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30 November 2009
The Government has accepted the findings and recommendations of an independent report on prescribing of antipsychotics in people with dementia. The report identifies an unacceptable level of people dying as a result of prescribing antipsychotics for people with dementia, when there is clear evidence that they are currently being over prescribed and alternative non-pharmacological approaches to dealing with anxiety and behavioural problems are available and should be used.
Action
Healthcare professionals should follow the NICE/SCIE guideline for the management of patients with dementia who have behavioural and psychological problems. The Government has stated that, in line with this guidance, antipsychotic drugs should only be prescribed when a person is a risk to themselves or others, and where all other methods have been tried. This should be for a short period of three months only, whilst a care plan is put in place.
The recent, independent Banerjee report on the use of antipsychotic medication for people with dementia is a ‘must read’ for healthcare professionals directly involved in, or commissioning services for, the management of people with dementia.
Why is action necessary?
The harms and limited benefits of using antipsychotic drugs for the treatment of people with dementia who exhibit challenging behaviours is well recognised. It has been the subject of several previous reviews and MHRA warnings (see Blog 312; Blog 275; Blog 263; Blog 246; MHRA 2004). In 2006, the NICE/SCIE dementia guideline provided clear recommendations for the precautions necessary and the limited situations when antipsychotic drugs could be prescribed for those people with severe non-cognitive symptoms (psychosis and/or agitated behaviour causing significant distress).
In recognition of widespread concern about the over-prescription of antipsychotic drugs, and as part of the priority being given to improving care for people with dementia in the Dementia Strategy, an independent clinical review for the Secretary of State on the prescribing of antipsychotic drugs to people with dementia was carried out by Professor Banerjee. The report describes an unacceptable level of people dying as a result of prescribing antipsychotics, when there is clear evidence that they are currently being over prescribed and alternative non-pharmacological approaches to dealing with anxiety and behavioural problems are available and should be used.
The Banerjee report should be consulted for further details. It identifies limited positive effects and significant harms in treating behavioural symptoms in dementia with antipsychotics, whilst recognising that some people do benefit from these medications. It suggests that antipsychotics are too often used as a first-line response to behavioural difficulty in dementia rather than as a considered second-line treatment when other non-pharmacological approaches have failed.
Although there is uncertainty in the figures, the report estimates that there are 180,000 people with dementia treated with antipsychotic medication in England per year. Of these, up to 36,000 may derive some benefit from treatment, but an additional 1,800 may die and an additional 1,620 suffer a cerebrovascular adverse event (around half of which may be severe) per year. The report suggests that if support was available to provide alternative methods of managing behavioral problems, prescribing of antipsychotics could be reduced by two-thirds in people with dementia.
What is proposed?
The Banerjee report includes a list of recommendations for prioritisation, improvements in leadership, audit, training of staff and improvements in the services offered to people with dementia. The Government has accepted the findings and recommendations of the report and has responded with a series of actions. As summarised by the Department of Health in a news story, these include:
- a new National Clinical Director for Dementia
- measures to ensure people with dementia and their carers have access to psychological therapies to tackle the root of agitation and aggression
- an audit to establish definitive prescribing figures
- clear local targets to cut antipsychotics use as a result of the audit
- better regulation
- collaboration with the General Medical Council and Royal Colleges to ensure all health and social care staff have specialist training in dementia
- joint Department of Health and Alzheimer’s Society guidance on what to do if a family member is given antipsychotics.
Further information on the management of dementia can be found on the CNS and Mental Health floor of NPC.
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