, what has been
judged to be affordable.
My experience is that in almost every situation where the
prescription of tranquilisers is considered, a range of other approaches
to understanding and managing difficulties has been explored and will
continue to be utilised even if medicines are to become part of the
therapeutic/care programme.
Why would anyone prescribe a medicine which has minimal efficacy? The
answer is that this is not a clinician’s experience. These medicines, even
when used in very low dosage, usually have a worthwhile beneficial effect
on distressing and disturbed symptoms and allow the individual to re-
equilibrate within their usual care setting, giving time for other
reassurances to re-establish their hold. The atypical antipsychotics are
less likely to produce Parkinsonism and similar unwanted effects and they
avoid the disinhibition often released by benzodiazepines and similar
compounds (3, 4).
So doctors, carers and patients see the benefits in response to
prescription.
It is undeniable that systematic reports from short- term drug trials
identify increased death rates and incidence of stroke (5, 6). The numbers
are, however, relatively small – amounting to something like a 2% increase
per annum. Death and stroke disease are common in late life and especially
within dementia. An additional two in a hundred is very hard to see and
impossible to attribute with certainty to a particular medication or other
intervention in an individual case. In these circumstances, clinicians,
carers and patients are more occupied by symptoms and their impact on
quality of life than its duration. They do not see the association which
the trialist-statisticians have identified.
So for clinicians, carers and patients the balance of benefits to
risks of using these medicines in particular circumstances is seen as
positive and is most often after discussion with a specialist (7). That is
not to say that they should be used as the only therapeutic strategy, nor
that they should be continued without proper regular review (8).
There are several assumptions and extrapolations in the report’s
estimates of how may antipsychotics are prescribed to people with dementia
and under what circumstances. It is from these that estimations of the
numbers of excess deaths and strokes are reported with apparent
confidence. International comparisons suggest no differences between
prescribing rates for older people in different countries with records.
Bewilderingly the report assumes that all such prescriptions in this
country are to people with dementia, although in Canada it is known that
this is not so. Thus it may be that rather fewer people with dementia are
receiving such medication and being exposed to their disbenefits.
The eleven recommendations are uniformly sensible and desirable. They
include a requirement for a baseline audit and then systematic annual re-
audits aiming to see a 2/3 reduction in prescribing rates within two
years. That target may be unreasonable; it certainly should not be seen as
the only outcome to be sought as a result of this report. Much more
important are the encouragements to provide better training for
professional carers and better services for people with dementia
especially when they are in Care Homes or in Hospital.
References
1) Burns A, Jacoby R and Levy R. Psychiatric phenomena in Alzheimer’s
disease. British Journal of Psychiatry 1990, 157: 86-94
2) Benbow S and Jolley D. Organisation of Services in Geriatric
Psychiatry, 2006. Chapter 99 pp 1163-1171 in Pathy MSJ, Sinclair AJ and
Morley JE: Principles and Practice of Geriatric Medicine – Fourth Edition
(volume 2) John Wiley and Sons, Chichester
3) Chan M et al. Antipsychotics and the risk of cerebro-vascular events in
the treatment of behavioural and psychological symptoms of dementia in
Hong Kong; International Journal of Geriatric Psychiatry 2009 Aug 3: [Epub
ahead of print]
4) Ballard C and Waite J. The effectiveness of atypical antipsychotics in
the treatment of aggression and psychosis in Alzheimer’s disease, Cochrane
Review 2006 Jan 25; (1) CD003476
5) Schneider L, Dagerman K and Insel P. Risk of death with atypical
antipsychotic drug treatment for dementia: a meta-analysis of randomised
placebo-controlled trials. JAMA 2005, 294(15) 1934-43
6) Barnett M, Werhinger H and Perry P. Comparison of risk of
cerebrovascular events in an elderly VA population with dementia between
antipsychotic and non antipsychotic users. Journal of Clinical
Psychopharmacology 2007; 27(6) 595-601
7) Groves T. Please don’t waste more resources. BMJ 2009; 339: b4818 rapid
response Nov 26th
8) Ballard C et al. The dementia antipsychotic withdrawal trial (DART-AD):
long-term follow up of a randomised placebo-controlled trial. Lancet
Neurology 2009; 8(2) 151-157
Competing interests:
None declared
Competing interests: No competing interests