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
Rapid Response:
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