1. Mini-collaborative
Medicines management/dementia care
Focus on Anti-psychotics
Update from ABHB October Caroline Linton Consultant Old Age Psychiatrist

2. Sharing experience: Recognising common goals Learning through pilots
Progress so far and future plans

3. Patient/Carer Involvement
Reduce the harm caused by the use of antipsychotic medication in patients with dementia
Policies
Communication
Patient/Carer Involvement
Monitoring
side-effects
Record Keeping
(at least 3 monthly)
Implement NICE Dementia Guidelines
Antipsychotics should NOT be 1st line treatment except where there is risk of extreme risk and harm
Assess for capacity and where person lacks capacity, follow ‘best interests’ process regarding use of antipsychotics
Alternatives to anti-psychotic medication should be considered
Consider psychological and alternative therapies first
Atypical antipsychotics preferred
Prescribe lowest dose for shortest duration possible
Review continuation regularly (at least 3 monthly)
Full assessment should include: physical health, pain, depression, infection etc. (with multi-disciplinary team input
Detailed ongoing communication between primary and specialist services and patient/carer
Patient/carer involvement at initiation
Full discussion on benefit versus risk of medication including increased risk of cardiovascular adverse events
Regular monitoring for side-effects
Sedation
Agitation/behaviour changes
Extrapyramidal effects
Weight gain
Hypotension
Hyperglycaemia
Poor temperature control
Record of indication for antipsychotic
Record risk/benefit assessment
Record aims for specific, quantified target symptoms
Record side-effects
Record rationale for continuing, changing or stopping medication
Medicines Management

4. Driver 3 out of the 5 areas targeted in the Improving Dementia care 1000 lives document

5. Draft

6. Recognising common goals
Realising it is in everybody’s interest that anti-psychotic prescribing and monitoring improves
Understanding who is involved along the patient journey and how each can influence the decision-making
Raising awareness at every opportunity
Incorporating good practice and monitoring into everyday practice and not as an “extra”
Targeting “interested parties” first and then sharing benefits with “more challenging” groups

7. Getting started Useful base-line information
eg. in Newport borough, from simple surveys:
>90% of those on anti-psychotics in care homes had their drugs initiated in secondary care (2009)
The highest prescribing rates of anti-psychotics are found in EMI Nursing Homes (2010)
The 3 large EMI Nursing Homes are “served by” 3 large GP practices
These practices offer an “enhanced” service to dementia sufferers in these homes

8. Appropriate initiation (1)
Secondary care
Introduced a starter and monitoring form on our own inpatient wards initially as a pilot – follows the patient into the community – extended to community patients
Developed a patient and carer anti-psychotic information leaflet – to all families/ on intranet/ distributed to pharmacists and primary care across the health board
Red dots!

11. Appropriate initiation (2)
In care homes
What is done prior to medication being prescribed?
Advice to care homes re steps to take before referring to primary/secondary care
Distributed to all care homes by in-reach nurse 2010 and redistributed this year again

14. Appropriate monitoring and discontinuation
Across primary and secondary care
Raising awareness in primary care
- tell them the evidence
- tell them what’s in it for GPs
Linking in with targeted practices
Making use of the systems in place
Community pharmacists can act as an effective link

15. Work so far and progress made
Several boroughs across ABHB have undertaken care home reviews and impacted the proportion of residents taking anti-psychotics (eg Caerphilly previously presented)
Newport initiative
Linked in with community pharmacist
Targeted EMI care homes in particular
Targeted 2 specific GP practices so far
Undertaking 3/12ly anti-psychotic reviews
Kept a simple data base
Shared our findings with GPs

16. Pilot: 2010 care home reviews
2 large specialist (EMI) care homes
(100 beds total)
home 1:
38 nursing beds plus 31 residential beds
home 2 :
31 nursing beds
During 12 month period, proactive anti-psychotic reviews undertaken by in-reach nurse and psychiatrist

17. baseline Percentage prescribed anti-psychotics
19% in residential care (6 out of 31)
34% in nursing care (28 out of 69)
Approximately 70 patient reviews undertaken over 12/12

18. At the end of 12 months
20 out of 34 (approx 60%)were reduced or stopped

19. Looking at 2011…so far
Extended formal reviews to 5 specialist care homes
3 EMI Nursing Homes
(total beds = 95)
2 EMI Residential Homes
(total beds = 61)
Total number of reviews 91 in 55 residents throughout the year so far
(Reviews undertaken by Psychiatrist and community pharmacist and follow up by in-reach nurse)

20. Results of reviews over 2011…
At review the drug was stopped or dose reduced about half the time

21. of 55 individuals, 26 have discontinued the drug to date

22. Just over a third of individuals have continued with the anti-psychotic - ?confirming the 2008 report suggesting half to two thirds may be stopped.

24. Learning along the way...
Consider the whole patient journey not just care home residents
Find an interested GP practice and learn how to get advised medication changes implemented...
pharmacists are key to facilitate communication/understanding
“change medication” template letter to fax to one nominated GP
lack of shared “systems” inhibits shared working
In the first year of reviews at any care home we find the “low hanging fruit”
Acknowledge the workload and don’t be too ambitious at the outset
Beware of seeing an increase in benzodiazepines!

25. Next steps/ proposals/ ideas
General Hospitals: pharmacists can raise awareness – using the “green pen” effectively
Identifying the target group: “MIQUEST” query programme
Develop a “reducing regime” guide for GPs
“Invest to save” bid for nurse time
Understand how the data base can support us!
And in Monmouthshire...