Prescribing for people with dementia - Carol Paton 262.2 KB

Do we do this?Medication review at treatment initiation (n=1897)100%90%80%70%60%50%40%30%20%10%0%3721525Documented in mental health clinical notesNo record in mental health clinical notes• A medication reviewshould be conductedbefore a diagnosis ofdementia is made.• This was not done in20%• 6% of the total samplewere prescribedanticholinergic drugs

ÃÎÑÒ Ð ÈÑÎ 15516—2011ÍÀÖÈÎÍÀËÜÍÛÉ ÑÒÀÍÄÀÐÒ ÐÎÑÑÈÉÑÊÎÉ ÔÅÄÅÐÀÖÈÈÑóäà è ìîðñêèå òåõíîëîãèèÑÏÓÑÊÎÂÛÅ ÓÑÒÐÎÉÑÒÂÀ Ñ ËÎÏÀÐßÌÈ ÄËß ÑÏÀÑÀÒÅËÜÍÛÕ ØËÞÏÎÊShips and marine technologies. Launching appliances for davit-launched lifeboatsÄàòà ââåäåíèÿ — 2012—07—011 Îáëàñòü ïðèìåíåíèÿÍàñòîÿùèé ñòàíäàðò ñîäåðæèò òðåáîâàíèÿ ê ðàáî÷èì õàðàêòåðèñòèêàì, ïðîåêòèðîâàíèþ,êîíñòðóêöèè, áåçîïàñíîñòè, òåõíè÷åñêîìó îáñëóæèâàíèþ è èñïûòàíèþ ñïóñêîâûõ óñòðîéñòâ, â êîòîðûõèñïîëüçóþòñÿ øëþïáàëêè ñ ëîïàðÿìè äëÿ ñïóñêà è ïîäúåìà ñïàñàòåëüíûõ øëþïîê.Íàñòîÿùèé ñòàíäàðò ðàñïðîñòðàíÿåòñÿ íà ñïóñêîâûå óñòðîéñòâà ñ èñïîëüçîâàíèåì øëþïáàëîê ñëîïàðÿìè äëÿ ñïàñàòåëüíûõ øëþïîê âñåõ òèïîâ ìîðñêèõ ñóäîâ, âêëþ÷àÿ ñïóñêîâûå óñòðîéñòâà äëÿ ñêîðîñòíûõäåæóðíûõ øëþïîê ïàññàæèðñêèõ ïàðîìîâ. Òàêæå íàñòîÿùèé ñòàíäàðò ðàñïðîñòðàíÿåòñÿ íààíàëîãè÷íûå óñòðîéñòâà ñóäîâ âíóòðåííåãî ïëàâàíèÿ. Íàñòîÿùèé ñòàíäàðò íå ðàñïðîñòðàíÿåòñÿ íàñïóñêîâûå óñòðîéñòâà äëÿ ñâîáîäíîïàäàþùèõ ñïàñàòåëüíûõ øëþïîê.Ï ð è ì å ÷ à í è å — Êàæäîå ïîëîæåíèå íàñòîÿùåãî ñòàíäàðòà, åñëè ÿñíî íå çàÿâëåíî èíà÷å, òàêæå ïðèìåíÿåòñÿê ñïóñêîâûì óñòðîéñòâàì ñî øëþïáàëêàìè äëÿ äåæóðíûõ øëþïîê, ïðåäíàçíà÷åííûõ äëÿ ñïàñàíèÿ æèçíè â÷ðåçâû÷àéíîé ñèòóàöèè íà âîäå.2 Íîðìàòèâíûå ññûëêè íàñòîÿùåì ñòàíäàðòå èñïîëüçîâàíû íîðìàòèâíûå ññûëêè íà ñëåäóþùèå ñòàíäàðòû:ÈÑÎ 2944 Ïðèâîäû ãèäðàâëè÷åñêèå è ïíåâìàòè÷åñêèå è èõ ýëåìåíòû. Íîìèíàëüíûå äàâëåíèÿ(ISO 2944, Fluid power systems and components — Nominal pressures)ÈÑÎ 3828 Ñóäîñòðîåíèå è ìîðñêèå ñîîðóæåíèÿ. Ïàëóáíûå ìåõàíèçìû. Ñëîâàðü òåðìèíîâ èîáîçíà÷åíèÿ (ISO 3828, Shipbuilding and marine structures — Deck machinery — Vocabulary and symbols)ÈÑÎ 4413 Ãèäðàâëèêà. Îáùèå ïðàâèëà è òðåáîâàíèÿ, êàñàþùèåñÿ ãèäðàâëè÷åñêèõ ñèñòåì(ISO 4413, Hydraulic fluid power — General rules and safety requirements relating to systems)ÈÑÎ 4414 Ïíåâìàòèêà. Îáùèå ïðàâèëà è òåõíèêà áåçîïàñíîñòè, êàñàþùèåñÿ ïíåâìàòè÷åñêèõñèñòåì è èõ êîìïîíåíòîâ (ISO 4414, Pneumatic fluid power — General rules and safety requirements relatingto systems)ÌÝÊ 60092 (âñå ÷àñòè) Ýëåêòðîîáîðóäîâàíèå ñóäîâ(IEC 60092 (all parts), Electrical installations in ships)ÌÝÊ 60529 Ñòåïåíè çàùèòû, îáåñïå÷èâàåìîé êîðïóñàìè (êîä IP) (IEC 60529, Degrees of protectionprovided by enclosures (IP Code))3 Òåðìèíû è îïðåäåëåíèÿ íàñòîÿùåì ñòàíäàðòå ïðèìåíÿþòñÿ òåðìèíû ïî ÈÑÎ 3828, à òàêæå ñëåäóþùèå òåðìèíû ñ ñîîòâåòñòâóþùèìèîïðåäåëåíèÿìè:Èçäàíèå îôèöèàëüíîå1

NICE: the controversyJudicial review• Rigid adherence to MMSE scores of 10-20 discriminatedagainst those who had a learning disability (DisabilityDiscrimination Act) or whose first language was not English(Race Relations Act).• The HTA has been revised to incorporate these points.• The NICE guideline on the treatment of dementia (2006)recommends that when assessing patients for treatment,MMSE scores are used as a guide only.

Impact of NICE guidanceMMSE score at treatment initiation (n=1897)

TNAccess to treatmentEstimated proportion of people with dementia in each PCTpopulation receiving treatment with an anti-dementia drug60%50%40%30%20%10%0%8.28.320.140.127.251.451.28.456.119.228.18.12.151.359.28.617.125.327.119.359.125.127.359.616.128.25.320.46.259.322.259.529.15.15.25.429.516.212.259.429.422.122.329.320.36.129.220.28.512.125.212.319.151.1PCT codeProportion of patients treated

Before prescribing a memory enhancing drugScreening and assessment at initiation of treatment

Which drug to choose?Donepezil•Selective inhibitor of AChE•First available and once dailyRivastigmine•Inhibits AChE and BuChEGalantamineSelective inhibitor of AChE•Agonist at nicotinic receptorsNo difference in efficacy or tolerabilityMemantine•NMDA antagonist

Managing ‘behaviours that challenge’• Group of non-cognitive symptoms• psychosis• mood disorders• agitation/aggression• resistive behaviours• shouting• wandering/pacing• Affect 50-80% to some degree as dementia progresses

Managing ‘behaviours that challenge’Management:• check physical health (constipation, pain, infection etc)• adapt surroundings (if possible)• ? depression• aromatherapy• antipsychotics

Managing ‘behaviours that challenge’Antipsychotics• traditionally widely used• association between risperidone and stroke/stroke likeevents (2004). RR=3, AR=1% or so.• olanzapine then other antipsychotics implicated• RCTs showing that the effect size was small• discontinuation studies find that most patients can stoptreatment with no adverse consequences• antipsychotics are not recommended as a routineintervention by NICE• need to document indication and review regularly• risperidone now licensed for short term management ofBPSD (up to 6/52)

Always a last resortThe proportion of residents prescribed anantipsychotic for BPSD per care homeHomeleigh (N=15)Oaks (N=105)Percent (%)45%40%35%30%25%20%15%10%5%0%1EMI homes nursing & residentialAdelaide (N=42)Abbotsleigh Mews(N=60)Parkview (N=67)Cedar Court (N=47)Malborough (N=28)Dovedale (N=46)Northbourne Court(N=60)Sunrise (N=40)

Summary1. Try to avoid prescribing anticholinergics drugs in the elderly2. Before prescribing antidementia drugs• Physical examination and lab tests to rule out treatablecauses• Use the MMSE only as a guide3. Managing behaviours that challenge• Exclude/treat physical illness• Ensure risks of antipsychotics are understood• Regularly review

Medicines InformationQuestions about psychiatric medicines?For staff• Telephone 01322 625002• Monday – Friday 9am-5pm• e-mail medicinesinfo@oxleas.nhs.uk

Oxleas Medicines LineFor Service Users and Carers01322 621 062Line open Monday – Friday, 2 - 4 pmTo speak to a pharmacist about medicines.