The prescribing of low-dose antipsychotics for challenging behaviour for people with dementia gained prominence following media attention and the publication of the Banerjee report in 2006. The report identified that there are an estimated 180,000 people with dementia on antipsychotic drugs. However, in only about one-third of cases were the drugs beneficial. There were 1,800 excess deaths per year as a result of their prescription and up to 1,620 cerebrovascular events.
The report suggests that, if support were available to provide alternative methods of managing behavioural problems, prescribing of antipsychotics could be reduced by two thirds in people with dementia.
In 2012 Dementia Action Alliance (DAA) launched a national campaign — “Right prescription: a call to action on the use of antipsychotic drugs for people with dementia” — to raise public awareness and to mobilise key people to act to address this issue.
The Buckinghamshire primary care medicines management (MM) team identified this as a priority that needed to be tackled with partner organisation support. Locally, the scale of the problem and what action would influence a change in practice had to be scoped.
Buckinghamshire call to action
A primary care pharmacist and joint commissioning manager worked with the DAA and the NhS Institute for Innovation and Improvement to produce commitment statements for key stakeholders. This formed part of the national campaign, the aim of which was to ensure all people with dementia receiving antipsychotic medicines had a clinical review and that prescribing was in line with best practice.
At a local level, the MM team led the Buckinghamshire response. This started with a local radio interview by the primary care medical director.
The MM team produced audit standards and a data collection tool, which was used by GP practices to identify levels and standards of prescribing. Audit participation and development of an action plan were included as a medicines management Quality and Outcomes Framework (QoF) target, and this was used as a driver for GP participation. The joint commissioning manager also carried out a survey of prescribing in care homes.
The mental health trust participated in the national Prescribing Observatory for Mental health audit. The acute trust took part in national audit of dementia developed by the healthcare Quality Improvement Partnership.
Audit data were analysed by the primary care pharmacist and various actions to improve practice were taken. These included:
- The joint commissioning manager included the reduction in inappropriate prescribing of low-dose antipsychotics in dementia as a key objective in the Buckinghamshire dementia strategy action plan. Progress was monitored and reported at board level.
- Guidance for GPs on reducing and stopping antipsychotic medication was requested and provided by a psychiatrist.
- A reaudit was agreed as a medicines management QoF target for 2012–13.
- GP practices developed and implemented practice-based policies for prescribing low- dose antipsychotics in dementia.
- The mental health trust produced guidance on the management of challenging behaviour for patients with dementia.
- A Commissioning for Quality and Innovation framework was used to implement the guidance on the management of challenging behaviour for dementia for patients at the acute trust.
- The care home survey identified a high level of low-dose antipsychotic prescribing for people with dementia in care homes. The primary care pharmacist, joint commissioning manager, GP lead and project manager submitted a bid to the dementia challenge fund to recruit a care homes pharmacist to review practice.
Data from the baseline and reaudit were used to measure change in practice (Table 1). Results are summarised here:
- The number of people with dementia was greater in 2012/13 compared to 2011/12, however the number of people prescribed a low-dose antipsychotic has decreased.
- There has also been an improvement in the number of (i) people with dementia who had a review of their antipsychotic within three months, (ii) people with dementia or their carers who had the risks of treatment discussed with them when an antipsychotic was prescribed and (iii) GP practices with a policy for prescribing low-dose antipsychotics for challenging behaviour for people with dementia.
The Dementia Challenge bid was successful and a care homes pharmacist has started.
|Number of people with|
|Prescribed a low-dose|
|Reviewed within three months||22%||41%|
|Risks of treatment discussed||12%||31%|
|Practices taking part||52||52|
|Practices with policy for|
prescribing low dose
In practice, it is often difficult to influence change on a large scale where multiple organisations are involved. However, in this case we have shown that a common goal and commitment between partner organisations, the use of quality improvement targets as drivers and board level support really can improve practice and resultant outcomes for people with dementia.
Collaborative actions between the Buckinghamshire primary care medicines management team and partner organisations have resulted in a reduction in the percentage of people with dementia prescribed an antipsychotic by 46 per cent in Buckinghamshire.
The number of GP practices that have a policy for prescribing low-dose antipsychotic medication for people with dementia has increased. This will sustain ongoing good prescribing practice. In addition, antipsychotic medication is reviewed earlier and the risks of treatment are discussed with patients and carers in more cases.
However, more can still be done. Our next step is to focus on and review people with dementia who are prescribed a low-dose antipsychotic in care homes and to support care home staff to consider and provide alternative methods to manage challenging behaviour.
Thanks to Ojalae Jenkins, joint health and social care commissioning manager, Buckinghamshire County Council, Aylesbury Vale and Chiltern CCGs.
1 Banerjee S. The use of antipsychotic medication for people with dementia: time for action. London: Department of Health; 2006.