90% of people with dementia experience behavioural and psychological symptoms (BPSD), such as aggression, agitation, loss of inhibitions and psychosis (delusions and hallucinations). These symptoms can be distressing for the person and their carers as well as putting the person at risk.
People with dementia who experience BPSD are often, and inappropriately, prescribed antipsychotic drugs used to treat schizophrenia. Antipsychotic drugs do reduce psychotic experiences such as delusion. However, they are also linked to serious side effects, have a moderate benefit and do not address underlying causes of BPSD. A Department of Health study concluded of the 180,000 prescriptions for people with dementia overall, 140,000 are inappropriate.
Inappropriate prescription of antipsychotic drugs is extremely harmful. Research has shown that there is up to a 9-fold risk of stroke in the first four weeks (Klijer, 2009) and that there is almost a doubling in the risk of mortality (Food and Drug Administration, 2005). Inappropriate prescription of antipsychotic drugs contributes to 1,800 deaths a year death (DH, 2009a).
Reducing the use of antipsychotic drugs for people with dementia is a national priority in England (DH, 2009a) and is a key element identified in the Dementia Plans for Wales (Welsh Assembly Government, 2010). An audit of antipsychotic prescriptions for people with dementia (NHS Information Centre, 2012) has revealed that antipsychotic prescriptions for people with dementia have reduced by 52 per cent between 2008 and 2011. However, it also revealed strong regional variations in the number of prescriptions.
There must now be continuing action at a local level in England, and urgent action in Wales and Northern Ireland to improve treatment and care in order to reduce the use of the drugs. The point must be reached where antipsychotic drugs are only prescribed to people with dementia when necessary and appropriate.
2. What the Alzheimer’s Society calls for:
- Improve treatment and care to prevent and manage BPSD. Person-centred care helps reduce the incidence of BPSD. At the outset, an holistic assessment of the person with dementia’s health, behaviour and personality should be conducted. This should be used to develop an individual care plan that helps staff to develop interventions tailored to the person's preferences, such as activities that are based on an individual's hobbies and interests. Tools and guidance on person-centred care are available in best practice guides (Alzheimer's Society; 2011a, 2011b).
- Commission specialist older people's mental health services for care homes. Commissioners must commission services with the multidisciplinary expertise to provide alternatives to antipsychotic drugs and support care staff to implement them. These services can significantly reduce the use of antipsychotic drugs (Ballard et al 2002). Currently, access to specialist support is patchy. One third of care home managers reported no support or very limited support from mental health services (Alzheimer’s Society, 2008). CCGs should commission an in-reach service to improve care quality and reduce the use of antipsychotic drugs.
- Train health and social care professionals in dementia. Caring for people with dementia can be immensely challenging. However, there are currently inadequate numbers of staff who have specialist training. Research has shown that training and support for care home staff reduces the need to use antipsychotics (Fossey et al 2006). Alzheimer's Society calls for health and social care professionals to be trained in providing person-centred care, communication skills, the behavioural and psychological symptoms of dementia, the risks and benefits of antipsychotic drugs and alternatives. Involving carers and people with dementia in decision-making, including the core principles of the Mental Capacity Act, must also be included.
- Introduce systems to monitor and review prescriptions. Careful monitoring and review is necessary whenever antipsychotics are prescribed. However, this is often not carried out. The Society recommends that an appropriate professional should review antipsychotics prescriptions before and then once every three months. Guidelines on the assessment process, including monitoring and discontinuation, should be available and used. Alzheimer's Society, with the Royal College of General Practice and the DH, have published a flow chart for GPs on the appropriate use of antipsychotics (Alzheimer's Society; 2011b).
- Involve people with dementia and carers in decision-making. People with dementia and carers must be consulted to ensure that they are involved in decision-making and have the information that they need to make an informed decision. People can refuse any drug treatment if they have the capacity to understand the impact of that decision. If someone lacks capacity, a carer, relative, friend or advocate should be involved as far as possible. Professionals must have reference to the Mental Capacity Act (2005). Alzheimer's Society's tool for people with dementia and carers seeks to empower carers to request a review and ask questions about the use of antipsychotics for a loved one (Alzheimer's Society; 2011a).
- Follow GMC and NICE-SCIE protocols. Anti-psychotic drugs have some modest beneficial effects for aggression and psychosis over a period of 6-12 weeks for people with Alzheimer's disease (Ballard and Howard, 2006). Risperidone must be prescribed within the specific terms of its licence. Other antipsychotic drugs must be prescribed within the remit of the GMC (2008) and the NICE-SCIE dementia guidelines (2006). The Royal Colleges, GMC and Department of Health should work together to raise awareness of the licence of risperidone; the GMC guidance on off-label prescriptions; and the NICE-SCIE guidelines.
- Review of risperidone. The drug risperidone is only licensed for 6 weeks treatment of persistent aggression in those with moderate to severe Alzheimer's disease, providing that all alternatives have been tried and there is a risk of harm. Now that this drug is licensed, a NICE appraisal on the cost-effectiveness of prescribing risperidone for people with dementia is within its remit. This must happen urgently.
13. References and further information
All Party Parliamentary Group on Dementia (2008) Always a last resort: inquiry into the prescription of antipsychotic drugs to people with dementia living in care homes. Alzheimer's Society. London.
Alzheimer's Society (2011a) Optimising treatment and care for people with behavioural and psychological symptoms of dementia: A best practice guide for health and social care professionals. Alzheimer's Society. London. (Available from 9 June 2011)
Alzheimer's Society (2011b) Reducing the use of antipsychotic drugs: A guide to the treatment and care of behavioural and psychological symptoms of dementia. Alzheimer's Society. London. (Available from 9 June 2011)
Ballard C. Howard R. (2006). Neuroleptic drugs in dementia: benefits and harm. Nature Reviews Neuroscience. 7, 492-500.
Dementia Action Alliance (2011) The right prescription: a call to action on the use of antipsychotic medication. (Online from 9 June 2011)
Department of Health (2009a) The use of antipsychotic medication for people with dementia: time for action. Department of Health. London.
Department of Health (2009b) Living well with dementia: A national dementia strategy. Department of Health. London.
Food and Drug Administration (2005). Further details can be found at: www.fda.gov/cder/drug/advisory/antipsychotics.htm
Fossey, J., Ballard, C., Juszczak, E., James, I. , Alder, N., Jacoby, R., and Howard, R. (2006). Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomized trial. British Medical Journal, 332, 756-761.
General Medical Council (2008) Good practice in prescribing medicines. General Medical Council. London.
Kleijer BC, van Marum RJ, Egberts AC, Jansen PA, Knol W, Heerdink ER. (2009). Risk of cerebrovascular events in elderly users of antipsychotics. J Psychopharmacol. Nov;23(8):909-14. Epub 2008 Jul 17.
Margallo-Lana, M., Swann, A., O'Brien, J., Fairbairn, A., Reichelt, K., Potkins, D., Mynt, P., & Ballard, C. (2001). Prevalence and pharmacological management of behavioural and psychiatric symptoms amongst dementia sufferers living in care environment. International Journal of Geriatric Psychiatry 16: 39-44.
National Audit Office (2007). Improving services and support for people with dementia. The Stationery Office. London.
NICE-SCIE (2006). Dementia: The NICE-SCIE guideline on supporting people with dementia and their carers in health and social care. The British Psychological Society and the Royal College of Psychiatrists. London.
Schneider LS. Dagerman K. Insel PS. (2006a). Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. American Journal of Geriatric Psychiatry, 14,191-210.
Welsh Assembly Government (2010). Dementia stakeholder groups- action plans. [online] http://wales.gov.uk/topics/health/publications/health/reports/stakeholders/?lang=en
Last updated: October 2014 by Laurence Thraves