Welcome to the Right Care webinar programme

1. Welcome to the Right Care webinar programme Now that you have joined in you will notice you are on mute. If you have any questions throughout the webinar please write them in the Q&A section located in the below right panel. There will be opportunity to have your questions answered at the end. We will take you off mute when your question is being answered so you have the opportunity to speak to the panel. If you would like to chat to other colleagues you can do so by typing in the chat section. There is a drop down menu which will allow you to select who you would like to send the message to. This webex event will be recorded.

2. The pharmacist contribution to the care of people with dementia across health & social care Denise Taylor, Anne Child, Jonathan Mason

3. Speakers • Chair: Dr Denise TaylorSenior Lecturer, University of Bath and President of CMHP D.A.Taylor@bath.ac.uk Speaker 1: Anne Child, Head of Pharmaceutical Care & Clinical Standards, Avante Care & Support Anne.Child@avantepartnership.org.uk Speaker 2: Jonathan Mason, Clinical Adviser (Medicines) at NHS England London Region Jonathan.Mason@nhs.net

4. Our Objectives • Scene setting - Getting medicines right for people with dementia • CMHP, CPPE & Royal Pharmaceutical Society • Royal College of Psychiatrists • Local research & need for proactive medicines optimisation in dementia • Pharmacist contributions to ensuring appropriate medicines use in people with dementia • NHS England Perspective • Q&A Time

5. Dementia “ a syndrome consisting of progressive impairment in two or more areas of cognition: (memory; language; visuospatial & perceptual ability; thinking & problem-solving; personality) sufficient to interfere with work, social function or relationships”

6. Local & National Getting medicines right for people with dementia CMHP, CPPE & Royal Pharmaceutical Society Royal College of Psychiatrists - liaison Secondary Care Prescribing of Antipsychotics

7. Prescribing Antipsychotics for Older People with Dementia • CSM 2004 warning: stroke increased by over 3-fold with risperidone or olanzapine and more than doubled with any other atypical antipsychotic agent. • Two epidemiological studies in 2005 showed typicals had similar risk pattern • Prime Ministers Challenge – reduce by 2011 • Audit 2012 – success story or….

8. Patient ID ANTIPSYCHOTIC RISK ASESSMENT IN DEMENTIA (AID - Assess, Investigate and Deliver best care) • DELIVER BEST CARE • Complete a Capacity Assessment for informed consent to the treatment. If lacking proceed under “Best Interest” guidance (see Mental Capacity Act) • Treat factors which worsen symptoms e.g. delirium & pain • Treat underlying thrombo-embolic risk factors , dehydration, causes of sedation e.g. medication and infection • Maximise mobility • Consider VTE prophylaxis • Review the need for an antipsychotic on a regular basis, initially daily • Review the need for their continuing use prior to discharge • If prescribed post discharge arrange a post-discharge review as soon as possible by primary care or specialist mental health services • Do not give an antipsychotic to a patient with Parkinson’s disease or Lewy Body dementia without advice from a psychiatrist or specialist physician experienced in their use. Do not use the drugs stated below • Start with the lowest dose possible for clinical effect. Use oral risperidone (max 2mg daily) or when oral administration is not possible intra-muscular haloperidol (max 3mg daily). • Do not use anticholinergic medication routinely for problematic side effect as they cause delirium in dementia as do other drugs with anticholinergic side effects. Reduce the dose or stop the antipsychotic • Discuss with the patient &their relative/carer the risks and benefits of their use. 1 in 3 people will benefit. 1 in 100 will experience a CVA • & 1 in 100 will die as a result of their use 1 ASSESS Does the patient have dementia with psychosis or exhibits severe physical aggression? 3 YES NO - do not prescribe an antipsychotic INVESTIGATE Look for factors which worsen symptoms & risk factors for thrombo-embolism (CVA, DVT, PE, MI) Delirium (see NICE CG103 – Delirium) Pain Dehydration Sedation InfectionImmobility VTE risk assessment 2 When completed Date:

9. Pharmacists Role • Look for underlying causes; ensure these are treated effectively • Look for underlying medication precipitants; withdraw if appropriate • Ensure smallest effective dose used of non-anticholinergic AP (risperidone); monitor for effect • Ensure withdrawn if ineffective or symptoms resolve

10. Possible care pathway for AD management in patients with behavioural symptoms Diagnosis of Alzheimer’s disease Does the patient have challenging behavioural symptoms? No Yes Consider psychological and alternative therapies Has there been a sufficient response? Yes No Monitor Pharmacological options Short-term management Longer-term management Professor Clive Ballard

11. Rationale for Non-pharmacological interventions • Liaison Services (eg. Ballard et al 2002) • Clinical Psychologist (eg. Bird et al 2007/2009) • Staff training (Fossey et al 2006, Chenoweth et al 2009) Social Interaction (Cohen-Mansfield et al 1997, 2007, Ballard et al 2009)

12. Aromatherapy, herbal remedies and food supplements

13. Recommendations for short-term antipsychotic use Non pharmacological Interventions and alternative pharmacological treatments need to be available Severity criteria need to be in place for the prescribing of Antipsychotics to people with dementia Relatives should receive full explanation Monitoring should be mandatory Treatment should not be continued beyond 12 weeks except in extreme circumstances - and this should be policed

14. Neuropsychiatric symptoms in AD: Potential alternative therapies * Not licensed for treatment of AD

15. Assessment Tools Assessing cognition in older People: a practical toolkit for health professionals. http://www.alzheimers.org.uk/cognitiveassessment

16. Recent Research • Pharmacist input • concomitant medication • swallowing difficulties • compliance issues • repeat prescribing problems, and • lack of proactive information provision

17. Potential Pharmacist Input See the RPS Practice Guidance for dementia http://www.rpharms.com/public-health-resources/mental-health.asp? • Medicines management issues • Concomitant medication • Medicines use reviews • Progression, and at any stage • Proactive provision of information

18. Medicine Management Issues • Counselling points • All medication • Cautions • Side Effects • Assessing Efficacy • Withdrawal Issues – all medication

19. Concomitant Medication • Check for anticholinergic load e.g oxybutynin; antidepressants; thioridazine; • Check for adverse CNS effects e.g. Long acting benzodiazepines, barbiturates; opiates; dopaminergics • Check need for antipsychotics – risperidone only licensed agent in aggression • Any agent potentially causing confusion e.g. LA hypoglycaemics; NSAID’s H2 antagonists e.g. cimetidine • Ensure all CV and diabetic risks treated appropriately

20. Medicines Use Reviewshttp://www.pm-modules.co.uk/pm_modules/dem_pm0713.pdf • Appropriate titration • Check for side effects • Cholinergic • Cardiovascular • Cramps • compliance issues and repeat prescribing problems • Other medicines – question everything

21. Compliance (Secondary Adherence) issues • Large numbers of medicines • Interactions or side effects • Timing • Remembering • Strain on main carer/PWD living on own • Repeat prescribing issues - stock, labelling issues, equal quantities of all medicines, formulation

22. Progression • Swallowing difficulties • Behaviour • Dietary intake and fluid • Bowels • Palliation

23. Proactive Information • On diagnosis • signposting to support groups & social service support • Lifestyle changes to keep healthy • healthy body is a healthy brain • On receiving a medicine for dementia • AE, compliance issues, concomitant medicines • Social, ethical and legal issues - Advance Directives, wills, Power of Attorney etc • Care & end of life issues

24. Social Care & Support • CPN monitoring • Psychiatric care support programme • Care & patient counselling/support/stimulation • Day hospital services • Social worker assessment • Respite care • End of Life Care – hospice?

25. Why is this Important? • Prolonged stress leads to poorer health outcomes for both carer and PWD and then institutionalisation • Better quality of life for people if better adherence to their medicines • Carers more supported in coping with supervisory medicines role

26. Public Health and Dementia? Lifestyle changes which improve cognitive reserve • Better and continuing education & occupation • Physical activity and exercise • Midlife obesity • Alcohol intake • Smoking cessation • ?improved social networking Improved treatment or prevention of certain medical conditions • Stroke prevention • Diabetes control, • midlife hypertension, • Midlife hypercholesterolaemia • Midlife fitness levels

27. QUALITY OUTCOMES FOR INDIVIDUALS WITH DEMENTIA Anne Child Head of Pharmaceutical Care and Clinical Standards Avante Care and Support

28. HERE WE ARE! - WHERE ARE WE ? Challenges faced in delivering quality outcomes for residents with dementia • Dementia is in itself a complex condition requiring a MDT approach • Residents are often living with more than two other LTC that need close monitoring and co-ordinated management across specialisms • There is a need to meet health and social care needs in order to promote overall well being

29. IMPROVED INTEGRATION HOW THIS WOULD HELP WITH MUR ! Access to specialist input in home environment - GPs can access support i.e. ask consultants: Is there a pathway where pharmacists could tap into specialist pharmacists and thus improve residents outcomes?

30. Continued • This could be used post review to enhance recommendations - more MDT working • Facilitate medicines optimisation and or facilitate withdrawal of low dose antipsychotics • how many community pharmacist would feel confident to initiate withdrawals? • Improve professional understanding • Help with management and positive care planning for residents

31. Example of medication review outcomes

32. POSITIVE CARE PLANNING I.E. LBD Pharmacist Input could be focused on the individual, not the drug profile: • Increase staff awareness to drug sensitivity of individuals with this diagnosis • Increase risk of postural hypotension and falls, target this area in MURs • Reduction in psychotropic medication by management of disease manifestations

33. Advanced care planning • Adequate information for individuals and their relatives to support decision making • Some areas have this well managed see PEACE pathway Kings College for last months of life • Medway has the my wish register

34. In practice at home level we apply best practice Watchful waiting - Psychosocial interventions - In some residents we have found it is appropriate to use this form of medication in line with the Banerjee report Regular review APPROPRIATE USE OF LOW DOSE ANTIPSYCHOTICS

35. OTHER HEALTH CARE PROFESSIONALSAvanteis lucky enough to have: • An Admiral Nurse who works with individuals, families and staff to improve understanding and manage expectations of care • A Health and Wellbeing specialist who oversees nutrition and hydration

36. MORE THAN THE DRUGSOUTCOME LINKED • Reducing avoidable hospital admissions linked to medication, falls, nutrition and hydration • Personalisation of care and improved expectations • Living well with dementia as opposed to suffering from dementia

37. Jonathan Mason Clinical Adviser (Medicines) at NHS England London Region ‘Why dementia matters to me, and why it should matter to Pharmacy’

38. Conclusions Dementia is a complex and life changing condition It affects spouses, partners, families and communities Needs are multiple and varied Medicines can play an important role in delaying progression and Improving behaviours Pharmaceutical Care for people with dementia and their carers needs to be proactive

39. Questions Today we have briefly looked at how pharmacists are and can help support people living with dementia in any care sector. We would value your questions or comments

40. Dementia Action Alliance. If you would like to join DAA for support in your practice in dementia please join here: http://www.dementiaaction.org.uk/join_the_alliance There are further resources after the the next slide

41. Thank you The Dementia Action Alliance will send you an invitation to join our Linkedin network over the coming weeks. For today’s slides and any other resources from past webinar events please visit: http://www.dementiaaction.org.uk/rightcarewebinars

42. Alzheimer's Society • Assessing cognition in older people: a practical toolkit for health professionals. http://www.alzheimers.org.uk/cognitiveassessment • Reducing the use of antipsychotic drugs: A guide to the treatment and care of behavioural and psychological symptoms of dementia http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=1133

43. Mortality risks: typical and atypical antipsychotics DAT/CB

44. Responses to atypical antipsychotics Response** based on CGIC score at 12 weeks: 32% Olanzapine group 26% Quetiapine group 29% Risperidone group 21% placebo group Overall comparison: p=0.22 ** A response was defined as continued treatment with the original phase 1 study drug and at least minimal improvement on the CGIC. DAT/CB Schneider L et al. NEJM 2006; 355:1525-38.

45. Differential Survival Ballard C et al. Lancet Neurol 2009; 8(2):151-7.

46. Psychotropic drugs and BPSD 40-60% people with dementia in NH are taking antipsychotics1 Table adapted from Ballard et al 2001

47. Stopping antipsychotics: Impact on QoL DAT/CB

48. Further Information- general • Mental Health Resources http://www.rpharms.com/support-tools/mental-health-resources.asp • Pharmaceutical care Guidance in Mental health http://www.rpharms.com/public-health-issues/mental-health.asp • Alzheimer’s Society http://alzheimers.org.uk/ • College of mental health pharmacy http://www.cmhp.org.uk • CPPE Focal Point on Dementia http://www.cppe.ac.uk/learning/Details.asp?TemplateID=Dementia%2DW%2D01&Format=W&ID=174&EventID=- • CPPE Mental health http://www.cppe.ac.uk/learning/programmes.asp?format=e&ID=47&theme=11 • CPPE http://www.thelearningpharmacy.com/ • Taylor D.A. Medicines Use Reviews in Dementia. CPD Module. Pharmacy Magazine June 2013.

49. Living with Dementia Living with dementia http://www.youtube.com/watch?v=WR74FEyc9KY&feature=related Communication http://www.healthtalkonline.org/Nerves_and_brain/Carers_of_people_with_dementia/People/Interview/839/Category/144/Clip/4016/dementia-communication#dementia-communication

50. Dementia Video Clips AlzPt 1 of 4 http://www.youtube.com/watch?v=_OD0z0u93sw&feature=channel AlzPt 2 of 4 http://www.youtube.com/watch?v=VHxdAYmMfK4&feature=channel Stan 3 of 4 http://www.youtube.com/watch?v=yykeknxMozk&feature=channel Mum 4 of 4 http://www.youtube.com/watch?v=nl9xqm_9KbE&NR=1 Living with dementia http://www.youtube.com/watch?v=WR74FEyc9KY&feature=related Dementia tour (what its like to live with dementia) http://www.youtube.com/watch?v=3hROU6f5TUQ