Antipsychotic use in care homes persists despite government drive

The rates of antipsychotic prescriptions being given to people living in care homes has remained unchanged, despite a government recommendation issued in 2009 to review the practice, researchers have found. 

The researchers studied data from 31,614 residents across 616 long-term residential care institutions over a four-year period from January 2009, but found no statistical difference in prescribing rates and no observable shift towards second-generation antipsychotics, another of the recommendations made in 2009. 

The recommendations, which form part of the government’s National Dementia Strategy, said that the risks associated with antipsychotics outweighed the benefits in many care home patients, owing to the risk of serious adverse events, including falls, stroke and death. They said antipsychotics were too often used as a first-line response to dementia and their use could be safely reduced by two thirds over a 36-month period. 

“Our study has identified a failure of the National Dementia Strategy to produce a sustained decrease in use of antipsychotics in care homes,” says lead author Ala Szczepura, professor at Coventry University’s Centre for Technology Enabled Health Research. 

The research, published in BMJ Open
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(online, 20 September 2016), showed that at baseline, before the National Dementia Strategy was published, the rate of antipsychotic prescribing was 18%. Four years later, it had barely changed at 19%. 

On the whole, the researchers found that dosage regimen were acceptable, only exceeding the maximum in 1.3% of cases, but duration of treatment was excessive (≥12 weeks) in two-thirds of cases. 

The authors also noted high regional variation in prescribing habits, with a six-fold difference between the areas with the highest and lowest rates, which ranged from 5.7% to 37.5%. Areas with the highest antipsychotic prescribing rates were more likely to be in a deprived neighbourhood and to be served by four or more GP practices compared with the areas with the lowest prescribing rates. 

Szczepura says the data shows that GPs are not reviewing patients’ medications as required. “Pharmacists could help with this,” she adds. 

“Also, standards specifying recommended agents, dosages and length of treatment for older residents in care homes would be helpful, as would guidelines on how residents can be safely withdrawn from these agents over a period of weeks,” she says. 

Care homes should be required to routinely report their use of antipsychotics, which are primarily used off-label, Sczcepura says. In the UK, only one antipsychotic — risperidone — is licensed for behavioural and psychological treatment of dementia for up to six weeks. 

“I think that we now need a national strategy to support care homes and monitor prescribing of antipsychotics,” she says. “Routine reporting of prescribing data for care home residents should become part of the prime minister’s challenge on dementia 2020.” 

Martina Kane, senior policy officer at the charity Alzheimer’s Society, says the continued reliance on antipsychotics to manage behavioural symptoms of dementia is concerning, and means that patients with dementia are not having the root cause of their behaviour addressed. 

“While it might be the right approach if the person is experiencing psychosis, there are still cases of them being routinely used as a ‘chemical cosh’ to sedate people who are restless or aggressive,” she notes. 

“Antipsychotics increase the risk of stroke, falls and even death so it is shocking that the evidence continues to be flatly ignored.” 

Kane also notes that a previous evaluation of the efficacy of recent efforts to curtail antipsychotic prescribing in dementia contradicts the findings of the current study, so the reasons for this will need exploring. 

“Alzheimer’s Society continues to call on the government to re-run the audit into antipsychotic prescribing across the board for people with dementia,” she says.