Reducing Antipsychotics for People with Dementia in Care Homes

Reducing Antipsychotics for People with Dementia in Care Homes.

Evaluating a Pilot Intervention in Coventry & Warwickshire.

Dr Karim Saad FRCPsychRegional Clinical Lead for Dementia, NHS West Midlands

Consultant in old age psychiatry, Coventry & Warwickshire Partnership Trust

Dr Bartley Sheehan MRCPsychAssociate Clinical Professor in old age psychiatry, Warwick University

Honorary Consultant in old age psychiatry, Coventry & Warwickshire Partnership Trust

Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council

800,000 people with dementia (PwD) in UK

Greatest health concern for people over 55!

44% PwD receive a diagnosis

2/3 PwD live in the community while 1/3 live in a care home

400,000 Care Home residents80% of people living in care homes have a form of dementia or severe cognitive impairment

20% prescriptions for (PwD) include an Antipsychotic (AP) drug (Fossey, 2006)

1000 AP prescriptions x 12 weeks = 10 Deaths + 18 CVAs + 58-94 Gait Disturbances (Banerjee, 2009)

↑ Mortality Risk persists at least 6 months after initial prescription (DART-AD, 2009)

Quetiapine accelerates dementia decline in Care Homes residents (Ballard, 2006)Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council

National & Regional Priority

NHS Operating FrameworkDepartment of Health Funding for each regionReduce Prescribing to 1/3 by October 2011W Mids Regional Strategy emphasises – quality dementia services – closer to home– focus on Prevention



Aims

Design an Intervention for PwD in Care Homes that:

1. ↓ AP Prescriptions2. Provides a viable alternative for management

of BPSD3. Represents good value4. Can be reproducible


The Intervention

• 1.2 WTE Nurse: – 0.6 WTE band 6 – 0.6 WTE band 5

• Duration: 3 months (2 months per Care Home)• Supervision: Authors & Pharmacist• Research Nurse sessions• Components:

A. Training InterventionB. Main Pilot Intervention


(A) Training Intervention

• 2 sessions per Care Homes (1 week apart)• Each Session: 45 – 60 min• Target: all staff• Delivered by band 6 nurse• Session 1: identify behaviours due to dementia• Session 2: identify +ve & -ve responses to behaviours• Contents: written materials, discussion, verbal

instruction, literature review• Video: simulated residents & carers (developed for

OPERA, HTA-funded)


(A) Training Intervention

• Session 1– Introduction (3 min)– What is dementia? (10 min)– BPSD (10 min)– Video, carer interacting with PWD with BPSD (5 – 7 min)– Discussion, what behaviours are due to dementia (15 – 17 min)

• Session 2– Recap of session 1 (5 min)– How do we respond to behaviours seen in dementia? (10 min)– Introduction of ABC & person-centred approach (10 min)– Video, carer interacting in a new way with PWD with BPSD (5 – 7 min)– Discussion of responses to behaviours in dementia (13 – 15 min)

• Feedback collected after each session


(B) Main Pilot Intervention

• Case note review with care home managers identified PWD on AP

• Guide to appropriate AP prescribing Proforma• Cases selected for AP Withdrawal• Withdrawal plans shared with GP & Care Home• Withdrawal supervised by consultant &/or

Pharmacist• Withdrawal monitored by band 6 & 5 nurse• NPI-NH version at weeks 4 & 8


Video

Results

The Care Homes

Care Home

Designation Location Number of residents

A Residential care, Pinnacle Care Group, dementia Rugby 18

B Care Home, privately owned, dementia Rugby 26

C Residential care, Crosscrown Ltd., dementia, old age, learning difficulties

Rugby 26

D Supported Housing, Extra care, over 55 Coventry 58 bungalows

E Care Home with Nursing, privately owned,dementia, mental health, excl. learning disability, old age

Coventry 64

F Care Home, Southern Cross, dementia Coventry 30

G Residential care, Anchor, dementia, old age Coventry 40

H Nursing Home, privately owned, old age, Rugby 40


A total of 40 residents were taking anti-psychotic (AP) medication, in 8 Care Homes

A B C D E F G H0

1

2

3

4

5

6

7

8

9

10


5 of 8 Care Homes withdrew residents from AP medication

A B C D E F G H0

1

2

3

4

5

6

7

8

9

10

Number taking a/p medication = 40Number withdrawn from a/p medication = 16


Prevalence of AP Prescribing: 40/302 residents (13%)

A. Resi

dential

care,

demen

tia

B. Care

Home. Dem

entia

C. Resd

iental

care,

demen

tia

D. Supporte

d housing

E. Care

Home with

Nursing,

demen

tia

F. Care

Home, dem

entia

G. Resi

dential

care,

demen

tia

H. Nursi

ng home

0

10

20

30

40

50

60

70

Number on a/pNumber of residents


Characteristics of 40 residents prescribed AP

• Highest rates of AP prescribing in dementia specialist Care Homes

• Lowest in Extra Care Housing Unit (no prescriptions)

• Of these 40, 16 selected for Withdrawal • All 16 were PWD


N=16 Withdrawn off AP

Residents taking a/p - 40Residents withdrawn = 16


AP Prescriptions

N=16 people withdrawn from antipsychotics, the following had been prescribed (range of daily doses in mg/24hr in brackets)

• Quetiapine 8 prescriptions (25-100)• Risperidone 5 prescriptions (0.5-1.5)• Haloperidol 2 prescriptions (0.5)• Olanzapine 1 prescription (10)

In the 24 people not withdrawn the following had been prescribed

• Quetiapine 10 prescriptions (12.5-100)• Risperidone 8 prescriptions (0.25-4.0)• Haloperidol 1 prescription (1.5)• Promazine 1 prescription (100)• Chlorpromazine 1 prescription (50)• Flupenthixol 1 prescription (0.6)• Olanzapine 1 prescription (5)• Amisulpiride 1 prescription (50)


Characteristics of those withdrawn n=16


Reasons for Non-Withdrawal n=24

Schizophrenia, n = 4Bi-polar, n = 4Behavioural, n = 6Information not provided by GP, n = 9Not known, n = 1


Domains and scoring for NPI – NHin residents withdrawn off AP

Domain Frequency

1 2 3 4

Severity

1 2 3

Frequency + severity

Occupational disruptiveness

0 1 2 3 4 5

A. Delusions

B. Hallucinations

C. Agitation/ Aggression

D. Depression/ Dysphoria

E. Anxiety

F. Elation/ Euphoria

G. Apathy/ indifference

H. Disinhibition

I. Irritability/ Lability

J. Aberrant Motor Behaviour

TOTAL SCORE

Highest possible score = frequency + severity for each domain = 70Lowest possible score = 0Occupational disruptiveness – assessed by carer


NPI –NH Outcomes in residents withdrawn from AP

Identifier Baseline score

4 week score

8 week score

Outcome

A1 4 – 0 missing missing

A2 8 - 4 8 – 4 missing restarted



A5 17 – 5 21 – 10 12 – 06 restarted

E1 25 – 7 22 – 9 28 – 15 restarted

E2 0 – 0 0 – 0 0 – 0

E3 14 – 5 10 – 2 9 – 3

E4 2 – 0 0 – 0 0 – 0

F1 6 – 0 9 – 0 6 – 0

F2 2 – 0 11 – 5 4 – 2 restarted

F3 0 – 0 0 – 0 0 – 0

F4 12 – 5 12 – 4 9 – 2

F5 32 – 8 12 – 2 10 – 1

G1 0 – 0 0 – 0 0 – 0

H1 0 - 0 26 - 19 4 - 2 restarted


5/16 residents were restarted on AP within 4 weeks All were restarted because of ↑ BPSD

Residents withdrawn from a/p - 16Residents restarted = 5


11/40 (27.5 %) successfully withdrawn for 4 weeks


Evaluation of staff training

Training session were held in the 8 Care Homes that participated in the Pilot study.

6 Homes completed 2 sessions

2 Homes completed only 1 session

Home A, no record of second sessionHome H, cancelled second session - infection control closure to all but essential staff


Numbers of staff attending training sessions (by years of experience as carer)

Home Session one: Session two:

Over 3 years experience

Under 3 years experience

Over 3 years experience

Under 3 years experience

A 4 1

B 5 3 4 7

C 2 1 1 1

D 5 6 4 5

E 3 1 2 1

F 4 1 4 1

G 4 0 4 0

H 5 2

Total: 32 15 19 15


Evaluation of staff training

Evaluation of training completed by participating staff (same questions used for both sessions):

Question 1: the session was relevant to my jobQuestion 2: I learned something new from this sessionQuestion 3: I am glad I attended this sessionQuestion 4: The session was just the right length


Evaluation of Session 1Question Total

respondedStrongly

agreeAgree Don’t

knowDisagree Strongly

disagree

1 47 42 3 0 0 2

2 46 35 9 1 0 1

3 46 38 7 0 0 1

4 47 34 8 3 1 1

Question Total responded

Strongly agree

Agree Don’t know

Disagree Strongly disagree

1 25 18 2 5 0 0

2 25 19 4 2 0 0

3 25 19 3 3 0 0

4 24 14 7 3 0 0

Evaluation of Session 2


Staff responded positively to the training, they found it relevant and useful and expressed enthusiasm for

further teaching ‘education on medication was useful’

‘gained more understanding of behaviours in dementia

and would like more training in depth to support to give

the right skills to help people with dementia’

‘was very informative and descriptive with regards to dementia

and medication associated with it’

‘found it very informal- more of an insight to what my

residents are feeling’

‘was very interesting but also would like more training on medication; found it very informative and useful.’

‘would like more training to have better understanding to enable me to help people with dementia’

‘more training on dementia medication - also more in depth training about mood swings in relation to dementia ‘

‘more training with dealing with conflicts’

‘very informative’


Findings 1

AP all causes N=4013% (National 20%)

AP Dementia N=16Successful

Withdrawal N=11*Failed

Withdrawal N=5

AP Other N=24

* Broadly in keeping with Banerjee, 2009


Findings 2

• Care Home Staff Training Sessions were well attended & well received (high levels of confidence & staff satisfaction)

• Main Pilot Intervention:– Secondary prevention (Withdrawal of AP)– Replaced with individualised supervised non-

pharmacological interventions• Estimated £80,000 direct savings and £240,000

quality of life improvements per annum (Based on Burns & Chambers, 2011)


Findings 3

• Approximately 150 Care Homes in Coventry & Warwickshire

• If 3 band 6 CPNs targeted this population FT for 1 year

• They could provide 220x2x3 half day visits = 1320 visits/year, or 8 – 9 half day visits per Care Home

• Enough to screen all residents, run 2 training sessions for care homes’ staff, monitor eligible residents at least twice, and offer some interventions


Findings 4

• Our model would successfully secure an extra 285 PWD off AP

• In doing so: – prevent 2 – 3 extra deaths, 2 – 3 extra strokes, 15

– 25 gait disturbances per year – reducing new prescriptions – enhancing staff skills all round


Conclusion

• Safe• Secondary Prevention Model• Clinically & cost effective• Specialist intervention• Easily reproducible• Improves experience & QoL for PWD


Recommendations

• Suited for localities seeking to redesign the interface with Care Homes & Primary Care

• Reducing inappropriate prescriptions of Psychotropic drugs?

• Consider other configuration e.g. Band 3 healthcare support worker for follow-up role (2.5WTE band 6 & 0.5wte HCA)


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Health & Medicine

Reducing Antipsychotics for People with Dementia in Care Homes