‘Systemic changes’ needed for prescribing of antipsychotic medicines in Welsh care homes
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Antipsychotic medicines are being prescribed inappropriately, in many cases as a first option rather than a last resort, to treat the behavioural and psychologic symptoms of dementia, often without adequate reviews or records being kept, according to a new report from a National Assembly committee.

The Health, Social Care and Sport Committee was told antipsychotics were increasingly being used in care home settings to ‘manage’ challenging behaviour of people with dementia.

The Committee wants the Welsh Government to ensure that all health boards are collecting and publishing standardised data on the use of antipsychotic medication in care homes and report back to it on progress within 12 months.

It also wants to make sure all health boards are fully compliant with NICE guidelines on dementia, which advise against the use of any antipsychotics for non-cognitive symptoms or challenging behaviour of dementia unless the person is severely distressed or there is an immediate risk of harm to them or others.

In 2009, a report by Professor Sube Banerjee on the use of antipsychotic medication for people with dementia found that antipsychotics appeared to be used too often in dementia and, at their likely level of use, potential benefits are most probably outweighed by their risks overall.

During evidence the Committee was told that medication reviews are not happening frequently enough for people with dementia, and that once medication is prescribed (including antipsychotics) it often rolls on with repeat prescriptions for long periods without being monitored effectively. This is particularly concerning as older people are more likely to have complex chronic conditions which require multiple medications.

The Committee has called for every person with dementia presenting challenging behaviour to receive a comprehensive person-centred care assessment of their needs.

“A person living with dementia presenting challenging behaviour often has an unmet need which they may be unable to communicate” said Dr Dai Lloyd AM, Chair of the Health Social Care and Sport Committee.

“As such, we believe it is vitally important to look at the person as a whole in order to understand what may be causing a particular behaviour.

“We know that there are various good practice checklists that could be used by staff in care homes to identify the possible causes behind an individual’s behaviour. Yet we were told that antipsychotics are being used as a default position in care homes and some hospital wards, when people with dementia are difficult to deal with.”

“Unnecessarily medicating vulnerable people in care is a profound human rights issue which must be addressed.”

“We believe cultural and systemic changes are needed to ensure antipsychotic medications are prescribed appropriately, and as a very last resort, not as a default first option.”

The Committee makes 11 recommendations in its report, including:

  • The Welsh Government should ensure that all health boards are collecting and publishing standardised data on the use of antipsychotic medication in care homes and report back to this Committee on progress within 12 months;

  • The Welsh Government should ensure that all health boards are fully compliant with NICE guidelines on dementia, which advise against the use of any antipsychotics for non-cognitive symptoms or challenging behaviour of dementia unless the person is severely distressed or there is an immediate risk of harm to them or others, and report back to this Committee on rates of compliance within 12 months; and

  • Within six months, national standards for dementia-care training be developed to equip care home staff with the necessary skills to deal with challenging behaviour. Dementia-care training and specific training to deal with challenging behaviour (as stated in NICE guidelines: including de-escalation techniques and physical restraint methods) should be mandatory requirements for all care home staff, and compliance with this should be scrutinised as part of CIW’s inspection regime.

Older People’s Commissioner for Wales, Sarah Rochira, said: “I strongly welcome the publication today of the Health, Social Care and Sport Committee’s report on the use of antipsychotic medication in care homes, an issue that I highlighted as part of my Review into the quality of life and care of older people living in care homes in Wales.

“Whilst it can be appropriate to use antipsychotic medication in some cases, the inappropriate use of these powerful drugs can have a devastating impact on older people and is quite simply unacceptable.

“The report reflects and builds upon the findings of my Care Home Review, making clear that a wide range of action is needed to ensure that antipsychotic medication is not prescribed inappropriately to some of our most vulnerable older people.

“I expect, as will older people and their families across Wales, a positive response from the Welsh Government and a commitment to take meaningful action in response to the Committee’s recommendations to address the issues identified within the report.”

Read the full report: Use of antipsychotic medication in care homes (PDF, 881 KB)

Picture (c) Ben Birchall / PA Wire.