Insert name of presentation on Master Slide

Appropriate Prescribing of Antipsychotics

in dementia care

Medicines Management & Dementia Care

target 3 collaborative

Dr Les Rudd NLIAH

Rhiannon Davies Powys tHB

1000+Lives improvement

measures in mental health• Depression in General Hospital settings

• First Episode Psychosis

• Eating Disorders

• Dementia 1) making and sharing the diagnosis

reduce time between onset of symptoms & diagnosis being communicated

2) dementia in the general hospitalImproved quality of general hospital care for people with dementia

and reduced length of stay

3) use of anti-psychoticsReduced inappropriate use of anti-psychotic medications in

accordance with NICE/SCIE guidelines.

4) support for care-giversImproved support for care givers

5) NHS in-patient care (mental health units) Improved quality of care

WG Dementia Policy - Summary • WAG National Dementia Vision for Wales – launched

on 16th February national conference

• WAG 2011-12 Annual Quality Framework (AQF)priority for implementation of the Dementia Intelligent Target.

• WAG Dementia Care Intelligent Targets – The 5 targets were developed in 2010 and Health Boards are currently planning for their phased implementation for 2011/12. They are not performance management targets.

• Dementia Action Plans 2010-2015 – Four plans focussing on:-1. Improved service provision through better joint working across health,

social care, the third sector and other agencies, including:

2. Improved early diagnosis and timely interventions

3. Improved access to better information and support for people with the illness and their carers

4. Improved training for those delivering care & greater awareness of need for advocacy

Up-date on implementation

2011

• AQF 2011-12 required HB ‘delivery of Dementia

and Depression care bundles based on clinical

and patient outcomes’.

• WG £1.5m pa funding to develop services for

younger people with dementia & Dementia Advisor posts

• Increase training capacity & expertise in Wales

– DSDC Wales commissioned (Dec. 2010 – April 2012)

to lead programme for ‘Train the trainers’ -

identification, training and development of champions

in dementia care settings

Up-date on implementation

2011

• Dementia sub-group of Mental Health Programme Board established– Chaired by Director of Social Services for Wales, Rob

Pickford

• Wales Dementia Helpline– New bilingual helpline available 24/7

– www.dementiahelpline.org.uk

• Book prescription Wales– 4 dementia books added

• With Alzheimer’s Society– Dementia information packs for issue to patients

diagnosed with dementia

– National campaign to raise awareness

1st April Letter to CEO’s

• As you know, one of the aims of our mental health standards is to drive more effective integration of physical and mental health care, such as where we have evidence of increased lengths of inpatient stay due to co-morbidity. This is a particular feature of the depression and dementia standards, which include a focus on improving early diagnosis/case identification, treatment and care in General Hospital ward settings. We are experiencing difficulty in some localities in accessing General Hospital wards to pilot our mental health standards and I would appreciate your support in prioritising access. Note: Could you therefore forward this letter to your Medical Director and 1000Lives Executive leads to help action this with your mental health clinical leads.

Introduction

• National Institute of Clinical Excellence (NICE) in

its clinical guideline (2006) sets out effective and

appropriate guidance regarding antipsychotic

usage.

• The use of antipsychotics should be a last

resort, to be used at times of severe distress or

critical need.

Introduction

Following an enquiry into the prescription of

antipsychotic drugs to people with dementia

living in care homes, the All-Party Parliamentary

Group on Dementia noted that inappropriate

and overprescribing was clearly a significant

problem (‘Always A Last Resort’ - April 2008).

1000Lives plus

Medicines Management/Driver 3 Mini-

collaborative -

Appropriate Prescribing of Antipsychotics

in Care Homes

May 2012

Rhiannon Davies, Powys tHB,

Pharmaceutical Adviser

Rhiannon.davies6@wales.nhs.uk

Overview

2nd Dem3/Meds mgt Mini-collaborative

Learning event – May 1st 2012

Emphasis in sharing ‘good practice’

All Health Boards represented

Varying degrees of progress and

engagement with the initiative

Varying models of delivery within the pilot

schemes

BPSD

Defined as symptoms of disturbed perception,

thought content, mood or behaviour that

frequently occurs with dementia:

Disinhibited behaviour

Delusions and hallucinations

Verbal and physical aggression

Agitation

Anxiety

Depression/Apathy

Key messages

Non-pharmacological options are

recommended (NICE, 2006) as the first-

line approach to BPSD

Unless a person is at risk to

themselves or others

If the approaches do not help the

person and their symptoms are severe

or distressing, medication may be

necessary

Key messages

90%of people with dementia will experience

BPSD

Sudden emergence of BPSD often has a

physical trigger

Individual biography, side effects of

medication, psycho social factors, physical

environmental factors also influence

behaviour

Most BPSD will stop after 4 weeks without

pharmacological treatment

Key messages

Develop an individually tailored care

plan to help carers and staff address

the behaviour that challenges

The importance of working with health

care workers and care home staff to

change entrenched/inappropriate

attitudes and behaviours through

training

Numbers of people with dementia by local authority

with projections to 2021 Source: Dementia UK Report, 2007

0 500 1000 1500 2000 2500 3000 3500 4000 4500

CardiffSwansea

RCTCarmarthenshi

ConwyPowys

GwyneddWrexham

Neath P TalbotCaerphilly

PembrokeshireDenbighshire

FlintshireVale of Glam

NewportBridgend

TorfaenMonmouthshir

CeredigionAngleseyBl Gwent

Merthyr Tydfil

2006

2021

South Powys, Pilot Project

Multidisciplinary team:

GP – Brecon Medical Practice

Nursing Home – Mountains EMI

Nursing Home and Brookside dual –

registered Care Home

CMHT – Consultant

Powys tHB - Medicines Management

team pharmacist

Recognised strengths

Enthusiasm and commitment of all those

involved. Already started reductions. Open to

new ideas.

Good working environment – staff feel valued,

low staff turn-over rate.

Care home staff informed, involved and fully

engaged.

Active activities officer working within the care

home.

Good interaction with families.

Issues identified

Discharge from hospital wards to care homes:

information delay and level of antipsychotic

prescribing

Three monthly review: responsibility - CMHT/GP

role?

Education: GP & Care home staff (perceptions and

attitude)

Need for non-pharmacological treatments/holistic

care approach/person-centred activities

Need for multi-agency approach and improved

communication

Interventions

In –house training (care homes/ GP practices)

Use of Alzheimer Society’s best practice guidelines

Care home support for behavioural interventions

Care home BPSD monitoring checklist, adapted

behavioural chart, pain management and sleep

charts

Better coordinated review procedures

Patient/carer leaflet – Alzheimer Society booklet

Staff information posters – care homes, hospital

wards, CMHTs, GP practices

Improved formalised links between CMHT and care

homes. Improved communication.

Data collection and Outcome

measure

Data collected every 3/12• Number of patients who have a diagnosis of

dementia

• %age patients who are receiving an antipsychotic

• % compliance with care bundle (all 6 interventions

documented)

• % of patients with dementia who have been

receiving antipsychotic medication for more than

9 months

DDD/1000 PUs for the agreed basket of

antipsychotics

Current situation

Regular meetings with care homes to assess

outcome of interventions (PDSA cycles)

On-going dialogue with lead GP and lead

Consultant

Initiative extended into a dual-registered

home

Baseline audit and 2 further audits

Plan to begin extending the initiative in to

other care homes

Mountains re-audit

Aug11: Total no. of residents prescribed antipsychotics for

dementia = 16/30

Nov11:

1 resident excluded from audit

1 resident deceased

1 resident dose increase

5 residents dose remained on same dose

1 resident dose reduction

7 residents stopped antipsychotic medication*

No residents newly initiated

1 dementia patient newly come in to home on an antipsychotic.

Reviewed and stopped.

Total number = 7/30

Feb12 Total number remains at 7

Brookside Care Home

Sept 11: Total no. of residents diagnosed with

dementia and prescribed antipsychotics for

dementia = 6/16

Nov11: 2 residents excluded from audit

1 resident deceased

1 resident dose remained on same dose

2 residents stopped antipsychotic medication*

No residents newly initiated

Total number =1/16

Feb12: Total number remains at 1

Baseline data

Out of 22 patients:

• 90%, documented indication

• 70% documented discussion re risk and benefits

• 75 % ‘best interest’ process followed

• 40% reviewed in past 6 months

• 50% attempt to reduce

• 45% other approaches tried

15 % compliance with care bundle

80% taking meds for longer than 9 months

After 6 months..

Out of 8 patients:

• 100%, documented indication

• 100% documented discussion re risk and

benefits

• 100 % ‘best interest’ process followed

• 60% reviewed in past 6 months

• 60% attempt to reduce

• 85% other approaches tried

85% compliance with care bundle

60% taking meds for longer than 9 months

Outcome Measure: Brecon

practice

0

10

20

30

40

50

60

70

80

90

100

DD

DsP

er1

00

0P

Us

Period

Antipsychotics DDDs/1000PUs

RICKETTS AL - 603352 (DB1)

Powys - 6039015 (DB1)

Outcome measure:

Powys

0

20

40

60

80

100

120

Ma

r-1

0

Ap

r-1

0

May

-10

Jun

-10

Jul-

10

Au

g-1

0

Sep

-10

Oc

t-1

0

No

v-1

0

De

c-1

0

Jan

-11

Feb

-11

Ma

r-1

1

Ap

r-1

1

May

-11

Jun

-11

Jul-

11

Au

g-1

1

Sep

-11

Oct

-11

No

v-1

1

De

c-1

1

DD

DsP

er1

00

0P

Us

Period

Antipsychotics DDDs/1000PUs

Aneurin Bevan - GP - 601 (DB1)

Cardiff And Vale Uni - GP - 602 (DB1)

Hywel Dda - GP - 603 (DB1)

Betsi Cadwaladr Uni - GP - 604 (DB1)

Abertawe Bro Morgannwg Uni - GP - 605 (DB1)

Powys Teaching - GP - 606 (DB1)

Cwm Taf - GP - 607 (DB1)

Next steps

Using the learning experience: Initiate a pilot scheme in North Powys involving a

Nursing home, GP practice and CMHT and

psychologist

Spread to other care homes in South Powys

Establish an education and support programme for

GPs

Establish an education and support programme for

Care homes

Undertake an economic evaluation of alternatives to

antipsychotic drugs for individuals living with

dementia in Powys

Economic evaluation

NHS Matrix Evidence document, October 11

Key messages:

Behavioural interventions provide good value for

money vs antipsychotic prescribing

Estimated that healthcare cost savings due to

reduced incidence of stroke and falls, outweigh the

increased cost of the intervention.

In England, estimated annual net benefits are £55

million

These figures are based on a total population of

134,000 dementia patients currently using

antipsychotics

Next steps....

Who is the clinical lead in your Health

Board for this Driver3/Meds Mgt

collaborative?

What progress has been made?

Is the health board taking a multi-

disciplinary approach?

What additional support is needed?

Encourage the sharing of good practice

Please let us know if you

need any support.

THANK YOU!

leslie.rudd@wales.nhs.uk

078 666 79064

Rhyngrwyd/Internet:

www.iechydcyhoedduscymru.wales.nh

s.uk www.publichealthwales.org

Mewnrwyd/Intranet:

nww.publichealthwales.wales.nhs.uk

Twitter: www.twitter.com/1000livesplus