Transcript Emerging themes in Dementia

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.