An audit of the use of antipsychotics in a geriatric psychiatry continuing care unit in Scotland

Abstract

SUMMARYBehaviour problems, dependency levels and use of antipsychotic medication were assessed, using an audit approach, in 104 patients in a geriatric psychiatry continuing care unit. High levels of dependency and behaviour disturbance were found. 37.5% of the population were receiving regular antipsychotic medication. The severity of a cluster of four symptoms (diurnal restlessness, agitation, irritability and active aggression) tended to discriminate this group from those on no antipsychotics, though frequency of problems and total number of problems were also higher in the group on regular antipsychotics. Antidepressants were rarely used, though conversely there was only one case of 'missed' depression. Changes following the audit are described and recommendations for improved monitoring of medication use are made.KEY WORDS-Dementia, audit, antipsychotic drugs, dependency, behaviour problems.The use of drugs to control behaviour disturbance associated with severe dementia is controversial. Antipsychotic drugs remain the first-line intervention though there is concern that they can be used inappropriately because of the difficulty in recognizing depression in severely demented patients. Studies tend to be complicated by methodological problems (Helms, 1985), by a sizeable non-response rate, and by the presence of side-effects despite the relatively low doses used. Schneider et al. (1990) found only seven studies (all inpatient) suitable for inclusion in a meta-analysis, reporting that in only 18% of cases could a clear drug effect be presumed. (Overall drug response 59% vs placebo response 41Y0.) They also report no significant differences between antipsychotic drugs used, though individual studies (Rada and Kellner, 1976;Petrie et al., 1982) suggest that high-potency antipsychotics are more effective than low-potency but have more side-effects. There is, however, no evidence to support the hypothesis that sedative compounds are more effective than non-sedating compounds, which suggests that clinical efficacy is a result of antipsychotic effects rather than the effect of 'blanket sedation'.Although large numbers of hospital beds are occupied by those with advanced dementia, there are few studies of the rates of antipsychotic use in this population (Christopher et al., 1978; Michel and Kolakowska 198 1 ;Gilleard et al., 1983; Mann et al., 1984). The first three found rates of 4248%, but the first two include 'prn' medication and all patients over the age of 65, without stating specifically how many had dementia, so rates are not strictly comparable. Mann et al. (1984) report lower rates (28%). Only Michel and Kolakowska (1981) reported numbers of patients on no psychotropics A number of studies examine specific behavioural problems in dementia (eg Burns et al., 1990;Berrios and Brook, 1985; Cummings et al., 1987;Merriam et al., 1988), but only Reisberg et al. (1987). Swearer et al. (1988) and Teri et al. (1988) give figures for total numbers showing behaviour problems in their (outpatient) study populations....

Fifteen year comparison of antipsychotic use in people with dementia within hospital and nursing home settings: sequential cross‐sectional study

“…Replicating the 1990 study (Connelly, 1992), frequency and severity of 12 behaviours (see Table 2) were each assessed (frequency: never ¼ 0, 2 days/week ¼ 1, 3 days/week ¼ 2; severity: mild ¼ 0, moderate ¼ 1, severe ¼ 2; max score ¼ 48). Walking, urinary continence, transfer from bed to chair, feeding, dressing, toileting and faecal incontinence were rated for each patient (range 7-38; 24 or over indicates a high level of physical dependency).…”

“…Our survey of the use of anti-psychotic drugs in 1990 (Connelly, 1992) found a tetrad of diurnal restlessness, irritability, active aggression and agitation accurately classified 74% of those taking either regular antipsychotics or no psychotropics with reasonable sensitivity and specificity. To ensure consistency with the 1990 study terminology, patients with at least three symptoms from this tetrad (or at least one of these symptoms to a severe degree) were termed 'core positive' and others 'core negative'.…”

“…A large variation in prescription rates has been reported (Rochon et al, 2007) and rates rise when dementia becomes more severe (Macdonald et al, 2002;Lindesay et al, 2003). Comparative rates of past use in NHS long stay settings are less well described but were similar (Connelly, 1992;Connelly, 1993;Loane et al, 1997).…”

“…Since then there has been an increasing focus on the use of non-pharmacological strategies for the management of behavioural and psychological problems. Given that the relationship between regular antipsychotic use, behaviour and physical dependency in hospital long-stay patients (Connelly, 1992) focussed prescription and showed reduced use 2 years later (Connelly, 1993), we predicted that antipsychotic use would have fallen and become more targeted to symptoms we defined as 'core' and reviewed more frequently. Due to possible improvements in community care since 1990, we also predicted that people with dementia in care homes would be more physically dependent and/or show more behavioural disturbance than had been shown in a longstay hospital environment.…”

Behaviour problems are underdocumented

“…Using a rating scale5 which is quick and simple to perform we assessed the prevalence and severity of behaviour disturbance in 104 patients aged 65-98 (mean 82) years in long term geriatric medical care and recorded the use of psychotropics in this group. In 52 of 76 patients tested the abbreviated mental test score was less than 6 out of 10, consistent with moderate to severe cognitive impairment.…”