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Medicines management: Dementia

Medicines management: Dementia

4 September 2013

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The scale of the problem of Alzheimer’s disease and dementia makes these conditions a significant financial burden

The scale of the problem of Alzheimer’s disease and dementia makes these conditions a significant financial burden
This article looks at the role that medicines management has to play in optimising care within the care home setting in older people with history of dementia for three reasons. Firstly, medicines use and procurement is one of the twelve quality, innovation, productivity and prevention (QIPP) priority areas and one of the few areas which is within direct control of the GP prescriber, therefore presenting opportunities to achieve rapid impact in terms of outcomes and spend Secondly, medication is one of the NICE quality standards for dementia in adults.Finally, the new GP led commissioners have a unique opportunity to shift the emphasis of medicines management away from purely cost savings, to quality and outcomes balanced against expenditure, keeping patients well, out of hospital and extending their quality and length of life.
Dementia is a disease that costs relatively little in the way of medication but presents a significant financial burden on the NHS and the economy due to the care associated with dementia related complications. Complications develop due to the natural progression of the disease, but also due to lack of lifestyle modification, poor medication adherence and monitoring of the patient to evaluate the effectiveness of current treatment.
Scale of the problem
There are 800,000 people with dementia in the UK with numbers set to rise to over million by 2021. This will soar to 1.7 million by 2050.1 One in three people over 65 will die with dementia and more than 60% of all care home residents aged over 65 have a form of dementia. There are over 17,000 people under 65 with dementia in the UK, and it affects 11,000 people from black and minority ethnic groups in the UK. Dementia costs the UK over £23 billion a year and this figure will rise to £27 billion per annum by 2018.1 Unpaid carers supporting someone with dementia save the economy £8 billion a year. Dementia is one of the main causes of disability later in life, ahead of cancer, cardiovascular disease and stroke. As a country we spend much less on dementia than on these other conditions.1
The challenges
Reports by the Care Commission and the Department of Health, care home use of medicines study (CHUMS) published in 2009 highlighted deficiencies in the provision of pharmaceutical care to care home residents.2
The Care Commission reported little evidence of medication reviews by GPs or pharmacists. It recommended that health boards should consider introducing regular visits and support from pharmacists to improve knowledge of medication management.2
CHUMS recommended that pharmacists should regularly review residents and their medication every six months and that they should also rationalise regimes to help home staff work more safely. Through this, pharmacists should identify and reduce the number of dispensing and administration errors. There was an unacceptable prevalence of medication errors in care homes, affecting some of the most vulnerable members of society. Action is required from all concerned.2 It looked at 256 patients in 55 homes. The prevalence of error was one hundred and seventy-eight – 69.5% of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively.2
Similarly, in 2009, Professor Banerjee, an expert in old age psychiatry at King’s College London, conducted the review of antipsychotic drugs, and as part of the priority being given to improving care for people with dementia. According to the Banerjee reports, if 1,000 patients were treated for 12 weeks for behavioral and psychological symptoms of dementia (BPSD) there would be 18 extra strokes, 10 deaths and 70 gait problems in these patients.3
The evidence has indicated that antipsychotic drugs are only partially effective at reducing agitation and behavioural problems in people with dementia, however, for the last five years there has been clear evidence that antipsychotic drugs can increase stroke and cardiovascular risk in these patients, eg DTB 2007;45:81-5. The Government welcomed the independent clinical report prepared by Professor Sube Banerjee on the prescribing of anti-psychotic drugs to people with dementia, and accepted the conclusions and recommendations he has reached. The report was commissioned by the Government in recognition of well-known concern about the over-prescription of these drugs, and as part of the priority being given to improving care for people with dementia.4  All clinical decisions to prescribe anti-psychotic drugs to people with dementia should be taken on the best evidence available, with proper regard to the existing NICE guidance. NICE guidance makes clear that people with dementia should only be offered anti-psychotics if they are severely distressed or there is an immediate risk of harm to the person or others.5 Antipsychotic prescriptions to people with dementia cost the UK £60 million per annum.1 Alzheimer’s Society research shows that person centred care can reduce these costs by half, saving £30 million a year.1 Alzheimer’s Society estimates that the antipsychotic drugs are inappropriately prescribed to over 100,000 people in care homes and many more in other care settings around the country.1
Role for medicines management
The true costs of dementia in England are not known. In cost-of-illness studies, the direct costs of Alzheimer’s disease alone exceed the total cost of stroke, cancer and heart disease. It was estimated that the direct costs in the UK of Alzheimer’s disease alone were between £7.1 billion and £14.9 billion in 2000. (Lowin et al, 2001). In 2003-4, the NHS spent around 43% of its hospital and community health service budget (£16.471 billion) on people over the age of 65. In the same year social services spent nearly 44% of its budget (£7.38 billion) on people over the age of 65. The figures are set to rise (‘Everybody’s business’, 2005). £600 million is spent on antipsychotic drugs per annum in the UK for patients with dementia, these drugs have severe side effects in some patients leading to falls, stroke and gait problems. Therefore the value to be gained from a local Medicines Management strategy is in supporting the GP practice in keeping patients out of hospital, optimising treatment and monitoring progress and patient outcomes, and improving quality and prescribing safely and appropriately in these patients.
How best to prescribe for dementia 
 – Avoid cascade prescribing.
 – Avoid improper use of antipsychotics in BPSD.
 – Avoid long term benzodiazepine prescribing review patients regularly. 
 – Prescribe spacer devices for inhalers for proper drug delivery.
 – Avoid polypharmacy – try and stick to the principle of one condition, one drug once a day. 
 – Consider drug interactions, eg. drugs with narrow therapeutic index such as warfarin, digoxin etc.
 – Assess pain using appropriate pain assessment tool.
Case study: medication review in care home patients
Mrs X is a 78-year-old female patient 
BMI of 20kg/m2
Blood pressure – 120/60 
Alcohol – 45 units a week
Smoking – 20 a day – attempting to stop 
Diagnosis: Alzheimer’s disease (AD), hypothyroidism, musculoskeletal symptoms, history of alcohol abuse, history of fall and fractures.
About 6 years ago she was diagnosed with AD. At the last review her condition was categorised as moderate to severe. She was prescribed donepezil 5mg to be tried for six months with a plan to review after every three months.
Question 1
Her mental and physical health has deteriorated significantly in the last six months, and she is unable to do much for herself. She used to be a well-mannered, gentle and cheerful lady. However, over last six months she has become very withdrawn, extremely grumpy and agitated; she sometimes becomes distressed and abusive when the carer tries to help her. Sometimes, she shouts obscenities loudly, especially at bedtime, as if she was having an argument with someone imaginary in the room. Carer asked her GP for a home visit. Are these behaviour symptoms characteristic of Alzheimer’s disease?
Common behavioural symptoms of Alzheimer’s include sleeplessness, agitation, wandering, anxiety, anger, and depression. Treating behavioural symptoms often makes people with Alzheimer’s more comfortable and makes their care easier for caregivers. Behavioural and psychological symptoms (commonly known as BPSD), or according to NICE & SCIE Dementia Guidelines CG42, they are referred to as non-cognitive symptoms and behaviours. This encompasses a wide range of complications that are experienced by people with dementia.5
Question 2
Is it advisable for the GP to prescribe an antipsychotic drug given at bedtime to control the behavioural symptoms?
It is not advisable to prescribe an antipsychotic drug for this patient due to the increased risk of stroke associated with the use of antipsychotics. (See above – Banerjee report). Non-pharmacological measures should be used in the first instance.5 Anti-psychotic drugs should only be used in circumstances where there is severe distress or immediate risk of harm to the person with dementia or others5 Use of antipsychotics in mild to moderate non-cognitive symptoms can increase the risk of cerebrovascular events and death; therefore should not be used. She should be referred for further assessment and a care plan to help carers to address her behaviour should be developed and reviewed regularly. This should be clearly recorded in her notes.
Question 3
When should the GP consider antipsychotics in this patient? 
The main issue in Mrs X’s case is the risk- benefit ratio for the use of antipsychotics. NICE guidelines advise antipsychotic drugs can be considered for patients with Alzheimer’s disease presenting severe non-cognitive behaviour symptoms under the following conditions: 
 – Following a full discussion with the patient or carer regarding the risks and benefits of the treatment with antipsychotics.
 – Assessing and recording the changes in cognition  and target symptoms at regular intervals.
 – Consider co-morbidity, eg. depression.
 – Choose the antipsychotic after careful assessment of risk versus benefits. Start with the lowest dose and titrate.
 – Review treatment regularly and time limit to every 3 months or according to clinical needs.5
 – Risperidone is the only anti-psychotic licensed for BPSD for short-term use, six weeks however, NICE CG 42 states no longer than 12 weeks. 
Question 4
Should this patient continue taking donepezil? 
Donepezil is indicated for mild to moderate dementia in Alzheimer’s disease. This patient needs to be reviewed and donepezil stopped if no benefits seen. Donepezil, galantamine, and rivastigmine can be used for the treatment of mild to moderate Alzheimer’s disease. Memantine can be used for moderate Alzheimer’s disease in patients who are unable to take acetylcholinesterase inhibitors, and for patients with severe disease; combination treatment with memantine and an acetylcholinesterase inhibitor is not recommended. Treatment should only be prescribed under the following conditions:
Alzheimer’s disease must be diagnosed and treatment initiated by a specialist; treatment can be continued by general practitioners under a shared-care protocol; the carers’ views of the condition should be sought before and during treatment; treatment should continue only if it is considered to have a worthwhile effect on cognitive, global, functional, or behavioural symptoms.
Healthcare professionals should not rely solely on assessment scales to determine the severity of Alzheimer’s disease when the patient has learning or other disabilities, or other communication difficulties. Refer to NICE guidance.
Question 5
Should Mrs X continue taking citalopram tablets?
Antidepressants and dementia (Lancet 2011;378:403). Depressive symptoms are common in patients with dementia and antidepressants are frequently prescribed however there is no strong evidence. This UK-based double-blind placebo controlled trial looked at this problem. 
No difference was found in reduction in depression score between those receiving placebo and those receiving mirtazapine or sertraline. 
The authors conclude that antidepressants are associated with harms and are no better than placebo; hence they should not be prescribed as a first line treatment for depression in dementia. 
Referral to specialist services for watchful waiting and low-grade psychosocial interventions is recommended.
Question 6 
Would you stop antidepressant citalopram tablets?
(BMJ 2012; 344:e1566) Mrs X’s antidepressant can be stopped; this study shows stopping antidepressant in dementia does not lead to deterioration in symptoms for the majority of patients.
Mrs X needs to be advised on lifestyle modifications such as reducing alcohol intake, and encourage smoking cessation. She also needs to be assessed on her compliance to medication by educating her on the implications of not taking them.
Her blood pressure needs to be monitored. NICE recommends if the systolic blood pressure falls by 20 mmHg or more when the person is standing: 
 – Review medication.
 – Measure subsequent blood pressures with the person standing.
 – Consider referral to specialist care if symptoms of postural hypotension persist.7
Do not prescribe antidepressants first line because the harms exceed the benefits. Refer to old age psychiatry so that they can receive psychosocial intervention and carer support.
Discussion Points
 – The pharmacists are in ideal position to address concerns and issues arising from the treatment initiated by GPs. A good two-way communication between the GP and the pharmacist in this case has brought about excellent patient-orientated outcome.
 – Resperidone is the only antipsychotic licensed for short-term use to control BPSD. 
 – Lifestyle interventions are crucial in this patient’s care and symptom management especially to prevent fractures due to falls.
 – Regular medication review is important to ensure safe and cost-effective management and correct monitoring and treatment of patient’s condition.
 – Review plans should be recorded in patient records along with the specific care plan for each individual patient in the care home.
Mrs X is a lot better managed now and was offered cognitive stimulation therapy sessions. She was referred to alcohol anonymous and had stopped smoking as well. Donepezil, amlodipine and nitrazepam were stopped and she is much happier, alert and cheerful now. 
There was a potential cost saving of £1069.44, and her medication regime was simplified.
 3. Government response to Banerjee report. 
 5. NICE Clinical Guideline 42
 7. NICE Clinical Guidance Hypertension.

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