This project aims to reduce the prescription of antipsychotic medication for people living with dementia in care homes across Windsor, Ascot and Maidenhead.

Patients with dementia in a care home who are prescribed antipsychotics are at risk of harm and should be reviewed by multi-disciplinary team. In Scotland, NHS Tayside, set out to reduce harm from prolonged prescribing of antipsychotics, reduce the number of prescriptions for antipsychotics, reduce variation in prescribing, reduce admissions to secondary care and increase adherence to treatment guidelines. They did this by reviewing patients in one care home on  antipsychotics  and then reviewing the need for these medications to continue. The aim was to review 80% of care home patients, educate care home staff and support GPs.

We would aim to adopt and adapt this project locally to one Berkshire East CCG (Windsor Ascot and Maidenhead CCG) and then roll out to the whole of Berkshire East Care Homes. We would expect 80% of patients reviewed in the initial phase to be reviewed, with 20% of patients on antipsychotics expected to have dementia and for 60% of these patients to have their antipsychotic stopped or dose lowered.

We would expect the initial phase to run over 12-18 months.

We would expect those patients with their antipsychotics stopped or  reduced to have their risk of stroke reduced (1 cerebrovascular event for every 100 patients  with dementia on an antipsychotic). There would also be a reduction in prescribing  costs of antipsychotics.

Objectives

• Review 80% of Care Home patients. Expect 20% on antipsychotics with dementia. Expect to stop and reduce 10% of patient’s antipsychotics.
• Improving outcomes for dementia patients and carers
• Adopting and improving on proven best practice
• Promoting safer prescribing of medication for dementia patients Reduction of inappropriate antipsychotic prescribing in dementia patients Raising awareness of alternatives methods  to manage behavioural and psychological symptoms in dementia
• Promoting dignity in care and a patient centred approach through medication review
• BCA have input into the training programme and arrangements for nurses and carers in care homes
• The training programme includes dementia practice, not just medicine management, and is delivered at no cost to the organisation or it’s staff
• The project is delivered in partnership

Anticipated outcomes

• Improve the quality of care of people with dementia living  in care homes
• To reduce medication related incidents for patients in care homes
• To promote early diagnosis and support for dementia patients including better access to anti-dementia drugs in line with NICE guidance.
• To promote and support carers use of non-pharmacological interventions in place of antipsychotics.
• To promote safer prescribing for dementia patients by reducing inappropriate anti­ psychotics prescribing and promoting non-pharmacological interventions to care staff to manage behavioural and psychological symptoms in dementia (BPSD) first line.
• To promote better quality healthcare outcomes for dementia patients through better use of medicines, medicines optimisation, stroke risk reduction, reduction in avoidable medicines related hospital admissions and better management of behavioural and psychological symptoms in dementia (BPSD) by promoting non­ pharmacological interventions to care staff as first line.
• Fewer medication related complications in dementia patients by  providing prescribing support and guidance to prescribers and to raise awareness of any treatable causes of  the BPSD (e.g. delirium, pain, depression) through better history taking. Any treatable causes should be  treated with the correct specific treatment (e.g. antibiotics for infection or antidepressants for depression).
• To produce, promote and make readily available to care home staff medication information and best practice guidance in dementia care.
• To highlight and refer patients in need of further intervention or support to the relevant persons/health professionals or  support team for non-pharmacological interventions for patients in care homes in place of  anti-psychotic prescribing.
• Promoting dignity in care by promoting awareness of Advance Care Planning (ACP) or ‘Escalation plans’ to include medication issues if relevant.
• To promote interventions that may avoid unnecessary hospital admissions e.g. falls prevention screening.
• To raise dementia awareness amongst carers and empowering them with information so that they are better placed to know when and where to seek advice.

Progress update

We were unable to recruit for the secondment post for the medication review pharmacist role so an existing member of staff has taken this on in addition to her existing workload.

Review results at October 2013 include:

• 506 care homes patients reviewed to date (majority have dementia)
• 61 people attended the multidisciplinary ‘Alternatives to Antipsychotics’ training event
• Less variation in antipsychotics prescribing (increase in Risperidone first line)
• Example of ‘Joint working at its best’
• Local councils now ready to commission ‘Alternatives to antipsychotics’ training for all care staff
• Antipsychotic prescribing reducing slowly