This project aims to ensure patients with dementia living in care homes in Buckinghamshire only have medication prescribed for them that meets their specific needs and enables them to enjoy life and live with dignity.

Objectives

• To reduce the use of low dose antipsychotics for challenging behavior in people with dementia in line with NICE-SCIE dementia guidelines (2006)
• To develop a pathway of treatment options and alternatives for the management of challenging behavior in people with dementia
• To improve signposting to alternatives to medication for people with dementia who present with challenging behavior
• To reduce prescribing of any medicine that can cause avoidable adverse effects e.g. falls or excess sedation
• To reduce prescribing of inappropriate medication. This will reduce waste
• To Identify patients that do not have a formal dementia diagnosis to enable them to access care appropriate to their needs
•  To train care home staff so that they have an understanding of the benefits, risks and alternatives to pharmaceutical treatment to ensure appropriate symptom management for people with dementia
• To ensure patients and carers are involved and informed about prescribed medication
• To review and develop medicines management processes within care homes to promote and standardise good medicines management practice

The outcomes of the project will be delivered by a clinical pharmacist who will identify and review patients in care homes with dementia focusing on those that are prescribed antipsychotic medication. The benefits of this model have been shown in pilot projects the details of which are available in the evidence section of this form. The pharmacist will:

• assess if antipsychotic prescribing for challenging behavior for dementia patients is in line with NICE-SCIE guidance. If medication is to be reduced or stopped, the pharmacist will manage and support this process in a controlled manner. They will also advice on alternative options and lead on a program to develop a pathway to manage challenging behavior in people with dementia for the care home
• identify and rectify patients being treated for dementia or the symptoms of dementia but do not have a formal, recorded diagnosis.  This will enable patients access care appropriate to their needs.
• carry out a full medication review, including review of medication for any physical conditions to ensure the patient still needs all the medication prescribed and it is appropriate for them. This would also reduce medicines waste due to inappropriate prescribing
• assess the patient for any medication related side effects and provide recommendations on management
• assess all medication prescribed to ensure it is not putting the patient at an increased risk of falls, which can result in a hospital admission
• provide staff training around medicines management. It will include training on the risks and benefits of antipsychotic medication and how to access/signpost to alternatives to pharmaceutical treatment for managing challenging behavior in dementia
• provide patients and carers with information about any prescribed medication

Any interventions to improve their overall quality of care will be agreed and actioned by the pharmacist in collaboration with care home staff, the G.P. and the carer.

Innovation

In some regions, pharmacists have been employed to work in care homes to carry out medication reviews. An innovative adaptation to this is to target dementia patients and specifically to manage reduction and discontinuation of antipsychotic medication and develop a process and pathway of steps to be taken to manage challenging behavior in people with dementia for the care home staff. This is an area that G.P.s have found difficult and requested support with. A pharmacist identifying undiagnosed dementia patients would also be a new way of addressing the low dementia diagnosis rates in Buckinghamshire.

Anticipiated outcomes

• A reduction in the use of low dose antipsychotics for challenging behavior in people with dementia in line with NICE-SCIE dementia guidelines (2006)
• Development of a pathway for managing challenging behavior for people with dementia
• A reduction in prescribing of any medicine that can cause avoidable adverse effects e.g. falls, excessive sedation, further decline in cognitive function
• A reduction in prescribing of inappropriate medication. This will reduce waste
• Addressing dementia diagnosis rates in care homes by identifying patients that do not have a formal diagnosis and ensuring they have one recorded

Secondary outcomes

• Trained staff that understand the benefits versus risks  and alternatives to pharmaceutical treatment to ensure appropriate symptom management for people with dementia
• Improved information given to patients and carers about prescribed medication
• Improved processes for prescribing and reviewing medication to standardise good practice around medicines management and to improve record keeping processes