RCGP Wales response on use of anti-psychotic medication in care homes

RCGP Wales welcomes the opportunity to respond to the Health, Social Care and Sport Committee short inquiry on the use of anti-psychotic medication in care settings, particularly care homes.

Antipsychotics are drugs developed and licensed to manage schizophrenia and their use for this is wide.  Typical antipsychotics are associated with common and serious adverse effects, including over-sedation, hypotension, involuntary movements (including irreversible late onset tardive dyskinesia), Parkinsonian symptoms (rigidity, tremor and problems with walking) and the rare occurrence of cardiotoxicity (damage to the heart), high fever and vascular collapse (neuroleptic malignant syndrome). Since their introduction, the use of the atypical antipsychotics has become much more common, due to their generally favourable side effect profile, with the incidence of Parkinsonian side effects and tardive dyskinesia much lower and is to be supported even in care homes. They are also used commonly to manage disturbed behaviour e.g. agitation, aggression, wandering, shouting, repeated questioning and sleep disturbance, in patients with other conditions, particularly dementia or those with learning disability.

Many people in care homes and those with dementia have multiple co-morbidities and the use of any medication with significant side effects needs to be kept to a minimum, both in duration and in dosage. Antipsychotics, particularly the older typical ones have marked side effects  as mentioned above. The newer atypical antipsychotics have less incidence movement disorders and are now more commonly used. Traditional clinical trials have only looked at short term usage. There are suggestions that side effects are more frequent with long term usage of antipsychotics and in those who have repeat use, as well as those who have other co-morbidities.

Patients who are suffering from behaviour problems should be fully assessed to determine underlying problems e.g. disturbed sleep pattern, acute illness, pain, which is contributing to the alerted behaviour pattern.  This is consistent with NICE guidelines https://www.nice.org.uk/advice/ktt7/chapter/Evidence-context .  Should patients be started on antipsychotics they need to be monitored regularly for side effects including cardiac ones using ECGs. Dosages and duration of medication should be kept to a minimum.

Potentially, the development of behaviour problems may be higher in care homes than in patients’ own homes, where they are surrounded by familiar objects and people. The monitoring of patients in care homes for side effects should, however, be easier and more frequent than outside this environment.

When patients with dementia or learning disability are admitted to hospital, the change of environment and the underlying condition / reason for admission may exacerbate to precipitate behaviour problems. These patients may be given antipsychotics but notes should clearly indicate that these should be withdrawn following the acute episode and discharge to their normal surrounding.

More support is needed for primary care, such as,  access to multidisciplinary team input in managing patients who present with behavioural disturbance and quarterly review with a CPN for those on an anti-psychotics.

GPs are often under pressure from care home staff to use medication to manage disturbed behaviour in patients, who might be better managed by different forms of distraction or stimulation.

There is also pressure on GPs to prescribe antipsychotics from psychiatrists, particularly the elderly. GPs need to be supported by mental health colleagues to follow the good clinical guidelines set out by NICE and reduce the use of antipsychotics for these unlicensed uses of managing behaviour problems.