Take action to prevent misuse of psychotropic medicines in care homes

The Orchid View serious case review could be looked upon as yet another in a long list of instances in which care has been unsatisfactory and vulnerable people have been put at risk. However, this review was different in that it specifically involved a pharmacist and highlighted the importance of pharmacists raising concerns about the treatment of vulnerable people.

Viewed alongside the Winterbourne scandal, it is becoming increasingly clear to me that pharmacists need to be in a position to take immediate action to deal with inappropriate medicines use in care homes and be prepared to act as an advocate for people who reside there. The English Pharmacy Board considered various aspects of this challenge over recent months to inform a briefing to the care minister Norman Lamb.

The background figures here are large. There are around 431,500 elderly and disabled people in residential care, of whom 414,000 are aged 65 years or over. Care home residents tend to be older and frailer owing to the ageing population and policies to encourage elderly people to stay in their homes longer. Elderly people often have multiple health problems and may be prescribed many medicines, so they are particularly at risk of medication errors.

We have been advocating for better use of pharmacists’ skills in care homes — a setting where each resident takes an average of 7.2 medicines and where safety incidents are very likely to occur. Appropriate pharmacy involvement should benefit care homes providers, their residents and the NHS.

There are many issues surrounding the quality of care provided in care homes; medicines safety is a major area of concern. The Care home use of medicines study (CHUMS)^[1]
found at least one medication error in just under 70% of the 256 care home residents reviewed, which the report described as “unacceptable”. The authors suggest that pharmacists should regularly review residents’ medicines and rationalise regimens to help care home staff work safely. Such measures would do much to identify and prevent dispensing errors.

Overprescribing of psychoactive drugs, particularly antipsychotics, also continues to be identified. There is controversy around both the prescribing of medicines for challenging behaviours and the use of such medicines when mental illness is present. We know that 75% of residents in care homes are receiving at least one psychoactive medicine and 33% are taking an antipsychotic^[2]
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There is a range of factors that contribute to overprescribing of antipsychotics in care homes, including: poor co-ordination of care; patients having multiple conditions; the involvement of different clinical specialisms; lack of regular medication reviews; and insufficient support for generalists to undertake specialist reviews.  

We believe that pharmacist input can have a substantial impact on the way medicines are used. A pharmacy-led programme within GP surgeries in Medway demonstrated that pharmacist interventions led to cessation of antipsychotics or dose reduction in 61% of cases^[3]
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The clinical role of pharmacists must extend to ensuring that medicines are not being used in harmful, potentially abusive ways. And pharmacists must be empowered to act if they discover patients being mistreated.

The more serious cases that come to light, the stronger I support our stance. Working with other healthcare professionals in an integrated team, pharmacists should have a major accountability within care homes, take overall responsibility for the medicines used and have a clear mandate to uphold patient safety and protect against abuse.