Audit of antipsychotic prescribing in dementia: Cambridgeshire results and lessons learnt

Behavioural and psychological symptoms in dementia (BPSD) are common and distressing. Anti psychotic medication has been shown to have modest efficacy but is associated with well documented risks including excess cardiovascular events and increased mortality. The current NICE recommendations are that antipsychotics should only be prescribed to those with severe BPSD after exploring other possible interventions. There should be adequate counselling of the patient/family, an explicit risk-benefit analysis and regular review.

As part of the POMH-UK National Audit on antipsychotic prescribing in dementia we reviewed the notes of 67 patients in the Cambridgeshire area who had a diagnosis of dementia.

Of the 67 patients reviewed, only 9 (13.4%) were currently being prescribed antipsychotics for BPSD. Of these patients, all were living in their own homes and were experiencing multiple distressing target symptoms. 5 had been prescribed an antipsychotic for less than 3 months and only 1 had a total duration of treatment of more than 1 year. There was good evidence in all cases that alternative diagnoses and management strategies had been explored before prescribing an antipsychotic. However, in none was the full range of potential causes or interventions explored. In 6 cases a risk/benefit analysis for use of antipsychotic medicine was recorded and in 5 cases there was documented discussion of this with family or carers. Of the four patients who had been prescribed an antipsychotic for more than 3 months, three had had two or more medication reviews. The fourth patient had had a trial of stopping the medication. Prescribing of other psychotropic medication was also reviewed. Benzodiazepines were used sparingly (7.5%). Of note a significant minority of patients (10.4%) were prescribed 3 or more different psychotropic medications.

These results suggest that within this service antipsychotics are being used appropriately to enable patients with distressing and difficult behaviour to continue to remain at home. They were generally prescribed for a short time and reviewed. Areas for improvement include a documented discussion of risk in all cases and ensuring that all possible causes of BPSD have been ruled out. Regular review of efficacy and tolerability is essential for all pharmacological treatments for BPSD particularly for those prescribed multiple psychotropic medications.