Policies to Reduce Antipsychotic use Among Elderly are Failing

Results have implications for dementia care

Akansha Vaswani
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The latest research reveals that rates of antipsychotic prescribing to the elderly in the UK have not dropped despite national recommendations. The researchers examined the medical health records of people over age 65 who lived in long-term residential care in 616 institutions England.

“. . .reductions in the prescribing of antipsychotics driven by the NDS (National Dementia Strategy) have not been sustained in care homes. Furthermore, we demonstrate that contrary to guidance, older antipsychotic agents are still being used extensively rather than safer SGAs (second-generation antipsychotics). We observed that most residents were prescribed antipsychotics within acceptable dosages; however, in the majority of cases, length of treatment was excessive.”

“Excessive” treatment means that prescriptions exceeded not only the “recommended” treatment with antipsychotics of up to 6 weeks but also the “acceptable” treatment of 6-12 weeks. Moreover, the percentage of cases where treatment was excessive actually increased from 69.7% in 2009 to 77.6% in 2012.

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The study was undertaken to determine the impact of policies and recommendations outlined in the National Dementia Strategy that highlighted the risks of using antipsychotic drugs in response to behavioral and psychological difficulties that arise in the context of dementia care. The strategy report issued in 2009 stated:

“It appears that there are particular risks that are serious and negative in the use of antipsychotic medications for people with dementia. These include increased mortality and stroke. There is accumulating evidence that in care homes they are initiated too freely, they are not reviewed appropriately following initiation, and they are not withdrawn as quickly as they could be. However, it is also the case that behavioural problems in people with dementia can be dangerous and disruptive, and in some cases medication is the least worst option.”

Thus the report encouraged the development and initiation of non-pharmacological interventions as a first-line treatment for such problems. The number of persons living with dementia is estimated at 850,000 in the United Kingdom and is projected to rise over two million by 2051. In the United States, an estimated 5.4 million people live with Alzheimer’s disease, with 5.2 million people of the age of 65 or over.

An interesting finding of this study was the variability in prescriptions rates based on the neighborhood the residential care facility was located in – higher prescribing rates were found in “deprived” neighborhoods. This has been linked not to clinical need of the elderly residents, but rather as a strategy to deal with burden of care placed on nursing staff. Another factor affecting higher prescribing rates is what the authors label “prescribing culture”. In their study, facilities where there were several GPs prescribing led to higher prescription rates than facilities with only one GP. They believe this may be because many prescribers at a single facility may generate more inconsistent messages about appropriate prescription which may be confusing for non-clinical social care staff that actually manage the medication provision.

These findings are alarming given that in most countries, including the United States, antipsychotic drugs have not been approved by the FDA for behavioral and psychiatric dementia symptoms. Moreover, there have been reports that there is high and inappropriate long-term prescription of antipsychotics, for example with the likelihood of prescriptions being higher for elderly residents that exhibit aggressive behavior, passiveness or who have mild cognitive impairment. This suggests that the medication may be used more as a mechanism of control rather than for an appropriate clinical need. Given these dangers, the authors wonder “why off-label prescribing remained high and why length of treatment continued to exceed the recommended 6–12 weeks.”

The authors note that the present study is limited in terms of their not having data on the residential home characteristics and electronic health records.  They conclude by noting that the NDS did not include recommendations on long-term monitoring and also that prescribing patterns in residential care homes are not open to public scrutiny – both of which may be contributing to non-reductions in the rate of off-label prescription of antipsychotic medications to this potentially vulnerable population.

 

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Szczepura, A., Wild, D., Khan, A. J., Owen, D. W., Palmer, T., Muhammad, T., & … Bowman, C. (2016). Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a 4-year period. BMJ Open6(9), e009882. doi:10.1136/bmjopen-2015-009882 (Full Text)

11 COMMENTS

  1. Here in the United States, antipsychotics like Haldol, are used as chemical restraints for residents who are more vocal or less compliant than the staff want them to be. If the resident is opinionated and speaks out for herself or himself, the person runs a much higher risk of getting drugged. If you don’t go to bed immediately when the staff want you to go to bed, you will be recommended for drugging the next time the medical director shows up at the facility. Staff want you in bed by 7 PM so they have little to do for the rest of the evening. And remember, antipsychotics are more dangerous for the elderly because they cause the person to fall. Once you fall and break a hip you are on the downhill run for the cemetery. Many drug companies have instructed their drug reps to invade the nursing homes and convince the staff to use these toxic drugs because the elderly were a lucrative and unexploited population and are up for grabs since many of them have no one to speak in their behalf.

    And how do I know this many of you ask? I was the chaplain for a large retirement/nursing home complex and witnessed these things for myself with my own eyes and heard it with my own ears. I witnessed vibrant older people, who were willing to speak out and up for themselves, be turned into drooling vegetables locked in geri-chairs. These chairs are a means of physical restraint. People sit in these damned chairs from 8 AM to 1 PM and from 2PM till 7 PM. And the place I worked for was and is still considered to be one of the best in the state where I live. What goes on with the drugging in places not so nice and this place is?

    • The retirement center/nursing home where I worked had a GP as its medical director. He came once a week to the center and the nurses usually had a list of people that they wanted things done for. The list included the people that they wanted drugged with Haldol. He would then write the doctor’s order for everything.

  2. This article says the drugs are not approved for theses uses. But it is more serious than that: these drugs have a BLACK BOX in the US for increased mortality (by 60-70%) when used off-label in older adults. There is actually a US Federal program to reduce the use of these drugs in institutionalized older adults. I understand that this is a UK study, but the overuse of drugs and other controls instead of human care is common in the US. And the horrifying thing is that some staff may think this is good care, while other staff just want people sedated.

  3. If this drugging, and, thereby, killing of the elderly isn’t a scandal, it should be. There is little reason for it, except one, it makes things easier for the nursing staff to have placidly zonked out patients. People who have parents in these institutions need to make an issue out of the care they receive. Neuroleptics are not good care, they are damaging, and they increase the chances of a loved one dying early. The fact that, with all we know about neuroleptics and aging, use is increasing in UK nursing homes is very ominous. Hopefully, people will react to the situation in a effective fashion that can bring about real and lasting change. Killing more and more senior citizens is not (Duh!) progress.

  4. A friends sister is on these drugs. She lives on her own and has early dementia symptoms. Her daughter is nearby. She got up one night and was frightened that children were behind the TV and harassing her. The drugs are merely tranquilisers, what she really needs is someone to call in a few times a day and a phone number for when she gets scared. As time goes by she will need more personal care and eventually it might be 24 hour care.

    I think this might be a quite common way the drugs are used in the UK; elderly people with moderate dementia who live on their own being tranquilised to cut down the amount of personal care which the person really needs.

  5. Nursing homes are run for profit. Staff cost money. Shareholders want dividends. The government subsidises the drugs, so nice quiet residents = fewer staff = little interaction required = nice profit. Who cares about quality of life – after all Hitler would have gassed them as useless lives. This is the same thing, early deaths from strokes, cardiac events and falls = bigger turnover, there’s plenty more where they came from. Of course a little more money spent on activities staff might mean active, hornery residents might be amused and busy instead of bored and confrontational; an iPod each with the resident’s favourite music recorded on it might cause less agitation and reduce need for drugs OR staff involvement, but HEY, that’s not what the business is all about. It’s about MONEY!

  6. DEMENTIA has been defined as :- PROGRESSIVE IRREVERSIBLE INTELLECTUAL IMPAIRMENT.

    Time dependent neurotoxicity of both “First” and “Second Generation Antipsychotics” – (Correctly and originally classified honestly as MAJOR TRANQUILLISERS) – induces movement disorders such as AKATHISIA and TARDIVE DYSKNESIA.

    These drugs, in addition to profound mutii-systems long term toxicities, all have the neuro-toxic capability to cause:-
    PROGRESSIVE IRREVERSIBLE INTELLECTUAL IMPAIRMENT. (- AKA DEMENTIA!)

    What an “Alice in Wonderland” pseudo-therapuetic medical thought disorder – to accelerate intellectual decline in ageing human beings as a means of achieving COERCIVE COMMAND AND CONTROL.
    Is this apparently unethical practice compatible with any residual integrity in the practice of 21st Century Medicine?

    Retired and increasingly incredulous physician.