tackling the inappropriate use of psycho-active medication in scotland
DESCRIPTION
Dr Stella Clark, Medical Director,Primary Care, NHS Fife; Clinical lead for Mental Health Services, NHS 24Presentation from Alzheimer Scotland conference 2011 - Creating Better Dementia Care.TRANSCRIPT
- 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