The Pharmaceutical Journal
Vol 270 No 7236 p214
15 February 2003

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Age and Ageing abstracts
• An indicator of appropriate neuroleptic prescribing in nursing homes
• Explicit, evidence-based criteria to assess the quality of prescribing to elderly nursing home residents

Study highlights poor prescribing of antipsychotics in nursing homes

Most antipsychotics and benzodiazepines prescribed for nursing home residents are inappropriate, new research suggests.

The study, which was pharmacist-led, involved almost 1,000 elderly people in 22 nursing homes in the Thames region. The researchers found that almost a quarter of residents were prescribed an antipsychotic of some kind and that only 18 per cent of residents given antipsychotic therapy were receiving appropriate treatment. Side effects that could have been caused by this therapy were seen in 60 per cent of residents (Age and Ageing 2002;31:435).

Lead author, Alice Oborne, pharmacist for evidence-based practice, King's College Hospital, London told The Journal that inappropriate indications for antipsychotics were not the only problem. Other difficulties included a lack of review, a dearth of documentation for indications, insufficient attempts to reduce doses and open-ended prescribing without stopping dates. Thioridazine was the most widely precribed antipsychotic, followed by haloperidol and chlorpromazine.

Ms Oborne suggested that environmental changes, such as the introduction of "safe wandering areas", could be explored before pharmacotherapy was considered for elderly patients with problem behaviour.

The same researchers have also investigated the appropriate prescribing of benzodiazepines in the same nursing homes (Age and Ageing 2003;32:102). Although 24 per cent of residents received benzodiadepines, only 7 per cent received them appropriately. Three-quarters of these prescriptions were for use every day. The researchers found contraindications, including falls and depression, in 75 per cent of those given benzodiazepines.

Ms Oborne pointed out that current incentives for supplying pharmacists to provide pharmaceutical care to residents of nursing homes are small and this issue needs resolving.

Celia Feetam, chairman of the United Kingdom Psychiatric Pharmacy Group, commented that although the researchers make the point that non-pharmacological strategies should be employed to counter wandering, restlessness and inappropriate behaviour, antipsychotics, both typical and atypical, at low dosage, have a place when symptoms such as anxiety and agitation in the elderly cannot be dealt with by other means.

She added that no mention is made in the studies of antipsychotics with potent anticholinergic activity in patients diagnosed with dementia nor the degree to which anticholinergics such as procyclidine were prescribed to counter extrapyramidal side-effects. "These agents could seriously further compromise cognitive function in such patients as well as induce behavioural toxicity," she said.

Ms Feetam said that it would have been interesting "and of considerable practical use" to have included details of the type of pharmacy service provided to the residents of these homes and whether or not the contract was for supply alone or if it included a clinical component. "This might have made an interesting comparison and perhaps a model of improvement for the future," she concluded.