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Lessons in antipsychotics prescribing

A report commissioned in 2009 by Professor Sube Banerjee, professor of mental health and ageing at King's College London, recommends antipsychotics should only be used first line in dementia when a patient is severely distressed or poses an immediate risk of harm to self or others.

Otherwise, NICE advises antipsychotics should only be prescribed after other approaches have failed, started at the lowest dose and monitored regularly.

In reality, antipsychotics are often used as first-line treatments.

This is worrying because studies show they have a positive therapeutic effect in only 20% of patients and, moreover, increase the risk of adverse cerebrovascular events and death in dementia patients.

We identified patients with dementia who are on antipsychotics that do not meet the standards from Professor Sube Banerjee's 2009 report.

Data was collected from five care homes in Waterloo, Merseyside – the medicine administration records (MAR) of 16 patients with dementia, on antipsychotics and currently under the care of a consultant psychogeriatrician were identified.

MARs were reviewed using a pro forma to assess whether antipsychotics were indicated, started at the lowest dose, given with the intention of stopping after 12 weeks and reviewed at monthly intervals.

Of the 16 antipsychotic prescriptions, 94% were indicated, 44% were not started at the lowest dose, 81% were not prescribed with a view to discontinuation after 12 weeks and 88% were not reviewed monthly.

Some 80% of patients were female, Alzheimer's disease was the most common diagnosis and quetiapine was the most popular antipsychotic. Psychosis was the number one indication.

Where possible, nursing and psychosocial input should be considered first for patients with the behavioural and psychological symptoms of dementia.

If antipsychotics are indicated they should be initiated at the lowest dose and reviewed monthly with an aim to stop within three months.

From Dr Alister Pinto, Third-year core psychiatry trainee and Lucy Brakspear, Fourth-year medical student, Liverpool