Title Here

The Medicines Management of Reducing / Withdrawing Psychotropic medication in Service Users (patients)

with Learning Disability

Danielle Adams

Principal Clinical Pharmacist

Pharmacy Team

September 2016

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Learning Outcomes

• Gain an understanding of what patients with a Learning Disability and their carers

may want from pharmacy services

• Understand the key policy drivers influencing LD healthcare provision

• Identify gaps in your service and develop an action plan to improve medicines

optimisation in patients with a LD as a result of the good practice shared.

• Take the opportunity to share good practice and network with peers to develop

your knowledge base

• Assess the risks when antipsychotics are prescribed in people with a learning

disability (PwLD)

• Describe the issues that should be considered when deprescribing antipsychotics

in PwLD

• Describe the monitoring required when prescribing and deprescribing

antipsychotics in PwLD

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Background

Winterbourne Report concluded that

• services should have systems and policies in

place to ensure medication reviews are

undertaken safely and in a timely manner

• medication audits involving pharmacists, doctors

and nurses should be carried out

• (Department of Health 2012)

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Evidence

• Report into prescribing of psychotropic drugs to PwLD

and /or autism by GPs in England found 58% of adults

receiving antipsychotics and 32% of those receiving

antidepressants had no documented mental health

diagnosis. Nearly one third were receiving one or more

psychotropic medicine(Public Health England 2015)

• Cohort study of over 33000 PwLD found only 21%had a

record of mental illness,25% had documented

challenging behaviour but 49% were prescribed

psychotropic medicines (Sheehan R et al 2015)

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Evidence

• Winterbourne Pilot improvement project found that

patients, carers and relatives did not always understand

why psychotropic medicines had been prescribed. (NHS

Improving Quality (2015)

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Published research portrayed in the media

• http://www.nhs.uk/news/2015/09September/Pages/scale-of-

antipsychotic-chemical-cosh-use-explored.aspx

• http://www.dailymail.co.uk/news/article-3161626/Up-35-000-

wrong-prescribed-antipsychotics-Doctors-regularly-handing-

drugs-vulnerable-people-not-taking-them.html

• http://www.theguardian.com/society/2015/sep/01/antipsychotic-

drugs-may-be-used-as-chemical-cosh-to-control-behaviour

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The issues

• Over prescribing of psychotropic

medication

• No documented mental health diagnosis

• Inadequate monitoring of side effects

• Inadequate review of medication

• CALL TO ACTION

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Why are psychotropic medicines prescribed ?

• Evidence suggests that psychotropic

medication especially antipsychotics and

antidepressants are prescribed to “treat”

behaviour that challenges.

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Behaviour that challenges

• Behaviour is described as challenging when it is

of such intensity, frequency or duration as to

threaten the quality of life and / or the physical

safety of the individual or others and is likely to

lead to responses that are restrictive, aversive or

result in exclusion.(Royal College of

Psychiatrists, British Psychological Society

2016)

• Consequences

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Best practice

• Which antipsychotics are licensed to treat

Challenging behaviour in adults?

• None

• Risperidone is licensed for conduct disorder in

children and adolescence

– Risperidone is licensed for up to 6 weeks in

BPSD when non pharmacological

interventions have failed

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Current prescribing guidance

• NICE NG11 May 2015 Challenging behaviour and

learning disabilities: prevention and interventions for

people with learning disabilities whose behaviour

challenges

• Medication is a last resort – failure to respond to

treatment or risk to the person or their families is very

severe

• Risperidone po 0.5 – 2mg od

• Reason for prescribing to be documented in notes

• Review side effects and effectiveness after 3-4 weeks

• Stop after 6 weeks if no benefit

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Causes of behaviour that challenges

• Medical – infection, epilepsy, hyperglycaemia

• Psychological

• Social

• Environmental

• Poor communication

• Delirium

• Hormone disturbance

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Adverse Effects of Antipsychotics

Sedation

Movement disorders – EPSEs (dystonias, akathisia, tardive dyskinesia)

Metabolic Syndrome (insulin resistance, weight gain, hyperlipidaemia,

hypertension, increased risk of clotting)

Prolongation of QT interval

Reduces seizure threshold

Hyperprolactinaemia

Constipation

Increased risk of pneumonia

Association with increased risk of stroke in dementia 13

Adverse effects

• Evidence suggests that people with learning disability

(PwLD) have shorter life expectancy, poorer access to

healthcare and poorer outcomes.(Mencap 2007,

Emerson and Baines 2010)

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STOMPld

• The Stopping Over Medication of People with a learning

disability pledge was signed by RPS,RCN, RCP,GPs,

the British Psychological Society and NHS England in

June 2016 (NHS England 2016)

• Aim to improve quality of life of PwLD by reducing

potential harm caused by inappropriate prescribing of

psychotropic medicines

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Deprescribing

Focussing on antipsychotics

SPCs give info on prescribing but often very little info on

deprescribing

Deprescribing templates for reducing psychotropic

medicines are not currently available.

Published evidence for antipsychotics tends to relate to

antipsychotics prescribed for psychotic illness 16

Considerations when withdrawing antipsychotics

• Think about the removal of the effects and

particularly side effects and the impact this may

have on a person with a learning disability

• Reduce dose slowly

• Include the PwLD, their carers and relatives in

the process- what,why,who,when and how

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Considerations when withdrawing antipsychotics

• Sedation

• A reduction in dose may well lead to a reduction in

sedation.

• Advantage or disadvantage?

• As the antipsychotic is reduced /withdrawn may have an

impact on sleeping at night – what are the options?

sleep hygiene measures, does SU have a prescription

for temazepam or Z drug prn? If so monitor usage

• Positive effect of SU being more alert and able to

engage with activities, however are these activities in

place?

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Considerations when withdrawing antipsychotics

Sleep hygiene

Create a fixed bedtime routine

Maintain comfortable sleeping environment

Avoid caffeine, nicotine and sugar late at night

Avoid using back lit devices before going to bed

Avoid eating a heavy meal late at night

Avoid day time naps

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Considerations when withdrawing antipsychotics

• Metabolic syndrome

• Continue to monitor BP, lipids, weight gain and blood

sugar

• If SU prescribed a statin for primary prevention to reduce

vascular risk, this may need to be reviewed in the long

term. Also metformin, antihypertensives

• EPSE

• If continues to be a problem consider investigating other

causes

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Considerations when withdrawing antipsychotics

• Weight gain

• A reduction in dose may not necessarily lead to weight

reduction

• A reduction in dose does not mean SU can return to

eating unhealthy diet

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Considerations when withdrawing antipsychotics

• Hyperprolactinaemia

• May be dose related

• More likely with typicals and risperidone and amisulpride

• Less likely with aripiprazole, olanzapine, clozapine and

quetiapine

• Also can occur with hypothyroidism

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Considerations when withdrawing antipsychotics

• Hyperprolactinaemia

• What are the effects?

– Amenorrhoea

– Decreased fertility

– Reduced libido

– Poor bone health

– Can affect hormone dependent cancers

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Considerations when withdrawing antipsychotics

• Is reduction in prolactin levels to near normal an

Advantage or disadvantage?

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Considerations when withdrawing antipsychotics

• Reduction of prolactin levels in women

o Female SUs who have been on antipsychotics for

many years may experience amenorrhoea – may be

viewed as an advantage

o Need to alert SU and their support that periods may

return.

o Issues of supporting SU with menstrual cycle and

being alert to possible PMT which can adversly effect

mood.

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Considerations when withdrawing antipsychotics

• Reduction in prolactin levels in women

• Increase in fertility

• Advantage or disadvantage?

• In sexually active women who are not planning a

pregnancy ensure SU has access to appropriate

contraceptive advice and services.

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Considerations when withdrawing antipsychotics

• Hyperprolactinaemia and dopamine blockade can cause

sexual dysfunction eg reduced libido

• Is increased libido an advantage or disadvantage?

• In SUs displaying inappropriate sexual behaviour the

adverse effect of reduced libido may possibly be helpful.

If antipsychotic is withdrawn these behaviours may begin

to surface again

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Considerations when withdrawing antipsychotics

• SUs may consider replacing psychotropic meds with

complementary therapies - Risk of serotonin syndrome

with St Johns Wort and SSRIs

• SUs who are having trouble sleeping may take hypnotics

too frequently leading to dependence.

• Care/support staff may give lorazepam prn more often if

they consider behaviour is challenging. This needs to be

monitored.

• Consider implications for re emergence of behaviour

which challenges

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Implications for Pharmacy practice

• Prompt review of antipsychotic medication

• Side effect monitoring

• Consideration of issues associated with withdrawal

• Think about physical health medication no longer

needed

• Be aware of effects of physical health medication

• Alert to an increase in usage of other psychotropic

medicines as antipsychotics are withdrawn

• Optimising consultations

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Implications for Pharmacy practice

• Suitable medicines information for PwLD, carers and

parents

• Using antipsychotics off label

• Are you complying with the Montgomery Ruling and the

Accessible Information Standard? (Sokol 2015, NHS

England)

• Easy read medication leaflets are available on some

learning disability websites, but they do need to be

checked for accuracy as many have not been reviewed

for several years 30

Implications for Pharmacy practice

Think about your role in contributing towards

making healthcare more accessible for PwLD, to

achieve better outcomes and higher life

expectancy

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• Thank you for listening

• Any questions?

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References

• Department of Health (2012) Transforming Care: A National Response to

Winterbourne. DH, London.

• Emerson E, Baines S (2010) Health Inequalities and People with Learning

Disabilities in the UK: 2010. Improving Health and Lives: Learning

Disabilities Observatory, Lancaster.

• Mencap (2007) Death by Indifference. Mencap, London.

• NHS England (2015) The Use of Medicines in People with Learning

Disabilities. www.england.nhs.uk/wp- content/uploads/2015/07/med-advice-

ld-letter.pdf (Last accessed: August 28 2016.)

• NHS England (2015c) Accessible Information Standard.

www.england.nhs.uk/ourwork/patients/accessibleinfo/ (Last accessed:

August 28 2016.)

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References

• NHS Improving Quality (2015) Winterbourne Medicines Programme.

www.nhsiq.nhs.uk/media/2671659/nhsiq_winterbourne_medicines.pdf

(Last accessed: August 28 2016.)

• NICE NG11 National Institute for Health and Care Excellence (2015)

Challenging Behaviour and Learning Disabilities: Prevention and

Interventions for People with Learning Disabilities whose Behaviour

Challenges. NICE, London

• Sheehan R, Hassiotis A, Walters K et al (2015) Mental illness, challenging

behaviour, and psychotropic drug prescribing in people with intellectual

disability: UK population based cohort study. BMJ. 351, h4326.

• Sokol D (2015) Update on the UK Law on Consent. BMJ. 350, h1481.

• Public Health England (2015) Prescribing of Psychotropic Drugs to People

with Learning Disabilities and/or Autism by General Practitioners in England.

DH, London.

•

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Useful resources

• Bazire S.Psychotropic Drug Directory 2016 Lloyd – Reinhold

Communications

• Bhaumik B, Gangadharn S, Branford D et al (Eds) (2015) The Frith

Prescribing Guidelines for People with Intellectual Disability. Third

edition. John Wiley & Sons, Chichester.

• Taylor D, Paton C, Kapur S (2015) The Maudsley Prescribing

Guidelines in Psychiatry. Twelfth edition. John Wiley & Sons,

Chichester.

• https://www.disabilitymatters.org.uk/mod/page/view.php?id=3

• http://www.skillsforhealth.org.uk/images/resource-

section/projects/learning-disabilities/Learning-Disabilities-CSTF.pdf

• http://www.e-lfh.org.uk/programmes/accessible-information-

standard/how-to-access/

• CPPE learning resource due out Autumn 2016

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