Antipsychotic use following recent hospital discharge

Background (age, sex, occupation, baseline function)

• 78-year-old female normally independent and still driving
• Lives alone after husband’s death eight years ago
• No family locally, but good support from neighbours and friends
• Lives in bungalow with no stairs
• No particular exercise but will go on short walks

History of presentation/reason for review

• Recent discharge from hospital and needs a medication review

Current medical history and relevant co-morbidities

• Discharged two weeks ago after short admission (three days) with delirium from a suspected chest or urine infection
• Breast cancer - wide local excision followed by chemotherapy and radiotherapy – 14 years ago
• Hypertension – 24 years ago
• Type 2 Diabetes Mellitus – 24 years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions (ADRs): nil

Medication prior to recent admission

• Amitriptyline 50mg tablets: one tablet at night
• Amlodipine 5mg tablets: one tablet daily
• Bendroflumethiazide 2.5mg tablets: one tablet daily
• Metformin 500mg tablets: one tablet twice a day
• Oxybutynin 5mg tablets: one tablet twice a day

Medications started on recent admission

• Amoxicillin 500mg capsules: one capsule three times a day - course complete
• Trimethoprim 200mg tablets: one tablet twice a day - course complete
• Risperidone 500 microgram tablets: one tablet twice a day

Medications stopped on recent admission

• Amlodipine 5mg tablets: one tablet daily
• Bendroflumethiazide 2.5mg tablets: one tablet daily

Over the counter medicines: nil

Lifestyle and current function

• Daughter temporarily moved in to support her following hospital discharge
• Walking more slowly. Sleepy - seems slower cognitively. Some confusion especially later in the day
• Eating less than normal
• Managing to wash and dress but needing some assistance
• No issues with continence but taking longer to get to the toilet
• Clinical Frailty Score (Rockwood) 3 (managing well)

“What matters to me” (ideas, concerns and expectations of treatment)

• Would like to get back to previous level of independence
• Concerned by recent drop in function

Observations, examinations and results 

Note: local laboratory reference ranges may vary

• BP 176/84mmHg
• Pulse 80bpm
• Weight 52kg (58kg one year ago), Height 152cm, BMI 21.6kg/m²
• Urea and Electrolytes within normal range
• FBC normal at time of hospital discharge
• HbA1c 58mmol/mol (7.5%) on last check nine months ago

Most recent relevant consultations

• No consultations in the last year prior to admission

Person specific issues to address

• Currently functioning at below her normal physical and cognitive baseline, and would like to return to that

 

Person specific issues to address

• No drugs considered essential

 

Person specific issues to address

• Risperidone - added as an inpatient and likely no longer needed, and potentially causing side effects (sedation). When used in delirium, antipsychotics must be at the lowest possible dose for the shortest possible time
• Oxybutynin - strong anticholinergic, can increase confusion. No clear indication, consider deprescribing
• Amitriptyline - strong anticholinergic and risk of sedation and increased confusion. If no clear indication, consider deprescribing

 

Person specific issues to address

• Blood pressure now high. Amlodipine and bendroflumethiazide stopped in hospital. Due to concurrent diabetes consider ACE inhibitor, e.g. ramipril
• Type 2 diabetes: may be appropriate to consider statin, requires baseline LFTs with monitoring

 

Person specific issues to address

• Diabetes: HbA1c checked some months ago. Discuss appropriate target level with her when recovered considering age and frailty
• On several agents that can lead to sedation, cognitive impairment and increased falls risk. Consider need for risperidone, oxybutynin and amitriptyline; and deprescribe where appropriate
• Antipsychotics (risperidone) associated with increased cardiovascular risk and use. Need to be at lowest possible dose for shortest possible time. Consider deprescribing
• Consider further investigations if confusion worsens or persists
• Ensure Medication Sick Day Guidance for metformin and/or ACE inhibitor

 

Person specific issues to address

• All medicines are formulary choices 
• Advised to dispose of medicines through the community pharmacy 
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• Stop oxybutynin and risperidone
• Reduce amitriptyline
• Follow up blood pressure, HbA1c
• Check care needs have been met including adequate fluid and nutrition
• Refer to local community team for assessment of needs and rehabilitation
• Medical review if physical and cognitive function not improving