Dr Les Rudd NLIAH Rhiannon Davies Powys tHB...Improved quality of general hospital care for people...
Transcript of Dr Les Rudd NLIAH Rhiannon Davies Powys tHB...Improved quality of general hospital care for people...
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Appropriate Prescribing of Antipsychotics
in dementia care
Medicines Management & Dementia Care
target 3 collaborative
Dr Les Rudd NLIAH
Rhiannon Davies Powys tHB
1000+Lives improvement
measures in mental health• Depression in General Hospital settings
• First Episode Psychosis
• Eating Disorders
• Dementia 1) making and sharing the diagnosis
reduce time between onset of symptoms & diagnosis being communicated
2) dementia in the general hospitalImproved quality of general hospital care for people with dementia
and reduced length of stay
3) use of anti-psychoticsReduced inappropriate use of anti-psychotic medications in
accordance with NICE/SCIE guidelines.
4) support for care-giversImproved support for care givers
5) NHS in-patient care (mental health units) Improved quality of care
WG Dementia Policy - Summary • WAG National Dementia Vision for Wales – launched
on 16th February national conference
• WAG 2011-12 Annual Quality Framework (AQF)priority for implementation of the Dementia Intelligent Target.
• WAG Dementia Care Intelligent Targets – The 5 targets were developed in 2010 and Health Boards are currently planning for their phased implementation for 2011/12. They are not performance management targets.
• Dementia Action Plans 2010-2015 – Four plans focussing on:-1. Improved service provision through better joint working across health,
social care, the third sector and other agencies, including:
2. Improved early diagnosis and timely interventions
3. Improved access to better information and support for people with the illness and their carers
4. Improved training for those delivering care & greater awareness of need for advocacy
Up-date on implementation
2011
• AQF 2011-12 required HB ‘delivery of Dementia
and Depression care bundles based on clinical
and patient outcomes’.
• WG £1.5m pa funding to develop services for
younger people with dementia & Dementia Advisor posts
• Increase training capacity & expertise in Wales
– DSDC Wales commissioned (Dec. 2010 – April 2012)
to lead programme for ‘Train the trainers’ -
identification, training and development of champions
in dementia care settings
Up-date on implementation
2011
• Dementia sub-group of Mental Health Programme Board established– Chaired by Director of Social Services for Wales, Rob
Pickford
• Wales Dementia Helpline– New bilingual helpline available 24/7
– www.dementiahelpline.org.uk
• Book prescription Wales– 4 dementia books added
• With Alzheimer’s Society– Dementia information packs for issue to patients
diagnosed with dementia
– National campaign to raise awareness
1st April Letter to CEO’s
• As you know, one of the aims of our mental health standards is to drive more effective integration of physical and mental health care, such as where we have evidence of increased lengths of inpatient stay due to co-morbidity. This is a particular feature of the depression and dementia standards, which include a focus on improving early diagnosis/case identification, treatment and care in General Hospital ward settings. We are experiencing difficulty in some localities in accessing General Hospital wards to pilot our mental health standards and I would appreciate your support in prioritising access. Note: Could you therefore forward this letter to your Medical Director and 1000Lives Executive leads to help action this with your mental health clinical leads.
Introduction
• National Institute of Clinical Excellence (NICE) in
its clinical guideline (2006) sets out effective and
appropriate guidance regarding antipsychotic
usage.
• The use of antipsychotics should be a last
resort, to be used at times of severe distress or
critical need.
Introduction
Following an enquiry into the prescription of
antipsychotic drugs to people with dementia
living in care homes, the All-Party Parliamentary
Group on Dementia noted that inappropriate
and overprescribing was clearly a significant
problem (‘Always A Last Resort’ - April 2008).
1000Lives plus
Medicines Management/Driver 3 Mini-
collaborative -
Appropriate Prescribing of Antipsychotics
in Care Homes
May 2012
Rhiannon Davies, Powys tHB,
Pharmaceutical Adviser
Overview
2nd Dem3/Meds mgt Mini-collaborative
Learning event – May 1st 2012
Emphasis in sharing ‘good practice’
All Health Boards represented
Varying degrees of progress and
engagement with the initiative
Varying models of delivery within the pilot
schemes
BPSD
Defined as symptoms of disturbed perception,
thought content, mood or behaviour that
frequently occurs with dementia:
Disinhibited behaviour
Delusions and hallucinations
Verbal and physical aggression
Agitation
Anxiety
Depression/Apathy
Key messages
Non-pharmacological options are
recommended (NICE, 2006) as the first-
line approach to BPSD
Unless a person is at risk to
themselves or others
If the approaches do not help the
person and their symptoms are severe
or distressing, medication may be
necessary
Key messages
90%of people with dementia will experience
BPSD
Sudden emergence of BPSD often has a
physical trigger
Individual biography, side effects of
medication, psycho social factors, physical
environmental factors also influence
behaviour
Most BPSD will stop after 4 weeks without
pharmacological treatment
Key messages
Develop an individually tailored care
plan to help carers and staff address
the behaviour that challenges
The importance of working with health
care workers and care home staff to
change entrenched/inappropriate
attitudes and behaviours through
training
Numbers of people with dementia by local authority
with projections to 2021 Source: Dementia UK Report, 2007
0 500 1000 1500 2000 2500 3000 3500 4000 4500
CardiffSwansea
RCTCarmarthenshi
ConwyPowys
GwyneddWrexham
Neath P TalbotCaerphilly
PembrokeshireDenbighshire
FlintshireVale of Glam
NewportBridgend
TorfaenMonmouthshir
CeredigionAngleseyBl Gwent
Merthyr Tydfil
2006
2021
South Powys, Pilot Project
Multidisciplinary team:
GP – Brecon Medical Practice
Nursing Home – Mountains EMI
Nursing Home and Brookside dual –
registered Care Home
CMHT – Consultant
Powys tHB - Medicines Management
team pharmacist
Recognised strengths
Enthusiasm and commitment of all those
involved. Already started reductions. Open to
new ideas.
Good working environment – staff feel valued,
low staff turn-over rate.
Care home staff informed, involved and fully
engaged.
Active activities officer working within the care
home.
Good interaction with families.
Issues identified
Discharge from hospital wards to care homes:
information delay and level of antipsychotic
prescribing
Three monthly review: responsibility - CMHT/GP
role?
Education: GP & Care home staff (perceptions and
attitude)
Need for non-pharmacological treatments/holistic
care approach/person-centred activities
Need for multi-agency approach and improved
communication
Interventions
In –house training (care homes/ GP practices)
Use of Alzheimer Society’s best practice guidelines
Care home support for behavioural interventions
Care home BPSD monitoring checklist, adapted
behavioural chart, pain management and sleep
charts
Better coordinated review procedures
Patient/carer leaflet – Alzheimer Society booklet
Staff information posters – care homes, hospital
wards, CMHTs, GP practices
Improved formalised links between CMHT and care
homes. Improved communication.
Data collection and Outcome
measure
Data collected every 3/12• Number of patients who have a diagnosis of
dementia
• %age patients who are receiving an antipsychotic
• % compliance with care bundle (all 6 interventions
documented)
• % of patients with dementia who have been
receiving antipsychotic medication for more than
9 months
DDD/1000 PUs for the agreed basket of
antipsychotics
Current situation
Regular meetings with care homes to assess
outcome of interventions (PDSA cycles)
On-going dialogue with lead GP and lead
Consultant
Initiative extended into a dual-registered
home
Baseline audit and 2 further audits
Plan to begin extending the initiative in to
other care homes
Mountains re-audit
Aug11: Total no. of residents prescribed antipsychotics for
dementia = 16/30
Nov11:
1 resident excluded from audit
1 resident deceased
1 resident dose increase
5 residents dose remained on same dose
1 resident dose reduction
7 residents stopped antipsychotic medication*
No residents newly initiated
1 dementia patient newly come in to home on an antipsychotic.
Reviewed and stopped.
Total number = 7/30
Feb12 Total number remains at 7
Brookside Care Home
Sept 11: Total no. of residents diagnosed with
dementia and prescribed antipsychotics for
dementia = 6/16
Nov11: 2 residents excluded from audit
1 resident deceased
1 resident dose remained on same dose
2 residents stopped antipsychotic medication*
No residents newly initiated
Total number =1/16
Feb12: Total number remains at 1
Baseline data
Out of 22 patients:
• 90%, documented indication
• 70% documented discussion re risk and benefits
• 75 % ‘best interest’ process followed
• 40% reviewed in past 6 months
• 50% attempt to reduce
• 45% other approaches tried
15 % compliance with care bundle
80% taking meds for longer than 9 months
After 6 months..
Out of 8 patients:
• 100%, documented indication
• 100% documented discussion re risk and
benefits
• 100 % ‘best interest’ process followed
• 60% reviewed in past 6 months
• 60% attempt to reduce
• 85% other approaches tried
85% compliance with care bundle
60% taking meds for longer than 9 months
Outcome Measure: Brecon
practice
0
10
20
30
40
50
60
70
80
90
100
DD
DsP
er1
00
0P
Us
Period
Antipsychotics DDDs/1000PUs
RICKETTS AL - 603352 (DB1)
Powys - 6039015 (DB1)
Outcome measure:
Powys
0
20
40
60
80
100
120
Ma
r-1
0
Ap
r-1
0
May
-10
Jun
-10
Jul-
10
Au
g-1
0
Sep
-10
Oc
t-1
0
No
v-1
0
De
c-1
0
Jan
-11
Feb
-11
Ma
r-1
1
Ap
r-1
1
May
-11
Jun
-11
Jul-
11
Au
g-1
1
Sep
-11
Oct
-11
No
v-1
1
De
c-1
1
DD
DsP
er1
00
0P
Us
Period
Antipsychotics DDDs/1000PUs
Aneurin Bevan - GP - 601 (DB1)
Cardiff And Vale Uni - GP - 602 (DB1)
Hywel Dda - GP - 603 (DB1)
Betsi Cadwaladr Uni - GP - 604 (DB1)
Abertawe Bro Morgannwg Uni - GP - 605 (DB1)
Powys Teaching - GP - 606 (DB1)
Cwm Taf - GP - 607 (DB1)
Next steps
Using the learning experience: Initiate a pilot scheme in North Powys involving a
Nursing home, GP practice and CMHT and
psychologist
Spread to other care homes in South Powys
Establish an education and support programme for
GPs
Establish an education and support programme for
Care homes
Undertake an economic evaluation of alternatives to
antipsychotic drugs for individuals living with
dementia in Powys
Economic evaluation
NHS Matrix Evidence document, October 11
Key messages:
Behavioural interventions provide good value for
money vs antipsychotic prescribing
Estimated that healthcare cost savings due to
reduced incidence of stroke and falls, outweigh the
increased cost of the intervention.
In England, estimated annual net benefits are £55
million
These figures are based on a total population of
134,000 dementia patients currently using
antipsychotics
Next steps....
Who is the clinical lead in your Health
Board for this Driver3/Meds Mgt
collaborative?
What progress has been made?
Is the health board taking a multi-
disciplinary approach?
What additional support is needed?
Encourage the sharing of good practice
Please let us know if you
need any support.
THANK YOU!
078 666 79064
Rhyngrwyd/Internet:
www.iechydcyhoedduscymru.wales.nh
s.uk www.publichealthwales.org
Mewnrwyd/Intranet:
nww.publichealthwales.wales.nhs.uk
Twitter: www.twitter.com/1000livesplus