Dementia: Current Activities and Services

Patients with dementia are currently supported by primary care, specialist mental health services, acute health services and social care services. In January 2011 there were 220 patients with a diagnosis of dementia under the care of mental health services. These are likely to be patients with severe dementia and reflect the HFL expected prevalence estimate of 222 people with severe dementia demonstrating accurate correlation with predicted prevalence. In the year 2009/10 there were 145 admissions with a primary or underlying diagnosis of dementia. This was a decrease on the previous 4 year trend. Patients with dementia who are no longer able manage in their own homes are placed in designated ‘elderly mentally infirm’ placements. These may be nursing or residential care placements depending on the needs of the individual. There has been a fluctuation in the number of patients being placed over the last three years (see figure 4).

Figure 4 Elderly Mentally Infirm residential and nursing care placements 2008-2010

Prescribing
Lewisham has similar prescribing for anti-dementia drugs to the national average and is slightly lower than the London average.

Figure 5 Dementia Prescribing in London and PCT Cluster by average daily quantity per patient.

In the year November 2008 to December 2009 Lewisham spent £214,075 on dementia drugs (memantine, donepezil, rivastigmine and galatamine) and dispensed a total of 5,043 items. The expenditure from December 2009 to November 2010 was £245,075 and a total of 6,180 items dispensed. In October 2010, NICE reversed a previous ruling and issued new draft guidelines that said three drugs Aricept, Exelon and Reminyl, should be available on the NHS for people in the early and moderate stages of Alzheimer’s disease and another drug, Ebixa, should be made available to people in the moderate to late stages. These drugs will extend the period of time some patients are able to remain independent in their own homes. As well as increasing prescribing volumes and costs the NICE ruling may increase demand for specialist services who assess and initiate prescribing for dementia drugs. The use of antipsychotic drugs in dementia (used to manage difficult behavioural symptoms), has been under scrutiny due to evidence that the use of antipsychotic drugs can increase the risk of adverse cerebro-vascular events including stroke. The Department of Health committed to reducing the prescribing of antipsychotics in Dementia by two thirds by November 2011. In 2010 NHS Lewisham commissioned SLAM to conduct a baseline audit of antipsychotic prescribing in dementia. Of 60 inpatients, 30% had been prescribed an antipsychotic. Amongst community patients, of patients diagnosed with dementia was 352 of which 24 (7%) patients were prescribed an antipsychotic. Prior to prescribing an antipsychotic drug a number of conditions should be met including:

  • Exclude physical illness potentially precipitating behaviour and psychological symptoms in dementia e.g. constipation, infection, pain
  • Target the symptoms requiring treatment
  • Consider non-pharmacological methods first
  • Carry out a risk/benefit analysis tailored to individual patient needs when selecting a drug. Document this in the medical notes
  • Discuss treatment options and explain the risks to patient (if they have capacity) and family/carers
  • Titrate drug from a low starting dose and maintain the lowest dose possible for the shortest period necessary
  • Review appropriateness of treatment regularly (every 3 months) so that ineffective drug is not continued unnecessarily- (consider whether antipsychotic can be stopped or dose can be reduced at every review)
  • Monitor for adverse effects
  • Document clearly all treatment choices, reviews and discussions with patient, family or carers

This initial audit showed that all standards are rarely met. Those most commonly met include the elimination of a physical cause and a perceived benefit of the antipsychotic.

 

 

 

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