Tackling the inappropriate use of psycho-active medication in Scotland

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Dr Stella Clark, Medical Director,
Primary Care, NHS Fife; Clinical lead for Mental Health Services, NHS 24

Presentation from Alzheimer Scotland conference 2011 - Creating Better Dementia Care.

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Tackling the inappropriate use of psycho-active medication in Scotland

  1. 1. Creating Better Dementia Care <ul><li>Tackling the inappropriate </li></ul><ul><li>use of </li></ul><ul><li>psycho-active medication in Scotland </li></ul><ul><li>Dr Stella Clark </li></ul><ul><li>Alzheimer Scotland Conference </li></ul><ul><li>June 2011 </li></ul>
  2. 2. Psycho-active Medication? <ul><li>Antipsychotic </li></ul><ul><li>anti-depressant </li></ul><ul><li>anti-anxiety </li></ul><ul><li>hypnotic </li></ul><ul><li> </li></ul>
  3. 3. Strategy Commitments <ul><li>baseline assessment of the use of psychoactive medication for those with a diagnosis of dementia. </li></ul><ul><li>Reduction in the level of prescription during 2011 </li></ul><ul><li>a further reduction for future years. </li></ul>
  4. 4. <ul><li>We know that </li></ul><ul><li>Most people with dementia live at home or in care homes </li></ul><ul><li>Most people are registered with a GP </li></ul><ul><li>GP surgeries have computerised records </li></ul><ul><li>Prescriptions contain patient identifiers </li></ul>
  5. 5. <ul><li>The burden of psychotropic drug prescribing in people with dementia: a population database study” </li></ul><ul><li>Bruce Guthrie, Stella Clark, Colin McCowan Age and Ageing 2010; 39: 637–642 </li></ul>
  6. 6. What did we do? <ul><li>315 GP Practices in Scotland (1/3) take part in the SPICE-PC programme </li></ul><ul><li>People aged 65 or over on 31/7/2007 </li></ul><ul><li>Linked </li></ul><ul><li>-Psychotropic medication prescriptions </li></ul><ul><li>-Dementia register </li></ul><ul><li>-Anticholinesterase drugs </li></ul>
  7. 7. What did we show? <ul><li>4 key messages </li></ul>
  8. 8. 1 st message <ul><li>Under diagnosis of dementia particularly in the oldest age groups </li></ul>
  9. 9. 2 nd message <ul><li>If diagnosed with dementia </li></ul><ul><li>-antipsychotic drug x17 -Anti depressant x2 -Anxiolytics and Hypnotics x2 </li></ul>
  10. 10. 3 rd key message <ul><li>13-20 times more likely to have </li></ul><ul><li>combinations of these drugs </li></ul>
  11. 11. 4 th key message <ul><li>Once started, 93% become </li></ul><ul><li>“ repeat prescriptions” </li></ul>
  12. 12. What we cannot tell from this study <ul><li>Who starts the medication </li></ul><ul><li>If prescribing is influenced by where people are living </li></ul><ul><li>Prescribing of psychoactive drugs in 2011 </li></ul>
  13. 13. Who starts the medication? <ul><li>Audit of </li></ul><ul><li>Nursing home residents within one GP practice </li></ul><ul><li>discharges from one hospital </li></ul>
  14. 14. Who starts the medication? <ul><li>Most psychotropic drugs recommended by secondary care </li></ul><ul><li>Consultants should improve advice re length of treatment </li></ul><ul><li>GP should improve review mechanisms </li></ul>
  15. 15. NHS Fife Old Age Psychiatry Withdrawal of Antipsychotics in patients with Dementia Quick Reference Guide Patient with Dementia on Antipsychotic Medication for >12 weeks History of severe agitation, aggression, psychosis prior 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 /day Reduce 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 <ul><li>Reference to support Guide </li></ul><ul><ul><li>Chlorpromazine equivalent doses for the Newer Atypical Antipsychotics. Woods.S.(2003) J.Clin Psychiatry 64:6 </li></ul></ul>Dr Stella Clark, On behalf of the Old Age Psychiatrists March 2011 No GP led reduction in medication
  16. 16. Is prescribing is influenced by where people are living? <ul><li>living in care homes v </li></ul><ul><li>living at home </li></ul>
  17. 17. Health Informatics Centre <ul><li>Data for population of ~800k people </li></ul><ul><ul><li>Tayside data available since early 1990’s </li></ul></ul><ul><ul><li>Fife data available since 2008 </li></ul></ul><ul><li>Individual datasets linkable using unique personal identifier </li></ul>
  18. 18. What did we do? <ul><li>Data for 2005 and 2006 for people aged over 65 </li></ul><ul><li>Divided people into 2 groups depending on their address </li></ul><ul><li>Compared the numbers in each group prescribed psychoactive medications </li></ul>
  19. 19. What did we show? <ul><li>2 key messages </li></ul>
  20. 20. 1st message <ul><li>Living in a care home (6%) </li></ul><ul><li>-antipsychotic drug x14 -Anti depressant x1.8 -Anxiolytics x1.3 - Hypnotics x3.4 </li></ul>
  21. 21. 2nd key message <ul><li>People in care homes </li></ul><ul><li>70% of psychoactive medications started before admission </li></ul><ul><li>Antipsychotic drugs often started 30 days before or after admission to the care home </li></ul><ul><li>Once started, become long term prescriptions </li></ul>
  22. 22. Implications <ul><li>Improved links between GP and specialist services </li></ul><ul><li>Improve the services into care homes </li></ul>
  23. 23. Forth Valley Care Home Liaison Service <ul><li>6 weekly nurse led clinics </li></ul><ul><li>Ongoing assessments/reviews (out-with clinic) </li></ul><ul><li>6 week educational programme which is continually evolving </li></ul>
  24. 25. Summary <ul><li>High awareness of the problem </li></ul><ul><li>We need better co-ordination of action -care home liaison service -links between GP and specialist services </li></ul><ul><li>baseline assessment of the use of psychoactive medication for those with a diagnosis of dementia is underway </li></ul>

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