Mathematics and Statistics

The research – co-authored by Dr Tom Palmer, Lecturer in Medical Statistics at Lancaster University, and led by Coventry University was published today in the medical journal BMJ Open. It examined prescribing data between 2009 and 2012 from over 600 care homes (Prescribing patterns from 616 care homes and 31,619 residents were analysed) across the country, concluding that there was no statistically significant decline in antipsychotic prescribing rates over the four year period.

Antipsychotics were originally developed for use in patients with schizophrenia or psychosis, but the study shows that ‘off-label’ prescribing of these drugs to treat the behavioural and psychological symptoms of dementia is a common practice in care homes (‘Off-label’ prescribing is legal in clinical settings. Risperidone is the only antipsychotic that can be prescribed ‘on-label’ in the UK for the treatment of the behavioural symptoms of dementia).

The 2009 ‘Banerjee Report’, commissioned by the Department of Health as part of the NDS, examined the use of antipsychotics for people with dementia, concluding that the drugs had a “substantial clinical risk” associated with them and that their overuse “must not be allowed to continue”.

However, researchers from Coventry University, University of Warwick, Lancaster University, University of East Anglia, City, University of London – and also health technology company Invatech Health, discovered that although dosages were usually acceptable, prescribing levels did not reduce over the four years. Also, length of treatment was ‘excessive’ in over 77 per cent of cases by 2012, up from 69.7 per cent in 2009 (meaning it exceeded not only the recommended six week course, but also the maximum advised treatment length of 12 weeks).

Findings from the study also indicate that older first-generation antipsychotics (FGA) such as haloperidol and chlorpromazine are still being used extensively, with no measurable shift to safer second-generation antipsychotics (SGA) like risperidone – as recommended in the NDS.

According to the research:

• care homes in the highest prescribing 20 per cent are more likely to be located in a deprived area;
• care homes in the lowest prescribing 20 per cent are more likely to be served by a single GP practice, which could indicate that those homes benefit from a consistent message that is absent from homes served by multiple practices;
• average annual expenditure on antipsychotics was £65.60 per care home resident (based on 2012 prices), which is less than 1 per cent of the annual cost of a UK residential home place for a person with dementia;
• there was a six-fold variation between the geographical areas – in this case the areas covered by the former primary care trusts (PCT) – with the highest and lowest prescribing levels.

Dr Palmer said: “We analysed care home level data to investigate the prescribing of antipsychotics to dementia patients in a sample of UK care homes. The analysis shows that the prescribing of antipyschotics has not reduced in the selected care homes since the introduction of the National Dementia Strategy.”

Professor Ala Szczepura, from Coventry University’s Centre for Technology Enabled Health Research, said:

“Care homes remain the forgotten sector in UK policy debate around the use of antipsychotics. This appears to be due to a lack of systematic monitoring of prescribing data in these settings. Our study has not only identified a failure of the National Dementia Strategy to produce a sustained decrease in use of antipsychotics, it’s also shown large regional variations and has found evidence indicating that their use is higher in care homes in deprived neighbourhoods.

“Looking forward, the Prime Minister’s challenge on dementia 2020 aims to further slash inappropriate prescribing of antipsychotics by 67 per cent, and reduce variation across the country. It’s clear from our research that to achieve this in care homes, a significant change is required in prescription culture and management of vulnerable people with dementia.”