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| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
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Pharmacy Practice and Medicines Management Group, School of Healthcare, Baines Wing, University of Leeds, Leeds LS2 9UT, email: d.p.alldred{at}leeds.ac.uk
Pharmacy Practice and Medicines Management Group, University of Leeds
Older People’s Mental Health Department, Longley Centre, Norwood Grange, Sheffield
University of Leeds
Pharmacy Practice and Medicines Management Group, University of Leeds
P.B. has given talks for and received hospitality from Jansenn-Cilag.
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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To determine the prescribing patterns for antipsychotics in care homes for the elderly, a cross-sectional study was carried out using data from the intervention group of a randomised controlled trial of medication review in care homes.
RESULTS
Of 331 residents studied, 67 (20%) were prescribed an antipsychotic (70% atypical); 57 of these (85%) did not have a diagnosis of a psychotic disorder. The antipsychotic prescribing rate was 32% (46 out of 146) for those with dementia and 10% (17 out of 174) for those without dementia. A quarter (82 out of 331) had received a medication review by the general practitioner in the preceding 12 months.
CLINICAL IMPLICATIONS
One-fifth of residents were prescribed an antipsychotic with little evidence of review. Systems should ensure residents’ treatment is reviewed regularly.
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Introduction |
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Antipsychotics are associated with significant harm, including an increased risk of falls (Evans, 2003) and long-term cognitive decline (Wisniewski et al, 1994; McShane et al, 1997). After concerns about cardiac safety, the Committee on Safety of Medicines placed restrictions on the prescribing of thioridazine and sertindole; droperidol was discontinued by the manufacturer (Medicines and Healthcare Products Regulatory Agency, 1999, 2000, 2001). An increased risk of ischaemic stroke has been associated with atypical antipsychotic use in elderly patients with dementia (Medicines and Healthcare Products Regulatory Agency, 2004), and this led the Committee on Safety of Medicines to issue guidance that risperidone and olanzapine should not be used for treating behavioural symptoms of dementia. A more recent study suggests that the risk of ischaemic stroke is similar for both atypical and conventional antipsychotics (Gill et al, 2005). Furthermore, typical antipsychotics have been associated with a higher risk of death in the elderly compared with atypicals (Wang et al, 2005).
Prior to its restriction, thioridazine was the most commonly used antipsychotic in UK care settings, accounting for 51-74% of prescriptions (McGrath & Jackson, 1996; Oborne et al, 2002). To our knowledge the prescribing of antipsychotics in UK care homes has not been studied since thioridazine was restricted. The aim of this study was to determine the prescribing patterns of antipsychotics in care homes for the elderly since the restrictions on thioridazine.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Approval was obtained from the local National Health Service research ethics committee. We approached all care homes in the Leeds area with six or more residents aged 65 and over, seeking to include all residents taking one or more medicines on a long-term basis. We excluded those who were in another clinical trial or who were terminally ill. We excluded individuals at the general practitioner’s (GP’s) request. We obtained informed consent from those able to grant it and assent from the nearest relative from those with impaired capacity.
Data collection
Clinical data were collected from GP records from 59 practices between
April 2002 and July 2003. Details of repeat medicines were recorded for each
participant. Typical and atypical antipsychotics were defined as listed in the
British National Formulary, section 4.2.1
(British Medical Association & Royal
Pharmaceutical Society of Great Britain, 2005).
All participants were assessed for physical dependency using the Barthel Index (Wade & Collins, 1988) and cognitive ability using the Standardised Mini-Mental State Examination (SMMSE; Molloy & Standish, 1997).
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Table 2 details antipsychotic prescribing. Out of 331, 67 residents (20%) were prescribed an antipsychotic, with 47 (14%) and 20 (6%) prescribed an atypical and typical antipsychotic respectively. Of the 67 residents prescribed an antipsychotic, 10 (15%) had a documented diagnosis of a psychotic disorder and 46 (68.7%) had a diagnosis of dementia.
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Of the 146 residents with a diagnosis of dementia, 46 (32%) were prescribed an antipsychotic (typical 13 (9%); atypical 33 (22%)). Only 7 of those prescribed an antipsychotic (10%) had a documented diagnosis of psychotic disorder, although 15 out of 146 of the residents with dementia (10%) had a diagnosis of a psychotic disorder.
In contrast, of the 174 residents without a documented diagnosis of dementia, 17 (10%) were prescribed an antipsychotic (typical 7 (4%); atypical 10 (6%)). Again out of 174, 9 of the residents without dementia (5%) had a diagnosis of a psychotic disorder, but only 3 of these were receiving an antipsychotic. It is not clear why antipsychotics were prescribed to the other 6 residents. For the 11 residents for whom diagnostic information was not available, 4 were prescribed an antipsychotic (all atypical).
The most commonly prescribed antipsychotic was risperidone (mean dose 1 mg), which accounted for 57% of antipsychotic use (Table 3).
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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In our sample, risperidone had replaced thioridazine as the most commonly prescribed agent and demonstrated a shift from typical to atypical antipsychotic use. The mean dose of risperidone used was 1 mg daily. It seems likely that risperidone became the standard choice of antipsychotic for use in care homes after the restrictions imposed on thioridazine, without any reduction in the overall rate of prescribing. It is possible that since the safety concerns about risperidone and olanzapine have come to light, other antipsychotics may have taken their place. Given the reports that these concerns may be applicable to all antipsychotics (Gill et al, 2005; Wang et al, 2005), it would seem desirable to reduce the frequency of antipsychotic prescribing for residents of care homes, particularly as the majority of residents in this study had evidence of cognitive impairment.
This study was conducted in a randomised sample of approximately 10% of care home residents in Leeds. It included homes of a range of size and type, and covered inner city, suburban and rural areas. However, the results may not be generalisable to care home residents in other locations.
The UK National Service Framework for Older People requires an annual review of all medicines and a 6-monthly review for those on four or more medicines (Department of Health, 2001). However, in this study, only one-quarter of patients had a documented medication review by their GP within the previous 12 months. Antipsychotics can be withdrawn in up to one-half of patients with no adverse effects on behaviour and functioning (Avorn et al, 1992; Schmidt et al, 1998), and alternative strategies are effective in reducing agitation in people with dementia (Ballard et al, 2002; Holmes et al, 2002). Practices should therefore use the medication review markers on electronic records to ensure that all patients and their treatment are reviewed regularly and the review documented. The reviewer should always consider whether it might be appropriate to withdraw medication. Reviews should be conducted by clinicians with an interest in the management of dementia.
Behavioural approaches may be the treatment of choice for the behavioural and psychological symptoms of dementia, but may not be practical for very disturbed behaviour. Furthermore, such expertise and resources are limited in the care home setting. Antipsychotics may therefore be prescribed in desperation in the face of challenging behaviour. However, there is little evidence of the value of antipsychotics in this situation. Furthermore, since this survey, studies have suggested that they may be harmful to physical health (Medicines and Healthcare Products Regulatory Agency, 2004; Gill et al, 2005; Wang et al, 2005).
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Acknowledgments |
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References |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
