Worry over antipsychotic drugs in care homes

New research looking at prescription data has raised concerns that powerful drugs such as antipsychotics are being overused, with both The Guardian and the BBC News website covering the story. 

The stories are based on a useful study in Northern Ireland that looked at how psychotropic drugs were prescribed for elderly people in the community and care homes. Researchers wanted to see if there was a significant increase in these prescriptions once people moved into care homes.

Psychotropic drugs are medicines that affect the brain, and include:

• antipsychotic drugs (used to treat psychosis)
• sedatives (hypnotics)
• anxiolytics (prescribed for anxiety and agitation)

Concerns have previously been raised that psychotropic drugs are overused in people with dementia. Antipsychotics in particular increase the risk of fatal conditions such as stroke if they are used long-term.

The study found that more than 20% of elderly people in care homes were given antipsychotic drugs, compared with just over 1% of those living in the community. Worryingly, the prescription of antipsychotic drugs increased from just over 8% before entering a care home to 18.6% afterwards.

It is possible that people going into care homes may be more ill than those who continue to live in the community, and therefore may be more likely to be taking psychotropic drugs.

But, even accounting for this possibility, the researchers argue that the increase in the prescription of psychotropic drugs for people in care homes "cannot [be] wholly explained".

The research raises some valid concerns about the potential overuse of these drugs, particularly the use of antipsychotics, in care homes.

Where did the story come from?

The study was carried out by researchers from Queen's University, Belfast. There is no information about external funding. It was published in the peer-reviewed Journal of the American Geriatrics Society.

The study was covered well by The Guardian and the BBC.

What kind of research was this?

This was a population-based study that used data from a national prescribing database and care home information from a national inspectorate. The data was used to examine the use of psychotropic drugs among elderly people in care homes and the community in Northern Ireland.

Psychotropic drugs are medicines that alter the level of certain chemicals in the brain, changing mood and behaviour.

They include:

• antipsychotics – these try to calm brain activity in people with symptoms of psychosis (such as disturbed thoughts, delusions or hallucinations, symptoms that sometimes occur in dementia)
• hypnotics – commonly called sedatives, these are prescribed to help people sleep and are sometimes used as a short-term treatment for insomnia
• anxiolytics – prescribed for feelings of anxiety and conditions such as panic disorder

The authors say there has been ongoing international concern about how often these medicines are used in older people, especially among those in nursing homes. It is suspected medication is often used as a form of chemical restraint (often referred to as a 'chemical cosh') in nursing homes.

There is particular concern about the use of antipsychotic medicines, which are sometimes prescribed to control some of the symptoms of dementia. Research has found that antipsychotic drugs have a risk of serious adverse side effects, including higher death rates.

The authors say that in the UK it is estimated that about 21% of older people in residential and nursing care are receiving antipsychotic medication, and more than 80% of the drugs prescribed are for residents who do not have a diagnosis of a severe mental illness.

In particular, the authors aimed to find out if the prescription of psychotropic medicines was largely a continuation of prescribing practices that began when older people were still living in the community, or if the transition into care homes led to an upsurge in prescription rates.

The specific aims of the study were three-fold:

• to determine the proportion of patients moving into care in a particular timeframe
• to determine the amount of these patients who were using psychotropic medication before entry
• to assess any change in psychotropic medication use during the move into care

What did the research involve?

The researchers extracted data on prescriptions of psychotropic medication over a two-year period (October 2008 to September 2010) to people aged 65 and older. The information was taken from a national prescribing database, which holds data on all prescriptions dispensed in community pharmacies in Northern Ireland. Data was also extracted on antipsychotics, hypnotics and anxiolytics. The information on the database included each person's unique health and care number and their GP practice.

To determine whether people being prescribed psychotropic medicines were living in the community or a care home, address information was taken from a centralised system holding address details for all patients registered with a GP.

A care home was defined as any nursing, residential care or dually registered facility for people aged 65 and older.

The data was used to identify all individuals living in care at the start of the study period. For each month, data was collected on whether someone was living in a care home or the community, and whether prescriptions for antipsychotics, hypnotics and anxiolytics were dispensed for that month.

The researchers carried out two analyses:

• They measured the medication use of people who subsequently entered care homes, compared with the rest of the population. This was measured twice, one year apart (January 2009 and January 2010) for 228,394 people.
• They examined any change in medication use for people who moved into care homes during the study period. This second analysis involved 2,642 people.

What were the basic results?

Overall, psychotropic drug use was higher in care homes than in the community. For example, in January 2009, 20.3% of those in care homes were dispensed an antipsychotic, compared with 1.1% of those in the community.

People who entered care had higher use of psychotropic medications before entry than those who did not enter care. However, use of psychotropic drugs increased in the month of admission and continued to rise.

Antipsychotic drug dispensing increased from 8.2% before entry to 18.6% after entering care (risk ratio [RR] 2.26, 95% confidence interval [CI] 1.96 to 2.59) and hypnotic drug dispensing increased from 14.8% to 26.3% (RR 1.78, 95% CI 1.61 to 1.96).

How did the researchers interpret the results?

The researchers say that although older people who moved into care homes had higher psychotropic drug use before they entered care, this cannot wholly explain the higher dispensing of psychotropic drugs to people in care homes. 

They point out that one in six people with no history of psychotropic drug use in the six months before they entered a care home went on to be exposed to at least one antipsychotic medication within six months of entering care.

The authors conclude that although drug dispensing is generally high in older people in the community, there is a dramatic increase after entry to care. Routine medicine reviews are necessary in older people and are especially important during transitions of care.

Conclusion

This study looks at the changing use of psychotropic medication in older people moving from the community into care homes in Northern Ireland. Researchers found a sharp increase in people being prescribed these medicines once they enter care.

The study was well conducted and uses reliable national data on community prescriptions. However, as the authors point out, it has some limitations:

• Most importantly, the study did not have clinical information for the individuals included in the study, so it could not assess whether drug prescriptions were appropriate or not.
• Individual care homes were not identified, so it is unclear if the higher prescribing on entry to a care home was general or related to specific care homes.
• There may have been delays in change of address data, which could lead to inaccuracies.
• The prescribing data is from community pharmacies and does not include hospital pharmacies. Psychotropic drug prescribing for individuals with dementia is known to be higher in hospitals, so the study data would not have captured those who were admitted directly to the care home from hospital, where they had been prescribed a psychotropic drug. Therefore, it is possible that the proportion of residents who had started these medicines before entry to the care home is higher than the study found.
• This study was carried out on care homes in Northern Ireland and it is uncertain whether its findings apply to the rest of the UK.

In conclusion, this study raises concerns about the prescribing of psychotropic medicines for elderly people living in care homes.

Though it is not possible to say from this study whether prescribing was appropriate, the authors' conclusions seem appropriate: routine medicine reviews are necessary in older people, and are especially important during transitions of care.