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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 [email protected]
Speaker 1: Anne Child, Head of Pharmaceutical Care & Clinical Standards, Avante Care & Support
[email protected] Speaker 2: Jonathan Mason, Clinical Adviser
(Medicines) at NHS England London [email protected]
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/