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 / 2
Name of responsible (ratifying) committee / Dementia Steering Group and The Formulary and Medicines group.
Date ratified / 16 September 2016
Document Manager (job title) / Consultant Geriatrician
Date issued / 04 October 2016
Review date / 03 October 2018
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 / Author
2 / 16/9//2016 / New format. Document Manager change. Audit Criteria. / Catherine Charlton
1 / 13/9/2013 / New Policy

CONTENTS

QUICK REFERENCE GUIDE

1. INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

EQUALITY IMPACT SCREENING TOOL

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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)
  1. Ensure there are no contraindications for use: prolonged QTc, Parkinson’s disease, Lewy Body dementia. Seek specialist help
  1. Document the patient’s capacity to consent to treatment.
  1. 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
  1. 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

  1. Of those treated with antipsychotics 20% improve
  2. 1% given antipsychotics will die.
  3. Just under 1% given antipsychotics will suffer a stroke.
  4. Discuss extrapyramidal side effects (rigidity, tremor, neuroleptic malignant syndrome)
  5. Other risks include: falls, aspiration pneumonia, drowsiness, pressure areas, dehydration, and increased confusion.
  1. Give the family an information leaflet to take away regarding this situation.
  1. Once the drug is started ensure a daily review of the patient and the continued need for the drug.
  1. Refer to OPMH if the patient has needed medication for more than 4 days or an increase in standard treatment.
  1. 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.

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’

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
  • Chlorpromazine
  • Benperidol
  • Flupentixol
  • Fluphenazine
  • Haloperidol
  • Levomepromazine
  • Pericyazine*
  • Perphenazine*
  • Pimozide
  • Prochlorperazine
  • Promazine
  • Sulpiride
  • Trifluoperazine
  • Zuclopenthixol
  • Atypical AP’s
  • Amisulpride
  • Aripiprazole
  • Olanzapine
  • Clozapine
  • Quetiapine
  • Risperidone
  • Paliperidone
  • Pipotazine
  • Sertindole – named patient only.
  • Zotepine*

* Denotes medicine is not on the District Formulary

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.

6.PROCESS

Before starting antipsychotics (AP) for patients over sixty five with delirium and or dementia in hospital use this algorithm.


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.



Tool for Antipsychotic pilot for patients over the age of 65.

On Medicines reconciliation by Pharmacy staff Antipsychotic use will be identified.

This tool will be placed in drug chart for action to ensure compliance with policy and best practice.

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.

2)The Mental Capacity Act

3)PHT Clinical Guidelines for Delirium diagnosis and management in older people in a general hospital setting.

4)PHT clinical Guidelines for Diagnosis of Dementia Guidelines

5)PHT Pharmacy Drug Therapy Guidelines: Confusion and Behavioural Disturbance in Older People.

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

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity

Quality of care

Working together

Efficiency

This policy should be read and implemented with the Trust Values in mind at all times.

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum requirement to be monitored / Lead / Tool / Frequency of Report of Compliance / Reporting arrangements / Lead(s) for acting on Recommendations
Has a tool been put in the drug chartfolder highlighting that a patient is on an antipsychotic / Lead Pharmacist for MOPRS / Six monthly
10 charts / Policy audit report to
  • Dementia Steering Group
/ Consultant Geriatrician on Dementia Steering Group
Has the sheet been acknowledged by the medical team / Lead Pharmacist for MOPRS / Data Collection / Six monthly
10 charts / Policy audit report to:
  • Dementia Steering Group
/ Consultant Geriatrician on Dementia Steering Group
Is there a clear plan documented in the discharge summary for review of antipsychotics by the GP or OPMH team within one month of discharge / Lead Pharmacist for MOPRS / Data Collection / Six monthly
10 charts / Policy audit report to:
  • Dementia Steering Group
/ Consultant Geriatrician on Dementia Steering Group

This document will be monitored to ensure it is effective and to assurance compliance.

EQUALITY IMPACT SCREENING TOOL

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening
Title of Procedural Document: Antipsychotic Policy for patients over the age of sixty five
Date of Assessment / 15/09/2016 / Responsible Department / Medicine for Older people Rehab and Stroke
Name of person completing assessment / Jane Marshall / Job Title / Clinical Pharmacy Services Manager for Unscheduled Care
Does the policy/function affect one group less or more favourably than another on the basis of :
Yes/No / Comments
  • Age
/ Yes / For Patients over 65 years
  • Disability
Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia / No
  • Ethnic Origin (including gypsies and travelers)
/ No
  • Gender reassignment
/ No
  • Pregnancy or Maternity
/ N/A
  • Race
/ No
  • Sex
/ No
  • Religion and Belief
/ No
  • Sexual Orientation
/ No
If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2
More Information can be found be following the link below

Stage 2 – Full Impact Assessment
What is the impact / Level of Impact / Mitigating Actions
(what needs to be done to minimise / remove the impact) / Responsible Officer
This Policy will make prescribing of antipsychotics for patients over the age of 65 years safer. / High-
Improving
Patient safety / Nothing as prescribing will be reviewed thus leading to appropriate prescribing for this age group. / k
Catherine Charlton
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document: Specialty Governance Committee
Clinical Service Centre Procedural Document:Clinical Service Centre Governance Committee
Corporate Procedural Document:Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

Antipsychotic Policy
Version: 2

Issue Date: 04 October 2016
Review Date: 03 October 2018 (unless requirements change)Page 1 of 13