Dr Fiona Stormont Consultant Psychiatrist Sutton CMHT for Older People South West London and St George’s Mental Health NHS Trust Mental Health in Primary Care - 22.06.11 Why the concern?? What to do…… Challenging Behaviour Service Antipsychotic medication Older drugs: eg. chlorpromazine, haloperidol, promazine, stelazine, sulpiride, (thioridazine) Newer drugs (the “atypicals”): eg. olanzapine, quetiapine, aripiprazole, risperidone Indications: psychotic symptoms in schizophrenia and bipolar affective disorders Problems with using antipsychotics in context of dementia Stroke – x3 risk Mortality rate Speeds up cognitive decline Little evidence of benefit Why? Not the target population for these drugs Older, frailer More sensitive – Parkinson’s Disease, movement disorders, cardiac problems Increased comorbid physical illness Increased polypharmacy Wider context 700 000 people with dementia in the UK 180 000 people with dementia treated with antipsychotic medication per year ? 36 000 will get some benefit ? two-thirds may not need them ..... extra 1 800 deaths ..... extra 1 620 strokes (1/2 of which will be severe) “a specific symptom of a general cumulative failure over the years in our health and social care systems to develop an effective response to the challenges posed by dementia……” “our current systems have grown by chance rather than by active planning or commissioning” The use of antipsychotic medication for people with dementia: Time for action (2009) Drugged into oblivion: the shocking truth of how the elderly are treated in our care homes – Oct 2007 23,000 care home residents 'killed by chemical cosh‘ of dangerous tranquillisers – Apr 2008 'Chemical cosh' drugs given to dementia patients, nurses admit – Oct 2009 Curb dangerous chemical cosh drugs for dementia victims – Oct 2010 Behavioural and psychological symptoms in dementia (BPSD) Agitation Verbal aggression Physical aggression Wandering Sleep disturbance Depression Psychosis Apathy Shouting Hoarding Repeated questioning Sexual disinhibition Care home factors: eg staff (attitudes, training, tolerance levels) activities within the home care home environment level of appropriate social interaction Personal factors: eg boredom, overstimulation personal history, likes and dislikes The behaviour: description from carers (when, where, how often, what has happened just before, consequences). Risks and severity. Screening for treatable physical problems: delirium, pain, constipation, medication side effects. Mental state review Medication: not first line…… Only if significant risk to self / others, or severe distress. • Risk/benefit profile • Discuss – family, patient where possible • Target • Titrate the dose (‘start low, go slow’) • Time limited trial (3 months) • Review for side effects “The key to the prescribing issue, I think is because if care home staff can't cope then we feel obliged to help them with a quick fix…. ……in fact, GPs need to be empowered to challenge the home owners to ask them if staff have been trained - and if not, why not etc.” “Each PCT should commission....an in-reach service that supports primary care in its work in care homes. Regular assessment and review, support care home staff and attempt non pharmacological management, decrease antipsychotic prescribing” Sutton and Merton Challenging Behaviour Service Our Process On referral - letter to GP Our assessment includes: our own assessment pack, current presentation/behaviour, social and personal history, physical health and history, mental health & history, activities of living, environment, risks and current medication list plus: evidenced based assessment forms such as CBS scale, Barthel, Cornell/GDS, MMSE, ACE, Abbey Pain Scale, Waterlow Scale. Included in our assessment Meet with referred person Meet with staff Discussion with family Liaise with Social Services, PCT, GP’s where necessary Complete observations of the behaviours Request staff complete ABC, sleep charts, fluid intake for example charts for at least a week. Information Sharing Once all information is gathered, we send out assessment letters with our initial impressions (ideally within 4-5 weeks of referral) We also complete training at the care homes where we feel it is necessary Follow-up Meet with a minimum of 4 staff and complete a formulation session – sharing ideas and devise the care plan. Once this is typed we send it to the family, home and GP’s and follow up with weekly /fortnightly visits to the home to assist the staff implementing the interventions. With view to discharge in 16 weeks. If medication has been used for the behaviour we like to continue the interventions whilst the medication is reduced/stopped.