UK government report slams overuse of antipsychotic drugs in dementia patients

Article | 13 November 2009

In the UK, needless use of anti-psychotic drugs is widespread in dementia care and contributes to the death of many patients, according to a review commissioned by the government. About 180,000 patients a year are given the drugs in care homes, hospitals and their own homes to manage aggression.

A tough new action plan to tackle the over prescribing of antipsychotic drugs to people with dementia was announced yesterday by Care Services Minister Phil Hope.

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The action plan responds to an independent review by Sube Banerjee, professor of mental health at King’s College London Institute of Psychiatry, commissioned by the Department of Health. Prof Banerjee’s review shows that too many people with dementia are routinely prescribed antipsychotic drugs to treat aggression and agitation, contrary to National Institute of Health and Clinical Excellence (NICE) guidance.

The action plan will include:

• a new National Clinical Director for Dementia;
• measures to ensure people with dementia and their carers have access to psychological therapies to tackle the root of agitation and aggression;
• an audit to establish definitive prescribing figures;
• clear local targets to cut antipsychotics use as a result of the audit;
• better regulation;
• collaboration with the General Medical Council (GMC) and Royal Colleges to ensure all health and social care staff have specialist training in dementia; and
• joint Department and Alzheimer’s Society guidance on what to do if a family member is given antipsychotics.

Minister Hope said: “It is unacceptable that antipsychotic drugs are routinely prescribed to people with dementia. More than half of people with dementia will experience agitation or aggression at some point...We know there are situation where antipsychotic drug use is necessary – we’re not calling for a ban, but we do want to see a significant reduction in use. We expect the findings and recommendations to be taken into account by PCTs [Primary Care Trusts] and all other relevant organizations.”

Prof Banerjee, the report’s author, said that drugs, such as Eli Lilly's Zyprexa (olanzapine), Johnson & Johnson's Risperdal (risperidone), Bristol-Myers Squibb's Abilify (aripiprazole), AstraZeneca's Seroquel (quetiapine) and Pfizer's Geodon (ziprasidone), “are being prescribed to deal with behavior and psychological symptoms in dementia rather than just for psychosis.” All of the medications, including older, generic drugs such as Haldol (haloperidol) and Thorazine (chlorpromazine), have the same effect, Prof Banerjee said. As a result, doctors cannot switch patients from one medication to another to solve the problem. Instead, they need to focus on basic techniques, such as trying to determine the cause of a patient’s agitation, and behavioral therapies to improve the situation, he said. In some cases, simple problems such as lack of sleep or hunger can be the cause, he stated.

He continued: “Antipsychotics are used too often in dementia; up to two thirds of the estimated 180,000 people with dementia receiving these are prescribed them unnecessarily. This review identifies the potential risks and benefits of these medications in dementia and presents actions that we can take to address this problem. In doing so we would provide international leadership in this complex clinical area as well as improving the quality of life and quality of care for people with dementia and their carers in England.'

Adding his point of view, chief executive of the Alzheimer's Society, Neil Hunt, said: “This, long awaited, landmark review is a welcome recognition of the scale of the issue and Alzheimer's Society's view that these drugs should only ever be used as a last resort. The scandalous over prescription of antipsychotic drugs leads to an estimated 1,800 deaths a year, it must end. The report suggests prescriptions could be reduced by two thirds in three years, this is vital and the new action plan cannot afford to fail. Change will only be achieved with commitment from government, PCT’s and health professionals and clear local targets. Almost 150,000 people are being inappropriately prescribed these drugs as a chemical restraint. Today must mark a change in dementia care.'

Approved uses only, says drugmakers 

According to a Bloomberg report, Bristol-Myers, Johnson & Johnson, AstraZeneca and Eli Lilly spokespeople have all said that their drugs are not approved for elderly patients with dementia-related psychosis and do not support their use in this indication.

In 2005, the US Food and Drug Administration required makers of antipsychotics to include in dosage instructions a prominent warning surrounded by a black box about the increased risk of premature death in elderly patients with dementia, the news service added. A UK study released two years later found patients getting the drugs die six months earlier than those who do not receive them.