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Theme: Mental Health & Dementia
This review was led by the Evidence Synthesis Team.
Antipsychotic medications are often prescribed to manage symptoms like aggression, wandering, anxiety, depression, agitation and screaming in people with dementia. However, several large studies have shown that these drugs can cause serious side effects in people with dementia. Treatment guidelines recommend that before antipsychotics are used, the possible underlying causes of symptoms (e.g. hunger, thirst, pain, loneliness) are identified and treated and the use of alternative non-drug treatments is explored. Lots of different initiatives have been used to reduce the unnecessary prescribing of antipsychotics but it isn’t clear which of these works best.
The research was a systematic review. This brings together all existing research on a particular question. To find studies that might help us to answer the question we searched the relevant academic literature.
We found 22 studies from the United States, UK, Canada, Australia, Norway and Sweden.The studies ranged in size, from the smallest which included 21 people with dementia to a study which included 7000 people. Eleven studies assessed the effectiveness of an educational programme, four studies assessed a system of regular medication review, two studies involved multi-disciplinary teams visiting the care home and working with the staff and five studies included a range of different components.
A variety of initiatives have been used to limit the unnecessary use of antipsychotic medications in people with dementia living in care homes.
The most robust studies show that it is possible to reduce unnecessary prescribing of these medications in the short term.
There has been very little research to understand how to sustain these changes in the longer term.
We had hoped to explore which features of initiatives or approaches to changing practice worked better, but because of the relatively small number of robust studies in each category we were unable to do this. On a practical level, it is therefore not possible to make specific recommendations about which initiatives might be worth pursuing in the care home setting.
The evidence in this review suggests that the current guidelines to limit antipsychotic prescribing are difficult to implement in the day-to-day reality of practice, whilst juggling ethical concerns, staffing levels, staff competence with non-drug alternatives, and the wishes of distressed relatives and carers.
More information about efforts to reduce the unnecessary use of antipsychotic medications in people with dementia can be found in the Alzheimer’s Society position statement on antipsychotics in the Policy section of their website.
The National Institute of Health Research recently funded a 5-year programme of work (the WHELD project) to develop an intervention to improve the wellbeing of people living in care homes. Part of this work involved reducing unnecessary prescribing of antipsychotic medications. The researchers have developed a training package for care home staff. More details about this project can be found on their website.
Nick Cartmell, Stephen Pearson