Can DoH review fix dementia care?

Last month, Alzheimer's charities called on the government to release its long-awaited review into the use of antipsychotics in dementia care.

They hope the review will end the widespread use of these drugs as a 'chemical cosh' to make patients with dementia easier to handle.

A lack of training for GPs and care home staff on alternative methods of managing patients with dementia has led to regular use of drugs in this way.

Experts would like the DoH paper to pave the way for a change of culture, by recommending audits of drug use, and monitoring and reviews of prescribing.

They hope it will support GPs working with old-age psychiatrists and teams in nursing homes to promote therapy and other alternatives to drugs.

New era dawning
The DoH continues to insist the review will be published 'shortly', despite first planning to release it back in the spring.

Hopes of a new era for dementia care were first raised when ministers pledged a 'zero tolerance' crackdown on antipsychotic prescribing last summer. A BBC investigation had found that more than half of 355 surveyed GPs still prescribed risperidone and olanzapine despite safety concerns.

The MHRA had already advised against using the drugs to treat dementia after they were found to raise stroke risk.

But, for all the tough talking, little has been done so far. A GP investigation found that antipsychotic prescribing continued to rise across England well after the antipsychotic review was announced.

Figures released by the NHS Information Centre in May showed that there were three million prescriptions for risperidone and olanzapine in England in 2008.

This week, GP newspaper reveals that PCTs are continuing to neglect the issue. A Freedom of Information Act request, which brought responses from 62 PCTs, found that over half are failing to commission services to reduce antipsychotic prescribing.

Results of GP newspaper investigation on dementia

This is despite NICE guidance that patients should only receive the drugs if they are severely distressed or there is an immediate risk of harm to the person or others.

The reply by Kent's Medway PCT says 'the medicines management department does not commission a service to reduce antipsychotic prescribing among dementia patients; however we do remind prescribers of the risks'.

A response from NHS Birmingham East and North states: 'Educational information has been provided to GPs to encourage a reduction in antipsychotic prescribing. However, NHS Birmingham East and North does not commission anything specifically.'

Several other PCTs offered up similar replies, suggesting that, although they are well aware of the problem, little is being done except simply reminding GPs of the risks.

Some PCTs, including those in Swindon, Lewisham in south-east London and Hull, said they offer no services to reduce inappropriate prescribing.

Others are now providing services to limit prescribing, however.

Professor Clive Ballard, an old-age psychiatrist at King's College London and an Alzheimer's Society adviser, says PCT support is vital to help GPs curb inappropriate prescribing.

'If there was a rapid response team locally, including people like a clinical psychologist, which could help people with Alzheimer's, that would be useful,' he says. 'PCTs should be commissioning these sorts of services to support GPs.'

He hoped the DoH antipsychotic review would give details of the types of support PCTs should commission.

GPs must take control
North Shields GP Dr Dave Tomson, who has an interest in mental health, agrees that the review will help, but believes GPs themselves should do more to cut antipsychotic use.

Neil Hunt, chief executive of the Alzheimer's Society, says equipping staff to provide non-pharmacological approaches, as NICE dementia guidance suggests, will be key.

'In-reach services from older people's mental health teams into care homes are an important way to improve the knowledge and confidence of staff and reduce antipsychotic use.'

Because more than a million people are expected to develop dementia in the next 10 years, we must tackle the issue as a society, urges Mr Hunt.

'We must develop health and social care services that can respond to the challenge.'

But, unless the DoH faces up to this challenge and releases an antipsychotics review that can finally influence the behaviour of PCTs, dementia sufferers will continue to be subjected to standards of care that rank among the lowest in Europe.