Dementia patients being failed, says Medical Director

9 April 2009

A combination of poor training for doctors and a lack of action by regulators means too many people with dementia are being inappropriately-prescribed anti-psychotic drugs, says Bupa's aged care divisional medical director Dr Clive Bowman.

Dr Bowman, who has responsibilities for Bupa's care homes across the UK, Australia, New Zealand and Spain, says regulators and the training of doctors in the UK have failed people with dementia by not focussing on the root causes of anti-psychotic drugs use.

Responding to the UK Department of Health's "Review of Prescription of Anti-Psychotic Drugs to People with Dementia", Dr Bowman calls for some simple steps to correct the present poor practice. The problem is particularly difficult in care homes where nursing staff are obliged to dispense medication prescribed by a GP or hospital consultant.

He says that primary care trusts (PCTS) – which maintain responsibility for their patients living in care homes - should be given national targets for acceptable rates of anti-psychotic use. These could be administered by a Quality Outcome Framework (QOF) process and subsequently enforced by firmer regulatory action by the new regulator the Commission for Care Quality (CQC) or the General Medical Council.

Dr Bowman says;

"A lack of training has perpetuated the prescription of anti-psychotic drugs to people with dementia, especially those in care homes. Medical students and doctors in training typically first encounter acutely-confused people on medical and surgical wards where for safety reasons sedation, including the use of neuroleptics, may be prescribed.

"The problem is that they do not have further specific training regarding the use of anti-psychotics for the confusion and agitation that can complicate dementia. When, in turn, they become senior hospital doctors or GPs, they are guided in their prescribing by their experience in training - so poor practice is perpetuated."

He adds: "There should be a formal requirement for hospital doctors and GPs to record both the rationale for prescribing anti-psychotics and the intended duration of treatment.

"The transfer of many patients from hospital to a care home continues to be blighted by inadequate information - especially for receiving GPs who are often not the patient's usual doctor. It is not surprising that a GP is reluctant to begin drug reduction without adequate information because the patient's medical records have not yet arrived."

Who's to blame?

But Dr Bowman stresses that social care system also bears part of the blame. He says regulators have failed to investigate the prescribing of anti-psychotic drugs, apart from one study carried out in 2002 which has not been followed up.

Care home regulators principally investigate whether medication has been stored and administered in accordance with prescriptions but they do not routinely study the appropriateness of prescriptions. Dr Bowman says that while inspectors have raised standards of medicines management in care homes this has merely ensured that "inappropriately prescribed and dispensed treatment has been administered more consistently - rather than significantly reduced."

Local authorities and PCTs should also ensure that they carry out rigorous re-assessments of an individual's needs when commissioning care for people with dementia.

Dr Bowman adds: "While there are times when a provider is inadequate, we also see situations where the care being purchased for an individual is inadequate for their needs or that their needs significantly escalate.

"GPs are often obliged to prescribe anti-psychotics to safeguard individuals because of the hurdles, unresponsiveness or lack of capacity by PCTS or local authorities to reassess and, crucially, increase levels of care.

"Well-run care homes with positively-engaged GPs can make a real difference. I know of impressive examples where the sheer commitment of staff and positive co-operation of GPs has largely eradicated anti-psychotic usage in what in many circumstances would be recognised as a community with behaviours that could be very challenging.

"I hope the new CQC will obtain information on prescribing rates of anti-psychotics to care home residents and investigate outliers. This approach would bring a focus to the boardrooms of PCTs and local authorities."

An article by Dr Bowman called "Antipsychotic drugs, dementia and care homes" will appear in the March edition of the Royal Society of Medicine's journal "Clinical Risk".