Article date: May 2012
There have been increasing concerns over recent years about the use of antipsychotics to treat the behavioural and psychological symptoms of dementia (BPSD). Antipsychotics are associated with an increased risk of cerebrovascular adverse events and greater mortality when used in this population (see Drug Safety Update, March 2009). No antipsychotic (with the exception of risperidone in some circumstances) is licensed in the UK for the treatment of BPSD; however, antipsychotics are often prescribed off-label for this purpose.
National dementia strategy for England
In 2009, in the face of identified shortcomings in the provision of dementia services in the UK and with the increasing challenge to society posed by dementia, the government announced the first national dementia strategy for England. The strategy’s objective is to ensure significant improvements in dementia services across 3 key areas:
* improved awareness
* earlier diagnosis and intervention
* a higher quality of care
The government commissioned the Banerjee Report (Time for Action, an independent review of the use of antipsychotics in elderly people with dementia) as part of the strategy. The report concluded that antipsychotic use was too high in patients with dementia, and that the associated risks outweighed the benefits in most of these patients because these drugs seemed to have only a limited positive effect in managing dementia symptoms . More recently, the Prime Minister has launched a challenge to improve the care of people with dementia .
The report also concluded that antipsychotics seemed to be used too often as a first-line response to difficult behaviour in dementia (most often agitation), rather than as a considered second-line treatment when other non-pharmacological approaches have failed (see NICE guidelines for dementia). On the basis of these findings, the government pledged to reduce by two-thirds the use of antipsychotics for people with dementia by November 2011.
Currently available prescribing data suggest that there has been an encouraging overall reduction in the proportion of elderly people with dementia being prescribed antipsychotics in the UK since 2007. However, further work is needed to change prescribing habits as the reductions identified to date fall short of the hoped-for levels. The NHS Information Centre is carrying out a national survey and local information (such as the Prescribing Observatory for Mental Health survey) is important in changing practice.
The Alzheimer’s Society, Department of Health, Dementia Action Alliance, and the Royal College of General Practitioners have produced a number of documents to support healthcare and social-care professionals in implementing the actions required to realise the objectives of the national dementia strategy.
A best practice guide is available to help determine the best treatment and care for people with BPSD, with an emphasis on alternatives to drug treatment. It includes clinical checklists, information about prevention of BPSD, and information about specific interventions, together with pathways for determining appropriate treatment for someone who has a current antipsychotic prescription and someone who does not.
Advice for healthcare and social-care professionals:
- for prescribers considering using antipsychotics in patients without a current prescription:
- carefully consider, after a thorough clinical examination including an assessment for possible psychotic features (such as delusions and hallucinations) whether a prescription for an antipsychotic drug is appropriate—see appropriate pathway in best-practice guide[^7]
- for prescribers considering continuing antipsychotics in patients with a current prescription:
- identify and review patients who have dementia and are on antipsychotics, with the purpose of understanding why antipsychotics have been prescribed
- in consultation with the patient, their family and carers, and clinical specialist colleagues such as those in psychiatry, establish: whether the continued use of antipsychotics is appropriate; whether it is safe to begin the process of discontinuing their use; and what access to alternative interventions is available
- consult the best-practice guide[^7]
Dementia Action Alliance
Royal College of General Practitioners
BNF section 4.2.1 Antipsychotic drugs
Article citation: Drug Safety Update May 2012, vol 5 issue 10: H1