Antipsychotics and other perils of prescribing – A physician’s tale

Clive Bowman, Residential Forum
member, has kindly prepared this blog based on a talk given to a “DoL’s”
conference in March 2018

Many
years ago, and on the face of it an unremarkable request made by an experienced
and wise GP to attend an aged lady in a Residential Home because of anxiety,
you just knew there was a story to unpick – that there was more. A widow who
had been living alone, well supported by neighbours and her local church, she
had fallen and been admitted confused to hospital. With no bony injuries she
was rapidly dismissed clinically from a trauma perspective, but her confusion
led to high doses of antipsychotics being prescribed. These rendered her helpless;
a junior doctor subsequently considered her to have Parkinsonism and commenced treatment
for Parkinson’s disease. She was discharged to a nursing home and her friends
assisted in the sale of her house and dispersal of most of her possessions. Her
condition improved, and she transferred to residential care and increasingly
spent her days out walking and visiting old friends. Her anxiety returned when
she had a further fall, she was fearful that she would be transferred back to
nursing care.  My review, the first
specialist review she had received, concluded that her original confusional
state was almost certainly related to a head injury sustained when she fell (if
she had been younger the possibility of head injury would have not been
overlooked) and the antipsychotics merely produced further problems including
drug induced Parkinsonism. Needless to say, all her medicines were discontinued
and her only medical problem really was arthritis of her knees that had led to the
falls.

image

No
one had sought to deprive this lady of her liberty, indeed the records made
clear the real concern for her well-being, but she was denied expert opinion
that could have so easily led to a very different story.

Our
present approach to illness is one of diagnosis and treatment with the aim of
preventing unpleasant symptoms and complications whilst social care is very
much in the business of promoting independence and personal autonomy. Perhaps a
third dimension is the increasing medicalisation of death and dying using palliative
care largely developed in cancer patients with incurable malignancy.  

The
trajectory to death for older people as a population is evolving.  A large American review suggests that 20% of
people die suddenly from accidents and events such as a fatal myocardial
infarction, 20% from cancer and 20% from chronic disease such as renal, chest
or heart disease, the remaining 40% die from frailty or long-term progressive
typically neurological conditions such as Alzheimer’s disease. Clearly as
progress is made on the prevention and treatment of many traditional causes of
death, more people are likely to swell this last group and their course has
been called “progressive dwindling”.  

Formative care

“Progressive
dwindlers” have usurped the “feckless and reckless” of the Poor Laws as care
recipients, their needs neither fitting the capabilities of modern medicine or
the ambitions of progressive social care.

We have written elsewhere that this
population is distinct from people traditionally receiving palliative care. We
have proposed that they should have “formative care” that is care aimed at providing
the best quality of life within the reality of lives reframed by physical and
mental impairments mindful of the likely progression.

Restraint
in care takes many forms. Well into the 1980’s industrially well engineered tipping
chairs, items that may have been appropriate for a few, but tipped with the
table (at 45 degrees) fixed provided a complete restraint. Clearly not
acceptable, these chairs are largely discarded, however history repeats itself
with the particularly low arm chair. Initially care homes may have had one or
two of these but following feedback the manufacturers added large castors, a
foot board and Velcro attached a table and finally handles added to push the
chair around. It may well be that this sort of device is really useful on
occasion but on a 30-bed dementia unit how many of these are necessary – where
is the transition from appropriate to unjustified restraint. We have no guidance,
but my intuition questions the necessity for more than 2 or 3.    

Moral outrage

I
have explored the use of antipsychotics in care homes both from the perspective
of a hospital consultant and a medical director. Simply, in spite of the moral
outrage, short term policy initiatives, the use of antipsychotics remains
unmanaged and a factor in the loss of liberty for a large number of people. I
have slides which illustrate prescribing patterns across the care home population
in the catchment of a district hospital. The Gosport Memorial Hospital inquiry
of 2002 highlighted poor prescribing and poor controls, many would agree that
for Gosport substitute a large proportion of care homes across the UK. I have reported
data describing the common diagnoses attached to care home residents in several
surveys, perhaps the most important point is that the incidence of mental
incapacity at home and abroad is high and an indicator of high risk regarding
the prescribing of antipsychotic medicines and other medicines that may be
sedative.

When
the UK coalition government started acknowledging dementia as a major health
concern, focus was brought to bear on antipsychotic prescribing. At that time, I
had a small team ringing GPs whose patients seemed to be over or
inappropriately treated alerting them to the possibility of antipsychotic medicine
reduction or withdrawal. This worked in the short term but to some extent it
echoed painting the Forth Bridge! No sooner had one cohort of residents been dealt
with they were supplanted; the problem is one of custom and practise in
medicine and not largely driven by care homes.

We
have published a substantive survey of antipsychotic prescribing from before
the implementation of the National Dementia Strategy and 4 years post. The findings
and brutal reality is there has been no sustainable change – not in prescribing
rates nor in the type of drugs (old vs new) prescribed. This paper can be found
at  http://bmjopen.bmj.com/content/6/9/e009882  . What is interesting is that this thoroughly
peer reviewed paper, though reporting data on a grand scale, barely caused a
ripple. Essentially it seems to me that the “it’s just too difficult” box may
have been ticked and attention has moved on. Most recently I have reviewed the
rates of antipsychotic prescribing in a well-run highly regarded care provider
and antipsychotic prescribing rates are actually rising. It has been suggested
that austerity may be leading commissioners to under commission care,
individuals being sedated to compensate. I have no means of substantiating this,
but it is crucial that the responsibility for prescribing is understood to be
the legal responsibility of the prescriber not care provider or for that matter
a service commissioner.

Little or no written guidance to underpin what is a common practice

The
principal regulator CQC has done much to improve safety in medicines management
but it simply lacks the capability to systematically provide oversight of
medicines prescribed. My observations are that over 50% of antipsychotic
prescriptions for care home residents are initiated in acute hospitals. As a
physician I sympathise with this. If on an acute ward with desperately sick
people an older person is a danger to themselves and those around them control must
be established and fast. It’s a far cry from preferred practice but often the
only pragmatic solution. Where things go seriously awry is that what should has
been used as an emergency measure only becomes incorporated into long term
treatment regimes. It is important to reflect that most of these medicines were
developed and licensed for psychoses such as Schizophrenia and are now being
used off licence with little or no written guidance to underpin what is a
common practice. Doctors in training both for hospital or practice in the
community observe their seniors using these drugs in this manner and the “see
one do teach one” approach fills the void of evidence for rational practice.

Prescribing
antipsychotic medicines may be associated with high levels of supplemental
feeds and low levels of medicines as required and low prescribing of analgesia;
suggesting to me a one size fits all institutional approach. Whereas the
converse probably indicates a more personalised practice. The more
institutional approach I’ve described seems to be associated with large care
homes where patients may have general medical services from GP’s with whom they
are unfamiliar, whereas the more personalised approach is more often associated
with continuity of medical care.

So,
my view is that medicines and older people in care remain a cause for serious
concern. It’s not just a matter of simple medicines review that is needed for
most people but a clear understanding of why each medicine was prescribed so
that reviews can determine whether that is still valid. It’s not just
antipsychotics, I have observed a home presented to me as an example of good
practice with zero use of antipsychotics only to find high levels of sedating
analgesia being used.

image

Prescribing
in care homes is a bit like the fair ground game of “whack a mole” with new
challenges continually popping up. So, we need much greater guidance and controls
and I am optimistic that with “e” prescribing and big data from digitally
enabled medicines management systems (I declare an interest being chair of a
leading company in this endeavour) accountable care organisations should be able
to monitor trends actively in real time.

Published by Residential Forum

The Residential Forum is to promote the achievement of high standards of care and support for children and adults living in residential care and nursing homes, supported housing, residential schools and colleges, hospices and hostels. It contributes to improving the quality of service to the public. Members of the Forum are people of standing and experience drawn from the public, private and voluntary sectors, as well as some who can speak for service users and carers.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: