09 July 2018
Antipsychotic medicines are being prescribed inappropriately, in many cases as a default option to ‘manage’ challenging behaviour of people with dementia, according to a recent Health, Social Care and Sport Committee report which will be debated in Plenary on Wednesday 11 July.
Antipsychotics are a group of medications usually used in the treatment of mental health conditions such as schizophrenia. There have been increasing concerns in recent years about the use of antipsychotics for the behavioural and psychological symptoms of dementia.
Antipsychotics are associated with an increased risk of cerebrovascular adverse events and greater mortality when used in people with dementia, with the likelihood of premature death increasing with prolonged use.
In 2009, a report by Professor Sube Banerjee concluded that antipsychotics appeared to be used too often in dementia and, at their likely level of use, potential benefits are most probably outweighed by their risks overall.
Almost a decade later, the Committee heard evidence that antipsychotic medication is being routinely administered in response to challenging behaviour, in place of staff working to identify the root cause of the behaviour. The Committee report notes that a person living with dementia presenting challenging behaviour often has an unmet need which they may be unable to communicate, and calls for comprehensive person-centred assessments to identify and fully address people’s needs.
The report also highlights evidence that medication reviews are not happening frequently enough for people with dementia, and that once medication is prescribed (including antipsychotics) it often rolls on with repeat prescriptions for long periods without being monitored effectively (despite the increased risk of harm with prolonged use).
The Committee report notes that Members are ‘deeply concerned’ about the misuse of antipsychotics, and states:
Unnecessarily medicating vulnerable people in care is a profound human rights issue which must be addressed.
The Committee concluded that it is disappointed with the apparent lack of commitment to tackling this issue as a priority, and that Members believe cultural and systemic changes are needed to ensure antipsychotic medications are prescribed appropriately, and not as a first option.
The Committee makes 11 recommendations in its report, including calls on the Welsh Government around data collection; person-centred assessments to identify any unmet needs; the development of national standards for dementia care training and making the training mandatory for all care staff; ensuring all Health Boards are fully compliant with NICE guidelines, introducing mandatory three monthly medication reviews and making medicines monitoring a key part of Care Inspectorate Wales’ (CIW) inspection regimes.
Welsh Government’s response
In the Welsh Government (WG)’s response to the report, it has accepted four of the recommendations (recommendations 5, 6, 7 and 8), including:
R6. We recommend that medicines monitoring should be a key part of care homes inspection, and that Care Inspectorate Wales mandates documented evidence of medicines’ monitoring for older people prescribed antipsychotic medication in patient records.
The wording of the Welsh Governments response suggests this is already happening and states:
Going forward, CIW are considering how management and review of antipsychotic medication is included as part of the inspection process. This would be considered in its broadest sense with potential options including a line of enquiry about support, review and advice in relation to management of antipsychotic medication as part of the new inspection framework.
R8. The Welsh Government should take action to address the shortage of speech and language therapists, given their value in improving outcomes for people with dementia, and report its progress to this Committee within 12 months.
The WG response states:
It is recognised that AHPs and Speech and Language Therapists (SaLT) specifically are providing a key role in the delivery of community/primary care services.
Health Education Improvement Wales (HEIW) is currently scoping work to increase the numbers of AHPs (including SaLT) available in Wales. This will also include considering principles of organisational effectiveness to promote the aim of developing a workforce (of healthcare support workers, SaLT assistants) that can support registered SaLTs by delivering the treatment plans drawn up by the therapists, leaving the SaLTs to deliver the levels of intervention that only they can provide.
Within the summer our ‘Train Work Live’ campaign will be extended to include allied health professionals.
The WG rejected recommendation 9 which calls for the development of a method and guidance for assessing the appropriate skills mix required for care home staff. The WG feels that this issue is covered by Regulations already developed under the Regulation and Inspection of Social Care (Wales) Act 2016 – The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017.
The WG ‘accepted in principle’ the five remaining recommendations, including:
R1. The Welsh Government should ensure that, within 12 months, all health boards are collecting and publishing standardised data on the use of antipsychotic medication in care homes and report back to this Committee on progress at the end of that 12 month period.
The WG response stresses that there are significant limitations with routinely collected prescribing data ‘which means it is not possible to readily attribute prescriptions to residents in care homes’. It goes on to say:
Given the Committee has made several recommendations relating to the availability and reporting of prescribing data, I will convene a group of relevant experts to examine the usefulness of various data sources and provide me with advice on how they might best be used to support our aspiration to reduce inappropriate prescribing of antipsychotic medications.
R2. The Welsh Government should ensure that, within 12 months, all health boards are fully compliant with NICE guidelines on dementia, which advise against the use of any antipsychotics for non-cognitive symptoms or challenging behaviour of dementia unless the person is severely distressed or there is an immediate risk of harm to them or others, and report back to this Committee on rates of compliance at the end of that 12 month period.
The WG response says it shares the Committee’s concerns but ‘it is not straightforward to determine whether a medicine is being prescribed in accordance with NICE’s guidance’, and that the responsibility to comply rests with the health professionals.
In response to recommendations 3 (person-centred care assessments and a checklist tool to identify unmet needs) and recommendation 10 (national dementia care standards and mandatory training monitored by CIW) the WG highlights existing work including the ‘Good work’ Dementia Training and Education Framework, and the 2017 regulations (referred to previously). It also says that the forthcoming CIW thematic review of dementia care ‘is likely to include both staff training and skills in respect of dementia along with reviewing the issues around medication (including antipsychotics) for those with dementia’.
R4. We recommend the introduction of mandatory three monthly medication reviews for people with dementia who have been prescribed antipsychotic medication, with a view to reducing or stopping the medication following the first review where possible.
The WG says ‘the principle of mandatory three monthly medication reviews is an approach underpinned by NICE guidelines and recognised by the Welsh Government’.
The WG notes that the current Directed Enhanced Service (DES) requires that all new care home residents are seen within 28 days for a clinical assessment and that all residents have an assessment at least once a year. The WG believes the DES ‘likely presents the most appropriate avenue to explore changing the specification of the service to cover the activity set out in recommendation 4’. It goes on to say:
All enhanced services are currently undergoing a review by the Senior Medical Officer for Primary Care and with the support of Assistant Medical Directors across Health Boards. Therefore, this suggestion will be taken forward as part of that work and it should be noted that any changes to enhanced services would need to be negotiated with the General Practitioners Committee (GPC) Wales.
Article by Amy Clifton, National Assembly for Wales Research Service