The wrong prescription

Many older people in residential homes are spending their days
in a drug-induced haze as the use of anti-psychotic drugs reaches
record high levels. Ruth Winchester reports.

For a lot of young people, getting drugged up to the eyeballs in
search of semi-consciousness is the signature of a good weekend.
But it’s not something you’d normally associate with the over
sixties.

Unfortunately, the misuse of drugs appears to be a daily reality
for many older people, particularly those suffering from dementia
or mental health problems in residential and nursing homes.

Recent discussions in parliament, driven by Paul Burstow,
Liberal Democrat MP for Sutton and Cheam, have refuelled a
long-standing debate about the use of anti-psychotic drugs to
subdue problematic residents. Both Age Concern and the Royal
College of Physicians have published reports in the past looking
into the over-use of these drugs which have been dubbed “chemical
coshes” because of their heavy sedative effects. Other side-effects
include facial paralysis, tremors and unsteadiness, and there is
evidence that their use on people with dementia can hasten
cognitive decline and even death.

Despite the concern raised by campaign groups, the medical
profession and the press, figures released last week demonstrate
that the amount of prescriptions for new generation anti-psychotics
for people over 60 nearly doubled between 1999 and 2000 – up from
252,700 to 428,800.

Harry Cayton, chief executive of the Alzheimer’s Society, agrees
that these figures need to be “treated with some caution. There is
some evidence that they indicate a switch from older [typical]
anti-psychotics to the newer [atypical] ones, which have fewer side
effects.”

But he argues: “Use of these drugs on older people should be
dropping, and that clearly isn’t happening. There’s very
substantial evidence that these drugs are being over-prescribed,
and given too often, at too high a dose, particularly in care
settings where there is very little independent scrutiny of
prescribing practice. In the United States these drugs have been
severely restricted by law. I think they have to be used extremely
carefully.

“To put it bluntly, these drugs help doctors and nurses. They
don’t help the people who are taking them, they just make them
quieter and calmer and easier to look after. They are a substitute
for good care – some of the best care homes hardly use them.”

Care homes, for their part, are furious that the finger of blame
is being pointed at them, arguing that they are not responsible for
GPs prescribing habits and that doctors are required to carry out
assessments before writing out prescriptions for powerful
psychiatric drugs.

Unfortunately, there is some evidence to suggest that this is
not always happening. GPs are often under pressure from staff and
managers to help them cope with a resident, particularly in cases
where their behaviour is disturbing other people. Distressed family
members, too, can plead with care staff and family doctors to “do
something” to help keep someone calm and quiet. And there have been
allegations that assessments are cursory at best. Anecdotal
evidence suggests that there are a number of cases where GPs have
prescribed without a full assessment – even over the telephone.

Jim Kennedy is prescribing spokesperson for the Royal College of
General Practitioners. He says the RCGP is “very concerned about
the figures released by the Department of Health. We feel the
figures need clarification as they don’t equate with our experience
of current clinical practice.

“Much can be done to help elderly people without resorting to
prescribing drugs,” he adds. “Having a good level of staffing, and
providing training as well as a good environment can all help an
elderly person who is in an unfamiliar environment, without giving
them a prescription.”

But Paul Burstow suggests that both care homes and GPs need to
take responsibility for the situation. “I’m not suggesting that
these drugs don’t have a place – that they should never be
prescribed. In some cases they can be very useful, for instance if
someone is very distressed or if they are a danger to themselves.
But I think the problem is about how high the dosages are and how
regularly people are dosed with them. In most cases there is no
proper review, they are used at inappropriately high levels, and
they are used more for the convenience of managers and staff than
for the benefit of the elderly person.”

Burstow highlights the fact that the National Institute for
Clinical Excellence is to produce guidelines in December on the use
of anti-psychotics, although these are unlikely to contain specific
recommendations relating to their use with older mentally ill
patients.

He says: “Firstly, we need to have tighter prescribing
guidelines relating to these drugs. Second, we need the inspection
and regulation of homes caring for elderly people to look at the
way they are using these drugs – and not just to look at the
policy, but at the practice.

“The final thing that we need to look at is the investment in,
and training of, staff,” Burstow adds. “Two or three months ago we
surveyed local authority social services departments and found that
seven out of 10 social services departments could not meet the
demand for beds for older mentally ill patients. Six out of 10 said
they didn’t have access to the specialist dementia care staff at
the level to meet demand. What that tells me is that we simply
don’t have the skilled staff necessary, and so the level of
personal care is likely to be low.”

Cayton agrees: “No one is saying that caring for people with
dementia is easy – it’s not. But we should be asking ourselves how
we could reduce the need for drugs with better care, and a lot of
that is about ensuring that care staff get the resources and
training they need. Drugs should always be a last resort.”