Care home dementia study finds failure to reduce antipsychotic prescribing

A study by five universities has found that there was no sustained reduction in the prescribing of antipsychotics to dementia patients in UK care homes following the government’s 2009 National Dementia Strategy (NDS), which recommended a review of their use in light of potential serious side effects ¹

The research – led by Professor Ala Szczepura at Coventry University and published today in the medical journal BMJ Open – examined prescribing data between 2009 and 2012 from over 600 care homes ² across the country, concluding that there was no significant decline in antipsychotic prescribing rates over the four year period.

Antipsychotics were originally developed for use in patients with schizophrenia or psychosis, but the study shows that ‘off-label’ prescribing of these drugs to treat the behavioural and psychological symptoms of dementia is a common practice in care homes ³.

The 2009 ‘Banerjee Report’ ⁴, commissioned by the Department of Health as part of the NDS, examined the use of antipsychotics for people with dementia, concluding that the drugs had a “substantial clinical risk” associated with them and that their overuse “must not be allowed to continue”.

However, researchers from the universities discovered that – although dosages were usually acceptable – prescribing levels did not reduce over the four years, and length of treatment was ‘excessive’ in over 77% of cases by 2012, up from 69.7% in 2009 (meaning it exceeded not only the recommended six week course, but also the maximum advised treatment length of 12 weeks).

Findings from the study also indicate that older first-generation antipsychotics (FGA) such as haloperidol and chlorpromazine are still being used extensively, with no measurable shift to safer second-generation antipsychotics (SGA) like risperidone – as recommended in the NDS.

According to the research, which was carried out by Coventry University; University of Warwick; Lancaster University; University of East Anglia; City, University of London; and technology company Invatech Health:

• care homes in the highest prescribing 20% are more likely to be located in a deprived area ⁵;
• care homes in the lowest prescribing 20% are more likely to be served by a single GP practice, which could indicate that those homes benefit from a consistent message that is absent from homes served by multiple practices;
• average annual expenditure on antipsychotics was £65.60 per care home resident (based on 2012 prices), which is less than 1% of the annual cost of a UK residential home place for a person with dementia ⁶;
• there was a six-fold variation between the geographical areas – in this case the areas covered by the former primary care trusts (PCT) – with the highest and lowest prescribing levels.

Professor Ala Szczepura, from Coventry University’s Centre for Technology Enabled Health Research, said:> 

Care homes remain the forgotten sector in UK policy debate around the use of antipsychotics. This appears to be due to a lack of systematic monitoring of prescribing data in these settings. Our study has not only identified a failure of the National Dementia Strategy to produce a sustained decrease in use of antipsychotics, it’s also shown large regional variations and has found evidence indicating that their use is higher in care homes in deprived neighbourhoods.

Looking forward, the Prime Minister’s challenge on dementia 2020 aims to further slash inappropriate prescribing of antipsychotics by 67%, and reduce variation across the country ⁷. It’s clear from our research that to achieve this in care homes, a significant change is required in prescription culture and management of vulnerable people with dementia.”

George McNamara, head of policy at Alzheimer’s Society, said: 

This continued reliance on antipsychotics to manage behavioural symptoms of dementia is deeply worrying. Around 90% of people with dementia experience symptoms that affect their behaviour causing aggression, agitation, or even delusions and hallucinations. These symptoms can develop as part of their condition, but may also be caused by other factors – pain, discomfort, or unmet need. When this is the case, prescribing antipsychotics treats the person with dementia as the problem rather than the root cause of their behaviour.

Antipsychotics increase the risk of stroke, falls and even death – it’s shocking that the evidence continues to be flatly ignored. With person-centred approaches and training programmes for care home staff, continued inappropriate prescribing is a step backward into the dark ages.”

Professor Clive Bowman, a visiting professor in the School of Health Sciences at City, University of London, said:

“Our study shows that the National Dementia Strategy has failed to have a sustained effect on the excessive prescription of antipsychotic medicines for people resident in care homes. This is unacceptable, clear standards are required regarding the use of these drugs and a designated responsibility for monitoring medicines and their usage mandated. New technology can do this in real time, allow public scrutiny and free professional time to promote best practise.”

NOTES TO EDITORS

¹ All-Party Parliamentary Group on Dementia (2008). Always a last resort. London: Alzheimer’s Society.

² Prescribing patterns from 616 care homes (31,619 residents) were analysed.

³ ‘Off-label’ prescribing is legal in clinical settings. Risperidone is the only antipsychotic that can be prescribed ‘on-label’ in the UK for the treatment of the behavioural symptoms of dementia. 

⁴ Department of Health (2009). The use of antipsychotic medication for people with dementia: Time for action. A report for the Minister of State for Care Services by Professor Sube Banerjee.

⁵ Deprived areas have been defined in this release as those amongst the 10 per cent most deprived in England according to the overall Index of Multiple Deprivation. SOURCE: Department for Communities and Local Government (2011). The English Indices of Deprivation 2010.

⁶ Joseph Rowntree Foundation (2008). Calculating the costs of efficient care homes.

⁷ Department of Health (2016). Challenge on dementia 2020: implementation plan. March 2016.