1. Creating Better Dementia Care

• Tackling the inappropriate

use of

psycho-active medication in Scotland

Dr Stella Clark

Alzheimer Scotland Conference

June 2011

2. Psycho-active Medication?

Antipsychotic

anti-depressant

anti-anxiety

hypnotic

3. Strategy Commitments

baseline assessment of the use of psychoactive medication for those with a diagnosis of dementia.

Reduction in the level of prescription during 2011

a further reduction for future years.

4.

We know that

Most people with dementia live at home or in care homes

Most people are registered with a GP

GP surgeries have computerised records

Prescriptions contain patient identifiers

5.

The burden of psychotropic drugprescribing in people with dementia: a population database study

Bruce Guthrie, Stella Clark, Colin McCowanAge and Ageing 2010; 39: 637642

6. What did we do?

315 GP Practices in Scotland (1/3) take part in the SPICE-PC programme

People aged 65 or over on 31/7/2007

Linked

-Psychotropic medication prescriptions

-Dementia register

-Anticholinesterase drugs

7. What did we show?

4 key messages

8. 1 stmessage

Under diagnosis of dementia particularly in the oldest age groups

9. 2 nd message

If diagnosed with dementia

-antipsychotic drug x17 -Anti depressant x2 -Anxiolytics and Hypnotics x2

10. 3 rd key message

13-20 times more likely to have

combinations of these drugs

11. 4 thkey message

Once started, 93% become

repeat prescriptions

12. What we cannot tell from this study

Who starts the medication

If prescribing is influenced by where people are living

Prescribing of psychoactive drugs in 2011

13. Who starts the medication?

Audit of

Nursing home residents within one GP practice

discharges from one hospital

14. Who starts the medication?

Most psychotropic drugs recommended by secondary care

Consultants should improve advice re length of treatment

GP should improve review mechanisms

15. NHS FifeOld Age Psychiatry Withdrawal of Antipsychotics in patients with DementiaQuick Reference Guide Patient with Dementia on Antipsychotic Medication for >12 weeks History of severe agitation, aggression, psychosisprior to prescription Yes Seek psychiatric advice from local team who will base decision making on current SIGN/NICE guidance Other drugs Reduce by approximately 20% of the dosage every 2 weeks Quetiapine >150mgs/day Reduce by 50mgs every 2 weeks to a dose of 100mgs Quetiapine= 100mgs/day Reduce by 25mgs every 2 weeks until stopped Olanzapine >5mgs/day Reduce by 2.5mgs every 2 weeks to a dose of 5mgs Olanzapine = 5mgs/day Reduce to 2.5mg for 4 weeks and stop. Risperidone >2mgs/day Reduce by 0.5mgs every 2 weeks to a dose of 1mg Risperidone = 1mg/day Reduce to 0.5mg for 4 weeks and stop. Haloperidol >2mgs /dayReduce by 0.5mgs every 2 weeks to a dose of 1mg Haloperidol = 1mg Reduce to 0.5mg for 4 weeks and stop. Assess after 1 month to rule out Depression/anxiety/return of symptoms. Discuss with local Old Age Psychiatry team if symptoms recur

Reference to support Guide

• Chlorpromazine equivalent doses for the Newer AtypicalAntipsychotics.Woods.S.(2003) J.Clin Psychiatry 64:6

Dr Stella Clark,On behalf of the Old Age Psychiatrists March 2011 No GP led reduction in medication 16. Is prescribing is influenced by where people are living?

living in care homes v

living at home

17. Health Informatics Centre

Data for population of ~800k people

• Tayside data available since early 1990s

• Fife data available since 2008

Individual datasets linkable using unique personal identifier

18. What did we do?

Data for 2005 and 2006 for people aged over 65

Divided people into 2 groups depending on their address

Compared the numbers in each group prescribed psychoactive medications

19. What did we show?

2 key messages

20. 1stmessage

Living in a care home (6%)

-antipsychotic drug x14 -Anti depressant x1.8 -Anxiolyticsx1.3 - Hypnotics x3.4

21. 2nd key message

People in care homes

70% of psychoactive medications started before admission

Antipsychotic drugs often started 30 days before or after admission to the care home

Once started, become long term prescriptions

22. Implications

Improved links between GP and specialist services

Improve the services into care homes

23. Forth Valley Care Home Liaison Service

6 weekly nurse led clinics

Ongoing assessments/reviews (out-with clinic)

6 week educational programme which is continually evolving

24. 25. Summary

High awareness of the problem

We need better co-ordination of action -care home liaison service -links between GP and specialist services

baseline assessment of the use of psychoactive medication for those with a diagnosis of dementia is underway