Welcome to the Right Care webinar programme

Now that you have joined in you will notice you are on mute.If you have any questions throughout the webinar please write

them in the Q&A section located in the below right panel. There will be opportunity to have your questions answered at the end. We will take you off mute when your question is being answered

so you have the opportunity to speak to the panel.If you would like to chat to other colleagues you can do so by

typing in the chat section. There is a drop down menu which will allow you to select who you would like to send the message to.

This webex event will be recorded.

The pharmacist contribution to the care of people with dementia across health & social care

Denise Taylor, Anne Child, Jonathan Mason

Speakers Chair: Dr Denise Taylor Senior Lecturer,

University of Bath and President of CMHP D.A.Taylor@bath.ac.uk

Speaker 1: Anne Child, Head of Pharmaceutical Care & Clinical Standards, Avante Care & Support

Anne.Child@avantepartnership.org.uk Speaker 2: Jonathan Mason, Clinical Adviser

(Medicines) at NHS England London RegionJonathan.Mason@nhs.net

Our Objectives Scene setting- Getting medicines right for people with dementia- CMHP, CPPE & Royal Pharmaceutical Society- Royal College of Psychiatrists- Local research & need for proactive medicines

optimisation in dementia Pharmacist contributions to ensuring appropriate

medicines use in people with dementia NHS England Perspective Q&A Time

Dementia

“ a syndrome consisting of progressive impairment in two or more areas of cognition:

(memory; language; visuospatial & perceptual ability; thinking & problem-solving; personality)

sufficient to interfere with work, social function or relationships”

Local & National

Getting medicines right for people with dementia

CMHP, CPPE & Royal Pharmaceutical Society

Royal College of Psychiatrists - liaison

Secondary Care Prescribing of Antipsychotics

Prescribing Antipsychotics for Older People with Dementia

CSM 2004 warning: stroke increased by over 3-fold with risperidone or olanzapine and more than doubled with any other atypical antipsychotic agent.

Two epidemiological studies in 2005 showed typicals had similar risk pattern

Prime Ministers Challenge – reduce by 2011

Audit 2012 – success story or….

ANTIPSYCHOTIC RISK ASESSMENT IN DEMENTIA

(AID - Assess, Investigate and Deliver best care)

ASSESSDoes the patient have dementia with psychosis or exhibits severe physical aggression?

1

INVESTIGATE Look for factors which worsen symptoms & risk factors for thrombo-embolism (CVA, DVT, PE, MI)

Delirium (see NICE CG103 – Delirium) Pain Dehydration Sedation InfectionImmobility VTE risk assessment

2

DELIVER BEST CAREComplete a Capacity Assessment for informed consent to the treatment. If lacking proceed under “Best Interest” guidance (see Mental Capacity Act)

•Treat factors which worsen symptoms e.g. delirium & pain

•Treat underlying thrombo-embolic risk factors , dehydration, causes of sedation e.g. medication and infection

•Maximise mobility

•Consider VTE prophylaxis

•Review the need for an antipsychotic on a regular basis, initially daily

•Review the need for their continuing use prior to discharge

•If prescribed post discharge arrange a post-discharge review as soon as possible by primary care or specialist mental health services

• Do not give an antipsychotic to a patient with Parkinson’s disease or Lewy Body dementia without advice from a psychiatrist or specialist physician experienced in their use. Do not use the drugs stated below

Start with the lowest dose possible for clinical effect. Use oral risperidone (max 2mg daily) or when oral administration is not possible intra-muscular haloperidol (max 3mg daily).

Do not use anticholinergic medication routinely for problematic side effect as they cause delirium in dementia as do other drugs with anticholinergic side effects. Reduce the dose or stop the antipsychotic

Discuss with the patient & their relative/carer the risks and benefits of their use. 1 in 3 people will benefit. 1 in 100 will experience a CVA & 1 in 100 will die as a result of their use

3

YESNO - do not prescribe an antipsychotic

When completedDate:

Patient ID

Pharmacists Role Look for underlying causes; ensure

these are treated effectively Look for underlying medication

precipitants; withdraw if appropriate Ensure smallest effective dose used of

non-anticholinergic AP (risperidone); monitor for effect

Ensure withdrawn if ineffective or symptoms resolve

Professor Clive Ballard

Diagnosis of Alzheimer’s disease

Does the patient have challenging behavioural

symptoms?YesNo

Consider psychological and alternative therapies

Has there been a sufficient response?Yes

MonitorNo

Pharmacological options

Short-term management

Longer-term management

Possible care pathway for AD management in patients with behavioural symptoms

Rationale for Non-pharmacological interventions

Liaison Services (eg. Ballard et al 2002)

Clinical Psychologist (eg. Bird et al

2007/2009)

Staff training (Fossey et al 2006,

Chenoweth et al 2009)

Social Interaction (Cohen-Mansfield et al

1997, 2007, Ballard et al 2009)

Study Intervention Design Number Outcome

Holmes et al 2002

Lavender aromatherapy

Double blind crossover, 10 days

n=15, NH severe dementia

Significant improvement in agitation (p=0.02)

Smallwood et al 2001

Lavender aromatherapy and massage

Single blind RCT 2 weeks aromatherapy + massage v massage only

n=21 In patients severe dementia

34% improvement in motor agitation (p=0.056) with aromatherapy +massage

Ballard et al 2002

Melissa aromatherapy

Double blind RCT 4 weeks

n=72, NH severe dementia

Significant improvement in CMAI (p<0.0001)

Burns et al 2008/9

Melissa aromatherapy

Double blind 12 weeks

n=100 ESSENCE AD

To be completed october 2008

Akhondzadeh et al 2003

Oral Melissa Single blind RCT n=30 Agitation in 5% active v 40% placebo (p=0.03)

Freund-Levi et al 2008

Oral omega-3 supplements

Double blind RCT n=174 No overall effect, but significant reduction of agitation with apoE4

Aromatherapy, herbal remedies and food supplements

Recommendations for short-term antipsychotic useNon pharmacological Interventions and alternative pharmacological treatments need to be available

Severity criteria need to be in place for the prescribing of Antipsychotics to people with dementia

Relatives should receive full explanationMonitoring should be mandatoryTreatment should not be continued beyond 12 weeks except in extreme circumstances - and this should be policed

Neuropsychiatric symptoms in AD: Potential alternative therapies

Sodium valproate*

Meta-analysis (Lonergan et al 2008): Low doses ineffective, higher doses poor tolerability

Carbamazepine* 2 small 4-6 week RCT focusing on agitation/aggression, both with positive outcomes (Tariot et al 1998, Olin et al 201). Meta-analysis shows significant benefit on CGIC and BPSD (Ballard et al 2009). New Norwegian study this week trend to improvement of agitation. Hollis 2007 – no mortality.

Gabapentin* Systematic review (Kim et al 2008): few small case series only

Trazadone* Meta-analysis (Martinon-Torres et al 2008): 2 trials, 1 parallel group, 1 cross-over. Insufficient evidence to recommend as a treatment

Citalopram* Two promising RCT, 1 v placebo, 1 v risperidone

Memantine Meta analysis suggests significant benefit for “behaviour” (2.76 points on NPI –McShane et al 2008). Promising post hoc pooled analysis (Wilcock et al 2008)

Cholinesterase inhibitors

Ineffective over 12 weeks (Howard et al 2007 –CALM-AD). Meta-analyses and pooled analyses suggest 1.5-2 point advantage on total NPI over 6 months (Trinh et al 2003)

* Not licensed for treatment of AD

Assessment Tools

Assessing cognition in olderPeople: a practical toolkit for health professionals.

http://www.alzheimers.org.uk/cognitiveassessment

Recent Research

Pharmacist input- concomitant medication- swallowing difficulties- compliance issues- repeat prescribing problems, and- lack of proactive information

provision

Potential Pharmacist Input

Medicines management issues Concomitant medication Medicines use reviews Progression, and at any stage Proactive provision of information

See the RPS Practice Guidance for dementiahttp://www.rpharms.com/public-health-resources/mental-health.asp?

Medicine Management Issues

Counselling points All medication Cautions Side Effects Assessing Efficacy Withdrawal Issues – all medication

Concomitant Medication Check for anticholinergic load e.g oxybutynin; antidepressants; thioridazine; Check for adverse CNS effects e.g. Long acting benzodiazepines, barbiturates; opiates; dopaminergics Check need for antipsychotics – risperidone only licensed agent in aggression Any agent potentially causing confusion e.g. LA

hypoglycaemics; NSAID’s H2 antagonists e.g. cimetidine

Ensure all CV and diabetic risks treated appropriately

Medicines Use Reviewshttp://www.pm-modules.co.uk/pm_modules/dem_pm0713.pdf

Appropriate titration Check for side effects- Cholinergic- Cardiovascular- Cramps compliance issues and repeat prescribing

problems Other medicines – question everything

Compliance (Secondary Adherence) issues

Large numbers of medicines Interactions or side effects Timing Remembering Strain on main carer/PWD living on own Repeat prescribing issues

- stock, labelling issues, equal quantities of all medicines, formulation

Progression

Swallowing difficulties Behaviour Dietary intake and fluid Bowels Palliation

Proactive Information On diagnosis- signposting to support groups & social service

support Lifestyle changes to keep healthy- healthy body is a healthy brain On receiving a medicine for dementia- AE, compliance issues, concomitant medicines Social, ethical and legal issues- Advance Directives, wills, Power of Attorney etc Care & end of life issues

Social Care & Support CPN monitoring Psychiatric care support programme Care & patient

counselling/support/stimulation Day hospital services Social worker assessment Respite care End of Life Care – hospice?

Why is this Important? Prolonged stress leads to poorer

health outcomes for both carer and PWD and then institutionalisation

Better quality of life for people if better adherence to their medicines

Carers more supported in coping with supervisory medicines role

Public Health and Dementia?Lifestyle changes which improve cognitive

reserve- Better and continuing

education & occupation- Physical activity and

exercise- Midlife obesity- Alcohol intake- Smoking cessation- ?improved social

networking

Improved treatment or prevention of certain medical conditions- Stroke prevention- Diabetes control, - midlife hypertension,- Midlife

hypercholesterolaemia- Midlife fitness levels

QUALITY OUTCOMES FOR INDIVIDUALS WITH DEMENTIA

Anne Child

Head of Pharmaceutical Care and Clinical Standards Avante Care and Support

HERE WE ARE! - WHERE ARE WE ?

Challenges faced in delivering quality outcomes for residents with dementia

Dementia is in itself a complex condition requiring a MDT approach

Residents are often living with more than two other LTC that need close monitoring and co-ordinated management across specialisms

There is a need to meet health and social care needs in order to promote overall well being

IMPROVED INTEGRATION HOW THIS WOULD HELP WITH MUR !

Access to specialist input in home environment - GPs can access support i.e. ask consultants:

Is there a pathway where pharmacists could tap into specialist pharmacists and thus improve residents outcomes?

Continued This could be used post review to enhance

recommendations - more MDT working Facilitate medicines optimisation and or

facilitate withdrawal of low dose antipsychotics

how many community pharmacist would feel confident to initiate withdrawals?

Improve professional understanding Help with management and positive care

planning for residents

Example of medication review outcomes

POSITIVE CARE PLANNING I.E. LBD

Pharmacist Input could be focused on the individual, not the drug profile:

Increase staff awareness to drug sensitivity of individuals with this diagnosis

Increase risk of postural hypotension and falls, target this area in MURs

Reduction in psychotropic medication by management of disease manifestations

Advanced care planning

Adequate information for individuals and their relatives to support decision making

Some areas have this well managed see PEACE pathway Kings College for last months of life

Medway has the my wish register

APPROPRIATE USE OF LOW DOSE ANTIPSYCHOTICS

In practice at home level we apply best practice

Watchful waiting - Psychosocial interventions - In some residents we have found it is appropriate to use this form of medication in line with the Banerjee report

Regular review

OTHER HEALTH CARE PROFESSIONALSAvante is lucky enough to have:

An Admiral Nurse who works with individuals, families and staff to improve understanding and manage expectations of care

A Health and Wellbeing specialist who oversees nutrition and hydration

MORE THAN THE DRUGS

OUTCOME LINKED

Reducing avoidable hospital admissions linked to medication, falls, nutrition and hydration

Personalisation of care and improved expectations

Living well with dementia as opposed to suffering from dementia

Jonathan Mason

Clinical Adviser (Medicines) at NHS England London Region

‘Why dementia matters to me, and why it should matter to Pharmacy’

Conclusions Dementia is a complex and life changing

condition It affects spouses, partners, families and

communities Needs are multiple and varied Medicines can play an important role in

delaying progression and Improving behaviours Pharmaceutical Care for people with dementia

and their carers needs to be proactive

QuestionsToday we have briefly looked at how

pharmacists are and can help support

people living with dementia

in any care sector.

We would value your questions or

comments

Dementia Action Alliance.

If you would like to join DAA for support in your practice in dementia please join here:http://www.dementiaaction.org.uk/join_the_alliance

There are further resources after the the next slide

Thank youThe Dementia Action Alliance will send you an invitation to join our Linkedin network over the coming weeks.

For today’s slides and any other resources from past webinar events please visit: http://www.dementiaaction.org.uk/rightcarewebinars

Alzheimer's Society Assessing cognition in older people: a

practical toolkit for health professionals. http://www.alzheimers.org.uk/cognitiveassessment

Reducing the use of antipsychotic drugs: A guide to the treatment and care of behavioural and psychological symptoms of dementia

http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=1133

DAT/CB

Mortality risks: typical and atypical antipsychotics

Risks Typical Atypical References

Death ++ + Ballard, Rochon, Gill, Schneeweis,

Schneider, Wang

Stroke +(+) +(+) Gill, Hermann, Rochon,

Kleijer, Douglas

Heart death

+ + Ray, Wang

Pneumonia

+ ++ Knol

DAT/CB

Responses to atypical antipsychotics

Schneider L et al. NEJM 2006; 355:1525-38.

Response** based on CGIC score at 12 weeks: 32% Olanzapine group 26% Quetiapine group 29% Risperidone group 21% placebo group Overall comparison: p=0.22

** A response was defined as continued treatment with the original phase 1 study drug and at least minimal improvement on the CGIC.

Differential Survival

Ballard C et al. Lancet Neurol 2009; 8(2):151-7.

0%

10%

20%

30%

40%

50%

60%

70%

80%

Number of months

Differences in the survival rates in the DART-AD trial

Survival rate on placebo

Survival rate on a antipsychotic

Survival rate on placebo 71% 59% 53%

Survival rate on a antipsychotic 46% 30% 26%

24 36 42

Table adapted from Ballard et al 2001

40-60% people with dementia in NH are taking antipsychotics1

DrugsNone

(n=13)Delusions (n=28)

Agitation (n=72)

Depression (n=35)

Neuroleptics 4 (31%) 13 (46%) 38 (72%) 16 (46%)

Benzodiazepines

0 (0%) 4 (14%) 10 (14%) 5 (14%)

Antidepressants

2 (15) 6 (21%) 17 (24%) 13 (37%)

Other psych 1 (8%) 1 (4%) 3 (4%) 0 (0%)

Psychotropic drugs and BPSD

DAT/CB

n=42Baseline

(sd)

Follow-upEvaluation (Baseline v Follow-up)

FITS (sd)Control

(sd)

Social Withdraw

al

6.64 (8.96) -5.24 (13.56) -1.29 (5.42)

T 2.1 p=0.04

Daytime sleep

-20.69 (23.24)

-6.20 (24.58) -1.29 (24.38)

T 1.1 p=0.27

Type 1 Behaviour

s

+34.74 (19.53)

+13.44 (23.73)

+1.47 (24.29)

T 2.3 p=0.03

Wellbeing0.65 (0.69) +0.34 (0.59) +0.15

(0.98)T 2.2 p=0.03

CMAI42.88 (14.57) +0.75

(22.35)+5.29 (12.74)

T 0.83 p=0.41

Stopping antipsychotics: Impact on QoL

Further Information- general Mental Health Resources

http://www.rpharms.com/support-tools/mental-health-resources.asp Pharmaceutical care Guidance in Mental health

http://www.rpharms.com/public-health-issues/mental-health.asp Alzheimer’s Society http://alzheimers.org.uk/ College of mental health pharmacy http://www.cmhp.org.uk CPPE Focal Point on Dementia http://

www.cppe.ac.uk/learning/Details.asp?TemplateID=Dementia%2DW%2D01&Format=W&ID=174&EventID=-

CPPE Mental health http://www.cppe.ac.uk/learning/programmes.asp?format=e&ID=47&theme=11

CPPE http://www.thelearningpharmacy.com/ Taylor D.A. Medicines Use Reviews in Dementia. CPD Module.

Pharmacy Magazine June 2013.

Living with Dementia

Living with dementiahttp://www.youtube.com/watch?v

=WR74FEyc9KY&feature=related

Communicationhttp://www.healthtalkonline.org/Nerves_and_brain/

Carers_of_people_with_dementia/People/Interview/839/Category/144/Clip/4016/dementia-communication#dementia-communication

Dementia Video ClipsAlz Pt 1 of 4http://www.youtube.com/watch?v=_OD0z0u93sw&feature=channelAlz Pt 2 of 4http://www.youtube.com/watch?v=VHxdAYmMfK4&feature=channel Stan 3 of 4http://www.youtube.com/watch?v=yykeknxMozk&feature=channelMum 4 of 4http://www.youtube.com/watch?v=nl9xqm_9KbE&NR=1Living with dementiahttp://www.youtube.com/watch?v=WR74FEyc9KY&feature=relatedDementia tour (what its like to live with dementia) http://www.youtube.com/watch?

v=3hROU6f5TUQ

Carer Views on Medication Over-sedatedhttp://www.healthtalkonline.org/Nerves_and_brain/

Carers_of_people_with_dementia/People/Interview/833/Category/160/Clip/3519/dementia#dementia

Problem in giving medicationhttp://www.healthtalkonline.org/Nerves_and_brain/

Carers_of_people_with_dementia/People/Interview/830/Category/102/Clip/3693/dementia-medication#dementia-medication

Availability of medicationhttp://www.healthtalkonline.org/Nerves_and_brain/

Carers_of_people_with_dementia/Topic/2075/