The use of antipsychotic medication for people with dementia: time for action

There have been increasing concerns over the past years about the use of these drugs in dementia. The findings of this review confirms that there are indeed significant issues in terms of quality of care and patient safety. These drugs appear to be used too often in dementia and potential benefits are most probably being outweighed by their risks.

It appears that around 180,000 people with dementia are treated with antipsychotic medication across the country per year. Of these, up to 36,000 may derive some benefit from the treatment. In terms of negative effects that are directly attributable to the use of antipsychotic medication, use at this level equates to an additional 1,800 deaths, and an additional 1,620 cerebrovascular adverse events, around half of which may be severe, per year. The proportion of these prescriptions which would be unnecessary if appropriate support were available is unclear and will vary by setting, but may well be of the order of two-thirds overall.

The author argues that the high level of use of antipsychotics means that the potential benefit of their use in specific cases is likely to be outweighed by the adverse effects of their use in general. This overuse of antipsychotic medication is a clear, specific example of the general set of problems in the way our health and social care systems serve people with dementia and their carers.

The report makes 11 recommendations for improved treatment of dementia patients:

• reduce the use of antipsychotic drugs for people with dementia and assurie good practice when they are needed should be made a clinical governance priority across the National Health Service
• national leadership for reducing the level of prescription of antipsychotic medication for people with dementia should be provided by the National Clinical Director for Dementia, working with local and national services
• the National Clinical Director for Dementia should develop an audit to generate data on the use of antipsychotic medication for people with dementia in each primary care trust in England. It should be repeated one, two and three years later to gauge progress
• people with dementia should receive antipsychotic medication only when they really need it. To achieve this, there is a need for clear, realistic but ambitious goals to be agreed for the reduction of the use of antipsychotics for people with dementia
• there is a need for further research to be completed, including work assessing the clinical and cost effectiveness of non-pharmacological methods of treating behavioural problems in dementia and of other pharmacological approaches as an alternative to antipsychotic medication
• the Royal Colleges of General Practitioners, Psychiatrists, Nursing and Physicians should develop a curriculum for the development of appropriate skills for General Practitioners and others working in care homes, to equip them for their role in the management of the complexity, co-morbidity and severity of mental and physical disorder in those in care homes
• there is a need to develop a curriculum for the development of appropriate skills for care home staff in the non-pharmacological treatment of behavioural disorder in dementia, including the deployment of specific therapies with positive impact
• each primary care trust should commission from specialist older people’s mental health services an in-reach service that supports primary care in its work in care homes
• The Care Quality Commission should consider using rates of prescription of antipsychotic medication for people with dementia, adherence to good practice guidelines, the availability of skills in non-pharmacological management of behavioural and psychological symptoms in dementia and the establishment of care home in-reach from specialist mental health services as markers of the quality of care provided by care homes
• the Improving Access to Psychological Therapies programme should ensure that resources are made available for the delivery of therapies to people with dementia and their carers
• specialist older people’s mental health services and GPs should meet in order to plan how to address the issue of people with dementia in their own homes who are on antipsychotic medication