Hospital Pharmacist
Vol 10 No 3 p94
March 2003

News summary

Study led by hospital pharmacist reveals poor prescribing of antipsychotics in nursing homes

New research carried out by Alice Oborne (pharmacist for evidence-based practice, King's College Hospital, London) and colleagues suggests that most antipsychotics and benzodiazepines prescribed for nursing home residents are inappropriate.

The study involved 934 elderly people in 22 nursing homes in the Thames region. The researchers found that almost a quarter of residents (229) were prescribed an antipsychotic of some kind and that only 18 per cent of residents given antipsychotic therapy were receiving appropriate treatment.

Most prescriptions were inappropriate for more than one reason.Out of 234 prescriptions for antipsychotics, an inappropriate indication was found for 145 prescriptions (62 per cent). Indications were not objectively or quantitatively documented on 141 (60 per cent) and 159 (68 per cent) prescriptions, respectively. Dose reductions were not attempted for 68 per cent of prescriptions.

Thioridazine was the most widely prescribed antipsychotic, followed by haloperidol and chlorpromazine. Side effects that could have been caused by antipsychotic therapy were recorded in the clinical notes for 60 per cent of residents (Age and Ageing 2002;31:435–9).

Ms Oborne and colleagues have also investigated the appropriate prescribing of benzodiazepines in the same nursing homes (Age and Ageing 2003;32:102–8). Although 24 per cent of residents received benzodiazepines, only 7 per cent received them appropriately.

Clinical data were obtained for 223 residents taking benzodiazepines. Attempts at withdrawal or dose reduction were noted for only 17 residents, although the researchers found contraindications, including falls and central nervous system depression, in 75 per cent of those given benzodiazepines.

Ms Oborne told Hospital Pharmacist that environmental changes, such as the introduction of "safe wandering areas", could be explored before pharmacotherapy is considered for elderly patients with problem behaviour. She said that antipsychotics should be reviewed regularly, and gradually withdrawn when the indication is inappropriate or unclear. Ms Oborne said that studies have shown that antipsychotics can be withdrawn in up to 50 per cent of elderly nursing home residents with no deterioration in memory or behaviour.

Commenting on the studies, Celia Feetam, chairman of the United Kingdom Psychiatric Pharmacy Group, said: "Although the researchers quite rightly make the point that, whenever possible, non-pharmacological strategies should be employed to counter wandering, restlessness and inappropriate behaviour, there is good evidence that antipsychotics, both typical and atypical, at low dosage, have a place when symptoms such as anxiety and agitation in the elderly become unmanageable by any other means."