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An audit of anti-muscarinic drug use at the State Hospital

Queen Margaret Hospital, Majors Loan, Dunfermline, Fife KY12 OJU

Janice Duncan, Consultant Forensic Psychiatrist and Angela Short, Audit Facilitator

The State Hospital, Carstairs, Lanarkshire

	Abstract

Top Abstract Introduction Approved standards Objectives The study Findings Comment Recommendations References

 
AIMS AND METHOD

This paper is based on two audits carried out in 1996 and 1998 at The State Hospital, Carstairs. Each audit looked at anti-muscarinic drug use within the hospital, in relation to approved prescribing standards issued in 1996. All patients within the hospital on anti-muscarinic drugs were identified at the time of each audit. These prescriptions were compared with the approved prescribing standards. In the 1998 audit additional information was obtained from the case notes and the consultants, when the approved standards were not met.

RESULTS

The percentage of patients on regular anti-muscarinic drugs, falling outwith the prescribing standards, reduced between the two audits. However, in 1998 a small number of patients were still outwith the approved prescribing standards set in 1996.

CONCLUSIONS

An improvement in the prescribing practice of anti-muscarinics occurred following the introduction of prescribing guidelines. However, the guidelines were not fully met in the 1998 audit. This demonstrates the need for further audit and continued monitoring of anti-muscarinic prescription at the State Hospital.

	Introduction

Top Abstract Introduction Approved standards Objectives The study Findings Comment Recommendations References

 
Anti-muscarinic drugs are intended for short-term use only (World Health Organization, 1990; Barnes, 1990; Bazire, 1998). They are widely used in psychiatric practice for the treatment of neuroleptic induced extrapyramidal side-effects (Barnes & McPhillips, 1996). However, these drugs have their own side-effects (British National Formulary, 1999) and in the long term may exacerbate serious movement disorders (Perris et al, 1979). In addition such drugs are sometimes misused by patients (Crawshaw & Mullen, 1984; Marken et al, 1996). Therefore, monitoring of anti-muscarinics in psychiatric practice would seem to be of considerable importance.

Two audits of anti-muscarinic use were carried out at the State Hospital, Carstairs - the sole provider of psychiatric care, in conditions of special security, in Scotland and Northern Ireland (Snowdon, 1995). The audit in 1996 indicated that some patients were prescribed these drugs for extended periods without clear indication. Approved standards for the correct usage of these drugs was circulated in 1996. The audit was repeated in 1998 and compared with these standards.

Although patients are reviewed regularly at the State Hospital, there is a system for a more comprehensive multi-disciplinary review of the whole treatment/care package of each patient, at three monthly intervals. For this reason the standards that relate to anti-muscarinic prescribing focus on their continued prescription beyond three months.

	Approved standards

Top Abstract Introduction Approved standards Objectives The study Findings Comment Recommendations References

 

1. After three months regular anti-muscarinic treatment, a reduction in dose or complete discontinuation of the anti-muscarinic should be considered at the patients case review. Following the initial review, the continued use of the anti-muscarinic should be considered at subsequent case reviews. Patients taking a uniform dose and type of anti-psychotic, and an anti-muscarinic for three months or more, must be reviewed.
   
2. Only one anti-muscarinic should be prescribed in each patient.
   
3. The dose of anti-muscarinic should not exceed British National Formulary guidelines.
   
4. An anti-muscarinic should not be prescribed with clozapine unless an additional anti-psychotic is prescribed, or it is being used to treat hypersalivation.
   
5. The anti-muscarinic of choice at the State Hospital is procyclidine.
   

	Objectives

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1. To assess adherence to the standards set for the use of anti-muscarinic drugs in 1996, and identify if a problem of inappropriate usage exists.
   
2. To assess if the extended use of anti-muscarinics is occurring and if so, what reasons for this are given in the clinical notes or by the consultant.
   
3. To see if the introduction of an approved standard improved prescribing practice.
   

	The study

Top Abstract Introduction Approved standards Objectives The study Findings Comment Recommendations References

 
All patients on anti-muscarinic drugs on the 5 May 1998 were reviewed. These patients were identified with the assistance of the hospital pharmacist. Using the prescription kardexes, anti-muscarinic drug use was compared with the approved Standards 1-5. Where the approved standards were not met, the case notes were reviewed. If reasons for prescribing outwith the standards were not documented, the responsible consultant was approached to try and determine the reasons, if any. The results of this audit were compared with those from the earlier 1996 audit. In the 1996 audit, all patients on anti-muscarinic drugs were identified, on a given day, by the hospital pharmacist. Once again the prescription kardexes of these patients were used to compare with the Standards 1-5. However, in this first audit the case notes were not examined, nor were the consultants approached, regarding findings outwith the standards.

	Findings

Top Abstract Introduction Approved standards Objectives The study Findings Comment Recommendations References

 
Adherence to the standards for the use of anti-muscarinic drugs
Standard 1 (see Table 1)

Standard 3
No patients exceeded the recommended British National Formulary dosage guides in either the 1996 or 1998 audits.

Standard 4
All patients on clozapine alone and on an anti-muscarinic had had problems of continuing hypersalivation in both the 1996 and 1998 audits (see Table 2).

Standard 5
The preferred anti-muscarinic drug was procyclidine in both the 1996 and 1998 audits (see Table 3).

Assessing if the extended use of anti-muscarinic drugs occurs and the reasons for it
A review of the last case conference on each of the 70 patients on anti-mucarinics in 1998 was made. Out of the 70 patients, three did not have a case conference as they had not been in the hospital long enough. For the remaining 67 patients the medication the patient was on, including anti-muscarinics, was documented clearly in the case conference notes. Medication changes made at the time of the case conference and proposed future changes were also documented. However, out of the 67 cases, specific reference to neuroleptic induced side-effects and continued prescription of anti-muscarinics was made in only three cases. Reasons for continued anti-muscarinic prescriptions outwith Standard 1 were sought from the relevant consultant (see Table 4).

Complex reasons given for prescribing outwith the standards at the State Hospital included:

d. Previous experiences of severe extrapyramidal side-effects in patients when their anti-muscarinics were reduced.

e. Short-term future plans to change a patients neuroleptic or dosage.

f. Difficulty with particular patients being controlling over their medication/treatment. In these cases the benefits of neuroleptic medication were felt to out-weigh the risks of non-adherence if the anti-muscarinic was reduced as dictated by the standard.

g. Movement of patients within the State Hospital meaning they have acquired a new clinical team and are awaiting a case conference with that team.

	Comment

Top Abstract Introduction Approved standards Objectives The study Findings Comment Recommendations References

 
The proportion of patients at the State Hospital on regular anti-muscarinics has fallen slightly since 1996. Perhaps more significantly, there has been a reduction in the percentage of prescriptions of anti-muscarinics, which fall outwith Standard 1, between the 1996 and 1998 audits. This may be a reflection of an increasing awareness of the prescribing guidelines or it may be a reflection of the increasing use of certain atypical neuroleptics which have fewer extrapyramidal side-effects. It may be the case that some anti-muscarinic prescriptions that fell within the standards are not clinically required, but this is outside the remit of this audit.

A direct comparison of patients outwith the anti-muscarinic prescribing Standard 1 in the 1996 and 1998 audits cannot be made other than to compare the initial number. This is because the 1996 audit did not look at case notes or seek medical staff opinion. In the 1998 audit it would seem that 10 out of the 23 patients outwith the Standard 1, have no clear clinical reason to continue their anti-muscarinic at its present dose without review. The remaining 13 have reasons given for the extended continuation of the anti-muscarinic at its present dose. Reasons such as continuing extrapyramidal side-effects or hypersalivation (clozapine only) would seem pharmacologically valid. Other reasons given, relate to other aspects of the treatment ‘package’ as a whole and their validity would be a matter for debate.

In terms of medical documentation at the State Hospital, it is the case that the three monthly reviews document all medications prescribed. They also record changes to medication at the time of the review, and for the short-term after the review. As stated before specific reference to anti-muscarinic prescription is rarely made. This is a problem which could easily be addressed, and doing so would aid prescribing practice.

Referring back to the objectives, it would seem there was an improvement in the practice of prescribing anti-muscarinics since the 1996 audit, and the introduction of the prescribing standards at this time. In both audits Standards 2-5 were adhered to rigorously. However, extended use of anti-muscarinics still occurred in 1998, although to a lesser degree than in 1996. This problem, which relates to Standard 1, involves a small but nevertheless, important, number of patients. In the 1998 audit reasons for the extended prescription of anti-muscarinics are given in over 50% of these cases. However, 10 patients are left requiring immediate review. The introduction of standards in 1996 may be responsible for this improvement although it is well recognised that despite publication of prescribing surveys/audits there is a general inertia of change to prescribing habits (Clarke & Holden, 1987).

	Recommendations

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There is a need for greater attention to anti-muscarinic prescribing at case conferences and the alteration of case conference treatment plans to incorporate this at the State Hospital. There is also a need for further audit or monitoring of anti-muscarinic prescribing practice at the State Hospital.

	Acknowledgments

 
Sincere thanks to Morag Wright, State Hospital Pharmacist and her staff, for identifying the patients for the audit. I am also very grateful to Dr David Reid for his encouragement and constructive criticism of subsequent drafts which led to this paper being written.

	References

Top Abstract Introduction Approved standards Objectives The study Findings Comment Recommendations References

 
BARNES, T. R. E. (1990) Comment on the WHO Consensus Statement. British Journal of Psychiatry, 156, 413-414.[Free Full Text]

BARNES, T. R. E. & MCPHILLIPS, M. A. (1996) Anti-psychotic-induced extrapyramidals symptoms. The role of anticholinergic drugs in treatment. CNS Drugs, 6, 315-330.

BAZIRE, S. (1998) Psychotropic Drug Directory 1998. Dinton: Mark Allen Publishing.

BRITISH NATIONAL FORMULARY (1999) British National Formulary. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain.

CLARKE, A. F. & HOLDEN, N. L. (1987) The persistence of prescribing habits: A survey and follow-up of prescribing to chronic hospital in-patients. British Journal of Psychiatry, 150, 88-91.[Abstract/Free Full Text]

CRAWSHAW, J. A. & MULLEN, P. E. (1984) A study of benzhexol abuse. British Journal of Psychiatry, 145, 300-303.[Abstract/Free Full Text]

MARKEN, P. A., STONER, S. C. & BUNKER, M. T. (1996) Anticholinergic drug abuse and misuse. CNS Drugs, 5, 190-199.

PERRIS, C., DIMITRIJEVIC, P., JACOBSSON, L., et al (1979) Tardive dyskinesia in psychiatric patients treated with neuroleptics. British Journal of Psychiatry, 135, 509-514.[Free Full Text]

SNOWDON, P. (1995) Facilities and treatment. In Seminars in Practical Forensic Psychiatry (eds D. Chiswick & R. Cope), pp. 164-209. London: Gaskell.

WORLD HEALTH ORGANIZATION (1990) Prophylactic use of anticholinergics in patients on long-term neuroleptic treatment. A consensus statement. British Journal of Psychiatry, 156, 412.[Free Full Text]

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