Time for action: the use of antipsychotics for people with dementia

1. Time for action: the use of antipsychotics for people with dementia Sube Banerjee Professor of Mental Heath and Ageing, The Institute of Psychiatry, King’s College London

2. Aims • Published November 2009 • Comprehensive review • Negative effects • Positive effects • Analysis of reasons for current clinical behaviour • Formulate practical clinical plan to deal with problems found

3. Anti-psychotics • Typical antipsychotics introduced in 1950s for schizophrenia • Atypical antipsychotics from 1980s • Adverse effects • over-sedation, • hypotension, • involuntary movements Parkinsonian symptoms (rigidity, tremor and problems with walking) • Cardiotoxicity

4. Antipsychotics in dementia • Behavioural and Psychological Symptoms in Dementia (BPSD) • Common • May be severe and complicated • agitation, • repetitive questioning, • depression, • aggression, • wandering and psychosis. • Largely unlicensed or ‘off-label’; • UK risperidone • “short-term treatment (up to six weeks) of persistent aggression in patients with moderate to severe Alzheimer’s dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others”.

5. 2002 manufacturer risperidone Canada higher rate of cerebrovascular adverse events (CVAEs) relative to those receiving placebo. 2003, US FDA published warnings 2004 the European Medicines Agency (EMEA) public advice about an increased risk of CVAEs and mortality in people with dementia receiving olanzapine. 2004, the UK Medicines and Healthcare products Regulatory Agency (MHRA) risperidone and olanzapine should not be used to treat BPSD because of increased risk of strokes 2005 FDA warnings for aripiprazole regarding the risk of CVAEs, including stroke, in dementia 2005 FDA informed health professionals 1.7 times increased risk of all-cause mortality 2006-8 Same risk shared by all antipsychotics Particular risks for people with dementia

6. Extent of use • Very poor data • Residential and nursing home populations in Leicestershire • 1990 (29.1%) and 1997 (30.7%) • 3 English cities (London, Newcastle and Oxford) • 168 (48%) of 348 people in nursing homes with dementia on an antipsychotic. • IMS Health (2009) • 20.3% of people with a recorded diagnosis of dementia included an antipsychotic • USA 2004 National Nursing Home Survey, • 24.8% of nursing home residents received antipsychotic medication; (23.5% received atypical antipsychotics and 1.9% typical antipsychotic medication). • Canadian province of Manitoba • prevalence of antipsychotic use among those aged over 65 years increased between 1996 and 2006 from 2.9% to 4.3% in men and from 4.1% to 6.0% in women

7. NHS Information Centre for Health and Social Care completed analyses using the IMS Disease Analyzer Practices from England, Wales, Scotland and Northern Ireland a representative UK sample by age and sex. 1,098,627 patients 12-month period from 1 April 2007 to 31 March 2008. 192,190 people (17.5%) over the age of 65 10,255 (5.3%) received a prescription for an antipsychotic. Estimates for the report 25% people with dementia receiving an antipsychotic 180,000 people with dementia receiving an antipsychotic Includes people with dementia at home as well as people in care homes New data and extrapolation

8. Summary of risks and benefits at a population level of the use of atypical antipsychotics for BPSD in people with dementia • data suggest that treating 1,000 people with BPSD with an atypical antipsychotic drug for around 12 weeks would result in: • an additional 91–200 patients with behaviour disturbance showing clinically significant improvement • an additional 10 deaths; • an additional 18 CVAEs, • around half of which may be severe; • no additional falls or fractures; and • an additional 58–94 patients with gait disturbance. • For UK • 1,800 deaths per year • 1,620 severe CVAEs

9. Antipsychotics should not be a first-line treatment except in circumstances of extreme risk and harm. First line detailed assessment to identify any treatable cause of the BPSD (eg delirium, pain, depression All treatable causes should be treated with the correct specific treatment (eg antibiotics for infection or antidepressants for depression). Analysis of behaviour is a problem primarily for the person with dementia, or for their carers high rate of spontaneous recovery watchful waiting Up to half of all cases may be self-limiting. Benign complementary approaches may be used. psychological approaches should be used in the first instance. Where medication considered, the potential recipient should be as involved as possible in the decision In all cases relatives involved in discussions about medication. information on positive and negative effects of the medication contribute fully to the discussion. ultimately a ‘best interests’ decision. atypicals rather than typicals The medication should be used lowest possible effective dose, shortest possible time <12 weeks. Once initiated, continuation should be reviewed regularly at least monthly); at review, reduction or cessation of the medication should be actively considered. Good practice clear – but very much the exception rather than the rule

10. Analysis of why • Symptom of underlying system failure in health and social care for people with dementia • 1960s response to a 21st century challenge • Why lack of response to clear warnings • It is complicated • System does not allow change • Knowledge • Attitudes • Provision • Need to treat the cause as well as the symptoms

11. Action

12. R1: Making the use of antipsychotics in dementia a clinical governance priority across the NHS. Using existing clinical governance structures Medical Directors (or equivalent) all primary care trusts, all mental health trusts and all acute trusts Review their level of risk in this area Ensure that systems and services are put in place to ensure good practice in the initiation, maintenance and cessation of these drugs R2: National leadership for reducing the level of prescription of antipsychotic medication for people with dementia Provided by the National Clinical Director for Dementia, Work with local and national services. Report on a six-monthly basis to the Minister of State for Care Services on progress against the recommendations in this review. 1. Use of quality improvement mechanisms

13. R3: National and local audit Developed by the National Clinical Director for Dementia with national and local clinical audit structures and leads, Audit to generate data on the use of antipsychotics for people with dementia in each PCT in England. Baseline audit should be completed as soon as possible April-July 2010 Generating baseline data across England. Repeated one, two and three years later to gauge progress. R4: Improving quality and decreasing quantity of prescribing clear, realistic but ambitious goals to be agreed for the reduction of the use of antipsychotics for people with dementia. To one third of current level in three years Explicit goals for improvement in their use where needed, agreed and published locally reviewed yearly at primary care trust, regional and national level, Information published yearly on progress towards them at each level. 1. Use of quality improvement mechanisms II

14. R9: Inspection CQC to consider using as markers of the quality of care provided by care homes and PCTs rates of prescription of antipsychotic medication for people with dementia, adherence to good practice guidelines, availability of skills in non-pharmacological management of BPSD the establishment of care home in-reach from specialist mental health services These data available by analysis of local audit data and commissioning decisions. 1. Use of quality improvement mechanisms III

15. R5: Further research including clinical and cost effectiveness of non-pharmacological methods other pharmacological approaches as an alternative to antipsychotic The National Institute for Health Research and the Medical Research Council should work to develop programmes of work in this area. R6: Developing skills for GPs and others working in care homes The Royal Colleges of General Practitioners, Psychiatrists, Nursing and Physician Curriculum for the development of appropriate skills for GPs and others working in care homes Equip them for their role in the management complexity, co-morbidity and severity of mental and physical disorder in those now residing in care homes. Part of CPD 2. Improving skills

16. R7: Curriculum for the development of skills for care home staff inc non-pharmacological treatment of behavioural disorder in dementia deployment of specific therapies Senior staff in care homes should have these skills and the ability to transfer them to other staff members in care homes. An NVQ in dementia care should be developed 2. Improving skills II

17. R11: Liaison for those in their own homes Contact between specialist older people’s mental health services and GPs to plan how to address the issue of people with dementia in their own homes who are on antipsychotic medication. Using practice and patient-level data from the completed audits on the use of these medications, they should agree how best to review and manage existing cases and how to ensure that future use follows best practice in terms of initiation, dose minimisation and cessation. 3. Specialist input • R8: Each PCT to commission specialist older people’s mental health in-reach services • Supporting primary care in its work in care homes. • Commission as a new function by PCTs • Provided by specialist older people’s mental health services • Capacity to work routinely in all care homes where there may be people with dementia. • May be aided by regular pharmacist input into homes.

18. R10: Psychological therapies for people with dementia and carers IAPT programme to ensure that resources are made available for the delivery of therapies to people with dementia and their carers. Information and support should be available to carers to give them the skills needed to deploy elements of non-pharmacological care themselves in the home 3. Specialist input II

19. Final thoughts at publication • Generation of a balanced report was attempted • The use of these drugs in those with dementia has substantial clinical risk attached • Conservative estimate 1,800 extra deaths and a similar number of extra serious adverse events such as stroke per year. • Action is needed quickly • Symptoms • Causes • Action plan • simple, • affordable, • coherent • Positive act in commissioning the review • Positive act in accepting the report and its recommendations • Now needs to be followed up by effective action • Local • Regional • National

20. What happened next… • Not a lot…

21. What makes things happen? commissioning

22. Operating Framework 2008/9 ‘dementia: providing people with dementia and their carers the best life possible is a growing challenge, and is one that is becoming increasingly costly for the NHS. Research shows that early intervention in cases of dementia is cost-effective and can improve quality of life for people with dementia and their families. The Department will shortly be publishing details of the clinical and economic case for investing in services for early identification and intervention in dementia, which PCTs will want to consider when developing local services ’

23. Operating Framework 2008/9 ‘dementia: providing people with dementia and their carers the best life possible is a growing challenge, and is one that is becoming increasingly costly for the NHS. Research shows that early intervention in cases of dementia is cost-effective and can improve quality of life for people with dementia and their families. The Department will shortly be publishing details of the clinical and economic case for investing in services for early identification and intervention in dementia, which PCTs will want to consider when developing local services ’

24. 60. There have been a number of important developments in the last year within the context of High Quality Care for All that will help PCTs determine how they develop and implement their local plans. These cover the following areas: alcohol; dementia; end of life care; mental health; military personnel, their dependants and veterans; mixed-sex accommodation; people living in vulnerable circumstances; and people with learning disabilities. 62. The National Dementia Strategy will be a comprehensive framework aimed at driving up standards of health and social care services to improve the quality of life and quality of care for people with dementia and their carers. PCTs will want to work with local authorities to consider how they could improve dementia services. 3.30 Nationally, there is a range of tools to assist PCTs and specialised commissioning groups in delivering their priorities as world class commissioners. These include, but are not limited to: the developing National Support teams(NST) for health inequalities, tobacco, alcohol, infant mortality, teenage pregnancy, sexual health, vaccinations and dementia… Operating Framework 2009/10

25. Revision to the Operating Framework for the NHS in England 2010/11 • One of only two new specific priorities • 13. During the recent sign-off of SHAs plans, two areas stood out as not being given sufficient emphasis. The first is ensuring that military veterans receive appropriate treatment… The second area is dementia. NHS organisations should be working with partners on implementing the National Dementia Strategy. People with dementia and their families need information that helps them understand their local services, and the level of quality and outcomes that they can expect. PCTs and their partners should publish how they are implementing the National Dementia Strategy to increase local accountability for prioritisation.

26. Revision to the Operating Framework for the NHS in England 2010/11 • One of only two new specific priorities • 13. During the recent sign-off of SHAs plans, two areas stood out as not being given sufficient emphasis. The first is ensuring that military veterans receive appropriate treatment…The second area is dementia. NHS organisations should be working with partners on implementing the National Dementia Strategy.People with dementia and their families need information that helps them understand their local services, and the level of quality and outcomes that they can expect. PCTs and their partners should publish how they are implementing the National Dementia Strategy to increase local accountability for prioritisation.

27. Quality outcomes for people with dementia: building on the work of the National Dementia Strategy (DH, 2010) ‘There are four priority areas for the Department of Health’s policy development work during 2010/11 to support local delivery of the Strategy. These areas provide a real focus on activities that are likely to have the greatest impact on improving quality outcomes for people with dementia and their carers. It is important to emphasise however that the priorities are enablers for local delivery of the Strategy in full, across all 17 objectives, as well as the work to implement the recommendations of the report in to the over-prescribing of antipsychotic medicines to people with dementia. The four priority areas are: • Good quality early diagnosis and intervention for all - Two thirds of people with dementia never receive a diagnosis; the UK is in the bottom third of countries in Europe for diagnosis and treatment of people with dementia; only a third of GPs feel they have adequate training in diagnosis of dementia. • Improved quality of care in general hospitals - 40% of people in hospital have dementia; the excess cost is estimated to be £6m per annum in the average General Hospital; co-morbidity with general medical conditions is high, people with dementia stay longer in hospital. • Living well with dementia in care homes - Two thirds of people in care homes have dementia; dependency is increasing; over half are poorly occupied; behavioural disturbances are highly prevalent and are often treated with antipsychotic drugs. • Reduced use of antipsychotic medication - There are an estimated 180,000 people with dementia on antipsychotic drugs. In only about one third of these cases are the drugs having a beneficial effect and there are 1800 excess deaths per year as a result of their prescription.’

28. Quality outcomes for people with dementia: building on the work of the National Dementia Strategy (DH, 2010) ‘There are four priority areas for the Department of Health’s policy development work during 2010/11 to support local delivery of the Strategy. These areas provide a real focus on activities that are likely to have the greatest impact on improving quality outcomes for people with dementia and their carers. It is important to emphasise however that the priorities are enablers for local delivery of the Strategy in full, across all 17 objectives, as well as the work to implement the recommendations of the report in to the over-prescribing of antipsychotic medicines to people with dementia. The four priority areas are: • Good quality early diagnosis and intervention for all - Two thirds of people with dementia never receive a diagnosis; the UK is in the bottom third of countries in Europe for diagnosis and treatment of people with dementia; only a third of GPs feel they have adequate training in diagnosis of dementia. • Improved quality of care in general hospitals - 40% of people in hospital have dementia; the excess cost is estimated to be £6m per annum in the average General Hospital; co-morbidity with general medical conditions is high, people with dementia stay longer in hospital. • Living well with dementia in care homes - Two thirds of people in care homes have dementia; dependency is increasing; over half are poorly occupied; behavioural disturbances are highly prevalent and are often treated with antipsychotic drugs. • Reduced use of antipsychotic medication - There are an estimated 180,000 people with dementia on antipsychotic drugs. In only about one third of these cases are the drugs having a beneficial effect and there are 1800 excess deaths per year as a result of their prescription.’

29. DH commissioning packs (Landsley 2010) Commissioning packs are tools to help commissioners improve the quality of services for patients, through clearly defined outcomes that help drive efficiency by reducing unwarranted variation in services. • Each pack contains a set of tailored guidance, templates, tools and information to assist commissioners in commissioning healthcare services from existing providers, or for use in new procurements. • Integral to each pack is an evidence-based service specification which ensures that patients are placed at the forefront of the service and are central to decisions about their care. • The specification is non-mandatory and can be adapted to reflect local needs and once agreed with the provider should inform part of a renegotiated contract or form the relevant section of the NHS standard contract. • By bringing together the clinical, financial and commercial aspects of commissioning in one place, the packs simplify processes and minimise bureaucracy.   1. Cardiac rehabilitation – Oct 2010 2. Dementia – March 2011 3. Chronic obstructive pulmonary disease

34. What happens next… • High likelihood of central pressure for change • Increasingly localised decision-making/ commissioning • What will be the effect of cessation without support? • Interesting times, but never a better chance for possible positive change

35. Thank you and good luck!