Clinical update

Dementia and the prescription of antipsychotics in hospital

Key points for nurses from the National Audit of Dementia by the Royal College of Psychiatrists
Patient notes

Key points for nurses from the National Audit of Dementia by the Royal College of Psychiatrists

Essential information

Dementia describes a range of symptoms that can include memory loss, difficulties with thinking, problem-solving and language, as well as changes in mood and behaviour. It is caused when the brain is damaged, for example by Alzheimers disease or a series of strokes.

Behavioural and psychological symptoms of dementia (BPSD) such as delusions, hallucinations, agitation and aggressive behavior often arise as dementia progresses. A range of medication, including antipsychotics, can be prescribed. Antipsychotics can be effective but they can also have side effects including severe physical symptoms and they can even worsen some symptoms associated with dementia.

Whats new?

All medications that are newly prescribed for people with dementia in hospital should have reasons for prescribing fully recorded in

...

Key points for nurses from the National Audit of Dementia by the Royal College of Psychiatrists


Picture: iStock

Essential information

Dementia describes a range of symptoms that can include memory loss, difficulties with thinking, problem-solving and language, as well as changes in mood and behaviour. It is caused when the brain is damaged, for example by Alzheimer’s disease or a series of strokes.

Behavioural and psychological symptoms of dementia (BPSD) such as delusions, hallucinations, agitation and aggressive behavior often arise as dementia progresses. A range of medication, including antipsychotics, can be prescribed. Antipsychotics can be effective but they can also have side effects including severe physical symptoms and they can even worsen some symptoms associated with dementia.

What’s new?

All medications that are newly prescribed for people with dementia in hospital should have reasons for prescribing fully recorded in the patient's case notes, findings from an audit of patient records has suggested.

The record should include the benefit to the patient as well as potential risks to themselves and others, according to a report, Hospital Initiated Prescription of Psychotropic Medication for BPSD, by the Royal College of Psychiatrists.

The report is based on findings from the National Audit of Dementia (NAD). The audit looked at prescriptions for almost 1,600 people with dementia in hospital in England in 2019 who had at least one prescription for a psychotropic medication.

The audit showed that more than two out of five patients who received new psychotropic medication in hospital had no reason recorded for their prescriptions. When it was recorded, the most frequently reasons were agitation and aggression.

The use of antipsychotic medication for people with dementia has been a cause of serious concern. An independent but government-funded report concluded in 2009 that, of the 180,000 overall prescriptions for antipsychotics for people with dementia, 140,000 were inappropriate.

Usage has dropped across the NHS since then, but the Alzheimer’s Society says continuing action is needed.

The report by the Royal College of Psychiatrists recommends that any new prescription of psychotropic medication that is started in hospital should be reviewed before discharge. Their NAD audit found this happened in 80% of the cases it reviewed.

Before medication is prescribed, National Institute for Health and Care Excellence guidance highlights that other possible causes of symptoms, such as untreated pain, should be investigated and managed.

In the Royal College of Psychiatrists audit, 82% of new prescriptions for antipsychotics had evidence that underlying causes had been considered before deciding what to prescribe.

Key points for nurses

  • Ensure that other possible causes of BPSD, such as untreated pain or negative effects caused by the environment, have been appropriately investigated and managed before any medication is prescribed
  • Record target symptoms when initiating a prescription for BPSD
  • Plans for reviewing any new prescription that is continued after discharge should be communicated to the service user’s primary care team with a review date clearly recorded in the discharge summary
  • Carry out periodic spot audits on prescriptions of antipsychotics and hypnotics/anxiolytics for people with dementia in line with the recommendations to help identify barriers to improving practice.

Expert comment

Rikki Lorenti, Admiral Nurse clinical lead and hospital clinical lead for dementia at South Warwickshire NHS Foundation Trust

‘This national audit supports what I am seeing on the ground, that medication is increasingly the last rather than the first treatment option for behavioural and psychological symptoms of dementia (BPSD).

‘In the past, medication was the treatment option at the first point of any BPSD, and this will still be the case in some places. But instead of reaching for a bottle, there is a fundamental need to understand what the patient is going through.

‘Nurses need to understand, and generally do, that medication is not the answer. It is about understanding the patient’s values and beliefs and acknowledging that hospital is not always seen as a safe place for people with dementia.

‘By knowing your patient you will be able to see the signs of frustration and anxiety and find ways of managing these behaviours in a positive, empathetic way. If medication is the answer, act as an advocate for the patient and encourage low-dose, short-acting and time-specific choices. Encourage a review before discharge.’

 

Erin Dean is a health journalist


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