A care home intervention to reduce the ‘chemical cosh’ boosts staff satisfaction, improves quality of life and saves money. Surely not?
There are 800,000 people with dementia in the UK, a third live in care homes. Dementia can generate behaviours such as agitation, aggression, wandering, shouting, repeated questioning, sleep disturbances, depression and psychosis which can challenge carers and residents.
Such behaviours are all too often the trigger for prescribing antipsychotic drugs, originally designed to treat schizophrenia. Dubbed ‘the chemical cosh’, they can reduce aggression, but also increase the risk of stroke, falls and death.
It is estimated that 2/3 current UK prescriptions of antipsychotics for people with dementia are inappropriate!
1,000 people with dementia on an antipsychotic x 12 weeks = 10 deaths + 18 cerebrovascular events + 58–94 gait disturbance
With Department of Health funds we set up a project to change this. We targeted care homes (where antipsychotics prescribing is prevalent) across Coventry and Warwickshire. Each care home received a two-session nurse-based training course on managing behaviour that challenges. Our well attended training package, also included a video depicting examples (good and bad) dementia care methods.
We identified residents who were inappropriately placed on antipsychotics, and with supervision plus input from a pharmacist, stopped the prescriptions gradually. By eight weeks, 75% were successfully withdrawn off antipsychotics, with no recurrence in challenging behaviour. Analysis shows that with greater primary care involvement, even more cases for withdrawal could have been identified.
Staff training, which involved all levels, junior and senior, was well received.
At 13%, antipsychotics prescribing rates in our area were lower than the 20% national average. Moreover, we demonstrated that our ‘simple’ intervention could reduce prescribing rates broadly within the Department of Health’s aspiration.
In fact, new data suggests that this is a constant trend in our locality and in 5 years Coventry clinicians slashed new prescriptions of antipsychotics for people with dementia from 11% to 1.5%
We estimate that using the same intervention across Coventry and Warwickshire would
- get 285 people with dementia off antipsychotics in a year
- prevent 2-3 strokes and 2-3 deaths
- be cost-effective.
We estimated that this preventative approach would generate in our locality £80,000 direct savings and £240,000 quality of life improvements benefits per annum.
Perhaps Coventry & Warwickshire is a step closer to becoming a dementia-friendly locality
Who said you cannot deliver much better healthcare for much less.
- The use of antipsychotic medication for people with dementia: Time for action. S Banerjee. 2009. http://www.dementiapartnerships.org.uk//wp-content/uploads/time-for-action.pdfhttp://www.rcpsych.ac.uk/pdf/Antipsychotic%20Bannerjee%20Report.pdf
- An economic evaluation of alternatives to antipsychotic drugs for individuals living with dementia. NHS Institute for Innovation & Improvement. A Burns & N Chambers. 2011 https://groups.its-services.org.uk/download/attachments/29688000/AntipsychoticsHealthEconomics2011.pdf
- Information Centre: National Dementia and Antipsychotic Prescribing Audit; Primary Care Trust (PCT) report. Audit period 2006 to 2011 http://www.ic.nhs.uk/webfiles/Services/NCASP/Dementia%20and%20Antipsychotic%20Prescribing%20Audit/Dementia_PCT_Report_5MD_COVENTRY_TEACHING.pdf