Academics find 'excessive' use of antipsychotics in care homes

A major study has found no reduction in the prescribing of high risk antipsychotic drugs to people with dementia in care homes, despite a Government strategy recommending their use be curbed.

The length of treatment with antipsychotics in care homes has been described as ‘excessive’ in more than 77 per cent of cases in 2012, (up from 69 per cent in 2009), according to research by five universities which analysed more than 600 care homes in England over four years.

Analysis of the prescribing data between 2009 and 2012, also found the length of treatment exceeded the recommended six week course and even the maximum advised length of 12 weeks.

The study’s findings fiy in the face of the 2009 ‘Banerjee Report’, commissioned by the Department of Health as part its National Dementia Strategy (NDS), which examined the use of antipsychotics for people with dementia and concluded the drugs were a “substantial clinical risk” due to their serious side effects and their overuse “must not be allowed to continue”.

No shift to safer drugs

However, the new study, which examined antipsychotic prescribing in care homes before and after the launch of NDS, discovered older first-generation antipsychotics (FGA) such as haloperidol and chlorpromazine are still being used extensively, with no shift to safer second-generation antipsychotics (SGA) like risperidone – as recommended in the NDS.

The researchers said: “We observed that most residents were prescribed antipsychotics within acceptable dosages; however, in the majority of cases, length of treatment was excessive.”

The care homes with the highest antipsychotic prescribing rates were more likely to include residents in institutions situated in a deprived neighbourhood, those in homes registered for dementia or residents in homes served by four or more GP practices.

'Increased risk of stroke, falls and death'

George McNamara, head of policy at Alzheimer’s Society, said: “Antipsychotics increase the risk of stroke, falls and even death – it’s shocking that the evidence continues to be flatly ignored.

"With person-centred approaches and training programmes for care home staff, continued inappropriate prescribing is a step backward into the dark ages.”

Researchers highlighted that the Government's NDS did not include long-term monitoring of antipsychotic prescribing, let alone enforcement mechanisms.

'Failure of Government's National Dementia Strategy'

The study concluded standards specifying recommended agents, dosages and length of treatment would be helpful and recommended routine reporting of patterns of prescribing for care home residents.

Lead researcher Professor Ala Szczepura at Coventry University said: “Care homes remain the forgotten sector in UK policy debate around the use of antipsychotics. This appears to be due to a lack of systematic monitoring of prescribing data in these settings.

“Our study has not only identified a failure of the National Dementia Strategy to produce a sustained decrease in use of antipsychotics, it’s also shown large regional variations and has found evidence indicating that their use is higher in care homes in deprived neighbourhoods.

"Looking forward, the Prime Minister’s challenge on dementia 2020 aims to further slash inappropriate prescribing of antipsychotics by 67 per cent, and reduce variation across the country. It’s clear from our research that to achieve this in care homes, a significant change is required in prescription culture and management of vulnerable people with dementia.”

The research was carried out by Coventry University, the University of Warwick, Lancaster University, the University of East Anglia, City, University of London and technology company Invatech Health.

The research also found care home residents aged 85 years and older were less likely to be prescribed more antipsychotics than younger residents aged 65–74 years old.

Residents in care homes served by a single GP practice were the least likely to be prescribed anti psychotics, compared with settings with multi-practice medical support. Researchers said the ‘treatment culture’ may be influenced by a more consistent message provided by one GP practice, with requests to continue use of these drugs addressed more appropriately. In the multi-practice, where up to 21 GP practices served a single care home, the study found ‘a lack of consistent messages may emerge’, despite the fact that residential homes, where medication is managed by non-clinical social care staff, require more consistent advice and support.

Professor Clive Bowman, a visiting professor in the School of Health Sciences at City, University of London, said: “This is unacceptable. Clear standards are required regarding the use of these drugs and a designated responsibility for monitoring medicines and their usage mandated. New technology can do this in real time, allow public scrutiny and free professional time to promote best practise.”

The average yearly expenditure on antipsychotic drugs was £65.60 per care home resident (based on 2012 prices).

Mr McNamara, head of policy at the Alzheimer’s Society added: "This continued reliance on antipsychotics to manage behavioural symptoms of dementia is deeply worrying. Around 90 per cent of people with dementia experience symptoms that affect their behaviour causing aggression, agitation, or even delusions and hallucinations.

"These symptoms can develop as part of their condition, but may also be caused by other factors – pain, discomfort, or unmet need. When this is the case, prescribing antipsychotics treats the person with dementia as the problem rather than the root cause of their behaviour."

The study 'Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a four year period' was published in the medical journal BMJ Open and can be viewed at:

http://bmjopen.bmj.com/content/6/9/e009882.full