Download Antipsychotic Policy - Portsmouth Hospitals NHS Trust

Antipsychotic policy
For patients over the age of sixty five with delirium or dementia
starting antipsychotics in hospital or those admitted on
antipsychotic medication in the community.
Version
1
Name of responsible (ratifying)
committee
Dementia Steering Group and The Formulary
and Medicines group.
Date ratified
20th September 2013
Document Manager (job title)
Dr Katharine Hardy- Consultant in Medicine
for Older People, Rehab and Stroke.
Portsmouth Hospitals Trust
Date issued
20th December 2013
Review date
01/12/2015
Electronic location
Clinical Policies
Related Procedural Documents
Key Words (to aid with searching)
Antipsychotic, sedative, delirium, dementia,
sedation
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
Author
CONTENTS
1) Quick reference Guide
2) Introduction, purpose and Scope
3) Definitions
4) Duties and responsibilities
5) Process
6) Guidelines for those being admitted to hospital on Antipsychotics.
7) Algorithm
8) Tool for monitoring antipsychotic use.
9) Training requirement and references.
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
QUICK REFERENCE GUIDE
ANTIPSYCHOTIC POLICY
For those patients over sixty five with delirium and
dementia starting antipsychotics in hospital.
If you have a patient with a delirium and or dementia who after senior
(Consultant or Specialty Registrar) clinical review needs to be
commenced on an antipsychotic medication, please ensure this
guideline is followed.
Prior to commencing drug
1. Ensure than all non-pharmacological methods of management have
been tried (see Delirium guidelines on intranet)
2. Ensure there are no contraindications for use: prolonged QTc,
Parkinson’s disease, Lewy Body dementia. Seek specialist help
3. Document the patient’s capacity to consent to treatment.
4. If, following assessment of capacity using the Mental Capacity Act, it is
felt that the patient lacks capacity to consent for medication ensure that
a best interests decision is documented in the notes including reasons
for treating, risks and benefits
5. Discuss with the family or carers as part of best interests decision and
document this discussion informing them of risks and benefits.
Some helpful information to guide this discussion
a. Of those treated with antipsychotics 20% improve
b. 1% given antipsychotics will die.
c. Just under 1% given antipsychotics will suffer a stroke.
d. Discuss extrapyramidal side effects (rigidity, tremor, neuroleptic
malignant syndrome)
e. Other risks include: falls, aspiration pneumonia, drowsiness,
pressure areas, dehydration, and increased confusion.
6. Give the family an information leaflet to take away regarding this
situation.
7. Once the drug is started ensure a daily review of the patient and the
continued need for the drug.
8. Refer to OPMH if the patient has needed medication for more than 4
days or an increase in standard treatment.
9. If a patient is due to be discharged on antipsychotics, ensure that on
discharge there is a clear plan for review of the antipsychotics by their
GP or OPMH team within one month of discharge.
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
1.
INTRODUCTION
In the last few years the use of antipsychotics has been extensively
reviewed. Dr Sube Banerjee reported to the Department of Health in
2009 on the Use of Antipsychotic Medication for people with dementia.
He highlighted that there is a large cohort of patients being prescribed
antipsychotic medication for behavioural and psychological symptoms of
dementia, and while there was evidence that these helped some in the
short term, there were significant concerns regarding long term use of
these medications. The worrying outcomes were cerebrovascular
disease and death which was directly attributed to the use of
antipsychotics. The thought was that some people with dementia did
benefit from these medications but there was a lack of onward review
and that once prescribed these drugs were continued, leading to
adverse outcomes. It was reported that up to two thirds of people on
antipsychotics for their dementia actually did not need them
Reducing the use of these drugs for people with dementia is a national
priority in England and Wales.
The National Audit for Dementia reviews the use of new prescriptions of
antipsychotics and benchmarks practice with other organizations.
Locally there has been an Article 43 ruling from the Portsmouth Coroner
highlighting the concern of Antipsychotic use within Portsmouth
Hospitals Trust.
The above have therefore initiated the following policy document.
2.
PURPOSE
This document has been written in response to Article 43 from the
Coroners Office and also forms part of the Commissioners Quality
Contract with Portsmouth Hospitals Trust.
The purpose of the document is to set out responsibilities for all those
involved in the care of patients over the age of 65 on antipsychotic
medication to achieve best practice.
3.
SCOPE
This policy applies to all of Portsmouth Hospitals Trust departments and
their staff involved in prescribing, administering, and dispensing
antipsychotic medication.
‘In the event of an infection outbreak, flu pandemic or major incident, the
Trust recognises that it may not be possible to adhere to all aspects of this
document. In such circumstances, staff should take advice from their
manager and all possible action must be taken to maintain ongoing patient
and staff safety’
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
4.
DEFINITIONS
Antipsychotic medications- are a range of medications used for some
types of mental distress or disorder- mainly schizophrenia and bipolar
depression. They can also be used to help severe anxiety, depression or
behavioural and psychological symptoms of dementia. They can also be
used to treat nausea and vomiting, intractable hiccough and can be used
to treat pain and restlessness in palliative medicine.
Typical antipsychotics- older or “first generation” antipsychotics, used
to block dopamine. More likely to cause side effects such as
Parkinsonism and tardive dyskinesia.
Atypical antipsychotics- newer drugs, more selectively block
dopamine. Many similar side effects but are generally tolerated better.
More likely to produce weight gain, diabetes and sexual problems.
“Depot” antipsychotics- A large proportion of antipsychotics are given
as tablets, but they can also be given as a slow release injection.
LIST OF ANTIPSYCHOTICS
 Typical AP’s
o Chlorpromazine
o Benperidol
o Flupentixol
o Fluphenazine
o Haloperidol
o Levomepromazine
o Pericyazine*
o Perphenazine*
o Pimozide
o Prochlorperazine
o Promazine
o Sulpiride
o Trifluoperazine
o Zuclopenthixol
 Atypical AP’s
o Amisulpride
o Ariprazole
o Olanzapine
o Clozapine
o Quetiapine
o Risperidone
o Paliperidone
o Pipotazine
o Sertindole – named patient only.
o Zotepine*
* Denotes medicine is not on the District Formulary
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
5.
DUTIES AND RESPONSIBILITIES
The responsibility for best practice falls to those prescribing the
antipsychotic medication but the ultimate responsibility for the quality of
medical care lies with the Consultant responsible for the patients.
Those involved in medicines reconciliation with those dispensing the
antipsychotic drug must also highlight this best practice to the medical
staff.
The Older Persons Mental Health Team will assist in information gathering
and medical review where a need is identified.
Each department must ensure that there juniors are educated about this
policy and best practice through interdepartmental training.
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
6.
PROCESS
Before starting antipsychotics (AP) for patients over sixty five
with delirium and or dementia in hospital use this algorithm.
Ensure that all other non-pharmacological measures have been attempted.
See Delirium guidelines on intranet
http://www.porthosp.nhs.uk/ClinicalGuidelines/Delirium%20diagnosis%20and%20management%20in%20Older%20People%20in%20a%20
general%20hospital%20setting.doc
http://pharmweb/publications/guidelines/Confusion%20and%20Behavioural%20Disturbance%20in%20Ol
der%20People.pdf
Note contraindications for antipsychotics:
Prolonged QTc, Parkinson’s disease, Lewy Body Dementia
Perform a capacity assessment related to the patient
commencing antipsychotic treatment.
Document this in the notes
If the patient lacks capacity to consent to antipsychotic treatment, ensure there has been a best
interests decision.
Ideally involve family and discuss risks and benefits
1.
2.
3.
4.
Of those treated with antipsychotics 20% will improve
1% of those will die related to the use of their drugs
Just under 1 in 100 people on AP’s will have a stroke.
Other risks, falls, aspiration pneumonia, dehydration, sacral sores, extrapyramidal side effects,
drowsiness.
Issue the family with an information leaflet
Commence the drug and ensure:
1) Appropriate prescription – NEVER IV route
2) Daily review of patient and drug
3) Stop when it is no longer needed
4) If the drug needed for more than 4 days
refer to OPMH
5) If any concerns about need to increase
dose contact OPMH for advice
Prior to discharge
Review the need for the drug
If still needed ensure that one month after
discharge there is a review of the medication
by OPMH or GP.
Give clear specific advice on discharge
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
summary regarding its use and plans
Guidelines for those people over sixty five being
admitted on antipsychotics
For those aged over 65 admitted on antipsychotic medication, ensure
the following is achieved.
1) Ascertain the diagnosis and reason for antipsychotics.
2) Additional information should be gathered from the GP including when
the drug was last reviewed and by whom. Find out if OPMH are
involved. If it is unclear, please telephone OPMH liaison (ext 6670) to
find out if the patient is known to them.
3) If the patient is stable on their antipsychotic with an admission
unrelated to their mental health needs continue their medication.
4) If the patient is known to OPMH and have been admitted with
worsening confusion or behaviour and there is a need to alter
antipsychotic medication consider referral to OPMH for review.
5) If there is no obvious reason for antipsychotics and this has not been
reviewed in the community then refer to OPMH for advice.
6) Anyone being discharged on antipsychotics needs this highlighting to
the GP to ensure regular follow up of the drug either by GP or OPMH.
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
Use this algorithm for those over Sixty five admitted
on antipsychotic (AP) medication
Ascertain diagnosis and reason for antipsychotics.
Call GP or OPMH liaison team for collateral if needed.
Identify when last reviewed and if OPMH are aware of
the patient.
If the patient is stable on
their AP medication with
an unrelated admission
continue the drug.
If the patient is on an AP with
worsening
confusion
and
behaviour consider referral to
OPMH for review
If the reason for the drug or diagnosis is
unknown with no recent review of medication
consider referral to OPMH for advice re drug
necessity/withdrawal.
ANYONE BEING DISCHARGED ON ANTIPSYHOTIC
Ensure clear documentation on discharge summary.
Ensure there is a request for review of this drug 1/12 after
discharge by either GP or OPMH.
Give clear information as to reason for treatment and any
information regarding future use.
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
Tool for Antipsychotic pilot for patients over the age of
65.
On Medicines reconciliation by
Antipsychotic use will be identified.
Pharmacy
staff
This tool will be placed in drug chart for action to
ensure compliance with policy and best practice.
Your patient has been identified as being on an Antipsychotic medication.
There is a national patient safety drive to ensure that, where possible, their use is only
short term and regularly reviewed, so please complete the following proforma.
Please tick the box to say that you have acknowledged this information
Please date and sign to say that you have completed the following.
On admission
1) Reviewed the intranet guidelines for antipsychotics and have formulated an
appropriate plan for the antipsychotic medication.
Signed………………………….
Date……………………………….
Prior to discharge
1) You have mentioned on the discharge summary that this patient is on antipsychotic
medication and this needs regular review on discharge.
2) Please include any relevant information on the discharge summary including if there
has been an OPMH review and their plans for medication review and follow up.
Signed ………………………….
Dated ………………………………….
Many thanks.
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
7.
TRAINING REQUIREMENTS
Training is the responsibility for each clinical team and CSC. Training
should be received by all pharmacy staff and medical and nursing staff
to highlight the importance. This should be included within local
induction.
By including the monitoring tool, it will increase exposure to this subject
and aid dissemination of information.
8.
REFERENCES AND ASSOCIATED DOCUMENTATION
1) A report for the Minister of State for Care Services by Professor Sube
Banerjee: The use of antipsychotic medication for people with
dementia. Time for Action.
http://www.dementiapartnerships.org.uk/wp-content/uploads/time-foraction.pdf
2) The Mental Capacity Act
3) PHT Clinical Guidelines for Delirium diagnosis and management in
older people in a general hospital setting.
http://www.porthosp.nhs.uk/ClinicalGuidelines/Delirium%20diagnosis%20and%20management%20in%20Ol
der%20People%20in%20a%20general%20hospital%20setting.doc
4) PHT clinical Guidelines for Diagnosis of Dementia Guidelines
http://www.porthosp.nhs.uk/Downloads/ClinicalGuidelines/Diagnosis%20of%20dementia%20guidelines.doc
5) PHT Pharmacy Drug Therapy Guidelines: Confusion and Behavioural
Disturbance in Older People.
http://pharmweb/publications/guidelines/Confusion%20and%20Behaviou
ral%20Disturbance%20in%20Older%20People.pdf
9.
EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as
is reasonably practicable, the way we provide services to the public and
the way we treat our staff reflects their individual needs and does not
discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement.
However, when sending for ratification and publication, this must be
accompanied by the full equality screening assessment tool. The
assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015
Antipsychotic Policy Issue 1 20/12/2013 Review date December 2015