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Ian Maidment, Stephen Guy and Dave
Branford are
members of the College of Mental Health Pharmacists
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The Broad spectrum feature is
open to any reader. Contributions of around 1,100 words commenting
on topical issues
may be posted to Graeme Smith, managing editor, or
e-mailed to graeme.smith@pharmj.org.uk for consideration
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The recent inquiry of the All-Party Parliamentary Group on Dementia into the prescribing of antipsychotic drugs to people with dementia living in care homes (“Always a last resort”) makes uncomfortable reading. It found that over-prescribing of antipsychotics continues to remain a problem in many care homes.
Dementia affects about a third of people aged 65 years or over. The most
common reason for using antipsychotics in this population is to treat
the behavioural and psychological symptoms of dementia (BPSD), such as
agitation, aggression, wandering and disinhibition. Approximately half
of people with dementia will exhibit some of these symptoms.
However,
BPSD are usually transient and frequently respond to behavioural interventions
or changes in the environment. Moreover, there is increasing evidence
that antipsychotics have only limited, if any, efficacy with regard to
BPSD.
The problems associated with antipsychotic drugs in people over 65 and
with dementia are increasingly well-understood; common side effects include
sedation, dizziness, falls, stroke and Parkinson-like problems, such
as tremor. More seriously, the anticholinergic activity of antipsychotics
worsens cognition and these drugs double mortality rates.
The parliamentary group’s report highlights possible reasons for
the high use of antipsychotic drugs and other medicines to manage BPSD,
including: • A lack of training of staff working in care homes (resulting in a
failure to provide patient-focused care)
• A lack of leadership within homes
• Limited external support
• Failure to use behavioural techniques as a management option
There are also failures to recognise that the prescribing of antipsychotics
should be a short-term response, and that inadequate review of the prescription
can lead to continued antipsychotic use even after BPSD have receded.
A large section of the report describes the potential role of regular
medication review (not to be confused with medicines use review) to improve
care and to ensure appropriate use of antipsychotics.
The US is cited as an example of good practice; its Nursing Home Reform
Amendment, which became effective in October 1990, limited the use of
antipsychotics. Care homes in the US are required by law to employ an
accredited pharmacist to review prescribed medicines, including antipsychotics.
The report also discusses the suggestion by dementia charities for an
extension of the role of the dispensing pharmacist to perform medication
reviews.
Although the report does not advocate any specific approach it states “a
single, named individual should have the responsibility for undertaking
the review and clarity is needed about who this should be”. Any
pharmacist delivering such a service would need the necessary skills
and knowledge and may need to be accredited. Details of any mechanism
for accreditation of the responsible person were not covered in the report
and require further elucidation.
The accessibility and capacity of community pharmacists lend themselves
to this role but there are a number of barriers that need to be overcome.
The first is the role of secondary care prescribers in initiating the
antipsychotic drug and the extent to which they continue to be involved.
The report highlighted that pharmacists with a lack of experience in
the field may be reluctant to challenge secondary-care-led prescribing.
Homes will need to develop alternatives to medicines use rather than
switching from antipsychotics to alternative types of sedative. Reducing
the reliance of a care home on medication requires, not only for the
pharmacist to have an understanding of mental health medication and alternative
treatment pathways, but also to have the ability to influence the original
prescriber.
A further possible barrier is evidence that suggests community pharmacists
are less comfortable with dealing with mental health issues than with
physical health problems (Psychiatric Services 2004;55:1434–6).
Any accreditation system would, therefore, need to ensure consistency
of service and to give pharmacists competence and confidence and, perhaps,
have a method of robust
supervision.
A second option would be to use specialist mental health pharmacists
working in both primary and secondary care. They are more likely to have
the necessary skills, knowledge and experience and some are accredited
via the College of Mental Health Pharmacists.
This second option would use accreditation mechanisms that are already
in place. However, most of the trained mental health clinical workforce
is based within secondary care, whereas patients are within primary care.
Moreover,
within secondary mental health care there is already high demand for
specialist mental health pharmacists and many mental health trusts
are experiencing difficulty with recruitment.
A possible solution to this conundrum, would be for pharmacists in
the various sectors to work together as a team. Community pharmacists
will
continue to have limited impact if they work in isolation and pharmacy
as a profession has been slow to recognise the potential of teams working
across organisational boundaries.
This approach would involve specialist
pharmacists providing liaison with secondary care prescribers and
community teams, and, in addition, training and providing supervision
to community
based pharmacists, who would deliver regular clinical pharmacy and
medication review in this population. Such potential for outreach
work for specialist
clinical pharmacists was identified in the recent pharmacy White
Paper for England.
One of the most successful schemes of this type to date was the Department
of Health-funded Derbyshire pharmaceutical care scheme for older
people with mental health problems, in 2001. This scheme involved
the training
of a number of community pharmacists, who made joint visits with
a key worker and undertook medication reviews and medicine adherence
reviews
in the homes of older people with mental health problems, including
dementia.
The programme was managed and co-ordinated by a pharmacist
who worked
closely with the community mental health teams and secondary care
mental
health pharmacists.
Whatever final system is developed, the need for team working that
involves the
specialist workforce is clear. Without such collaboration it is
likely that one of the most vulnerable populations in society will
continue
to be put at significant risk from
inappropriate medicines management. |
The
Pharmaceutical Journal