Antipsychotics in dementia | Right Decisions

Case summary

Background (age, sex, occupation, baseline function)

75-year-old retired female
Reduced mobility due to left sided weakness (previous stroke)
Lives with husband. Dependent on husband and carers for activities of daily living

History of presentation/reason for review

Admitted to hospital with fall, found by husband on floor beside the bed in the morning
Presentation of worsening cognition and function over the past three months
Over the past week, sudden increase in confusion, agitation and aggression. Refusing medicines today. Eating and drinking normally

Current medical history and relevant co-morbidities

Cerebrovascular disease: right partial anterior circulation stroke (PACS) leading to mild left arm and leg weakness three years ago
Mixed dementia (Alzheimer’s/vascular)

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

Allergies or adverse drugs reactions (ADRs): nil

Currently prescribed:

Aspirin 75mg dispersible tablets: one tablet daily
Atorvastatin 80mg tablets: one tablet daily
Donepezil 5mg tablets: one tablet daily
Perindopril 4mg tablets: one tablet daily
Solifenacin 5mg tablets: one tablet daily (started one month ago for urinary frequency)

Recent acute medication:

Hydroxyzine 25mg tablets: one tablet at night (started two weeks ago for an itchy rash on back)
Risperidone 250 microgram tablets: one tablet twice daily (prescribed one day prior to admission but not taken yet)

Over the counter medicines: nil

Lifestyle and current function

Carers four times a day
Mobile with a stick for short distances, lives in ground floor flat
Clinical Frailty Score (Rockwood) 7 (severely frail)
Ex-smoker (stopped 10 years ago), no alcohol

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

Lacks capacity for discussion
Husband is unable to cope with her increased aggression at home and concerned that she is refusing medication.

Observations, examinations and results

Note: local laboratory reference ranges may vary

Weight 65kg, Height 160cm, BMI 25.4kg/m²
Blood pressure 120/75mmHg, no postural hypotension
Pulse: 50 beats/minute
Urea and Electrolytes:
- within normal range
- eGFR greater than 60ml/min/1.73m²
Liver function tests: within range
CRP, white cell count, temperature within normal range
MSSU: nil of note
Full blood count (reference ranges given in brackets):
- Haemoglobin 85g/L (115-165g/L)
- MCV 187fL (80-100fL)
- Serum folate 2.5micrograms/L (4.6-18.7micrograms/L)
- Serum vitamin B12 96nanograms/L (180-700nanograms/L)
- Ferritin 95micrograms/L (15-300micrograms/L)
QTc: 470ms (normal range equivalent or less than 470ms in female)
Bowel chart: no bowel movement for past three days
Abbreviated Mental Test (AMT) score 4
CT head: normal

Most recent relevant consultations

Deterioration of cognition and function over past three months, awaiting old age psychiatry review
Urinary frequency: solifenacin started one month ago after trial of non-pharmacological options
Rash (itchy) causing distress especially at night: hydroxyzine 25mg at night prescribed

7 steps: Person specific issues to address

1. Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

Therapeutic objectives of drug therapy
Management of existing health problems
Prevention of future health issues, including lifestyle advice

Ask person to complete PROMs (Questions to answer before medicines review) before their review

Person specific issues to address

Patient with incapacity: authority from power of attorney sought
Investigate cause of fall
Management of deterioration of cognition and function
Management of sudden confusion, agitation and aggression
Refusing medications

2. Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice)

Drugs that have essential replacement functions (e.g. levothyroxine)
Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

None

3. Does the individual take unnecessary drug therapy?

Identify and review the continued need for drugs

what is medication for?
with temporary indications
with higher than usual maintenance doses
with limited benefit/evidence for use
with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

Atorvastatin: stop, currently non-essential
Donepezil: withhold due to low pulse. Investigate cause; if bradycardia due to donepezil then stop. Refer to psychiatry
Aspirin: CT head normal
Perindopril: BP tightly controlled, withhold until stable and re-assess. No past medical history of LVSD
Solifenacin: started one month ago, no improvement in urinary frequency. Stop as increased risk of anticholinergic adverse effects. Consider mirabegron as has no recorded anticholinergic activity
Hydroxyzine: rash now resolved. Stop as can increase risk of anticholinergic adverse effects
Risperidone: stop as past medical history of cerebrovascular disease. Risperidone can increase QTc. Treat underlying cause of agitation, use non-pharmacological approach as first line

4. Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

to achieve symptom control
to achieve biochemical/clinical targets
to prevent disease progression/exacerbation
is there a more appropriate medication to achieve goals?

Person specific issues to address

Low folate: Folic acid prescribed
Low vitamin B12: B12 injection prescribed
Constipation: Laxatives prescribed

5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

appropriate individual targets e.g. HbA1c, BP
drug-disease interactions
drug-drug interactions (see ADR table)
monitoring mechanisms for high-risk drugs
risk of accidental overdosing

Identify adverse drug effects by checking for

specific symptoms/laboratory markers (e.g. hypokalaemia)
cumulative adverse drug effects (see ADR table)
drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

Monitor bowels (use bowel chart)
Monitor blood pressure
Monitor pulse
Monitor haemoglobin, MCV, vitamin B12 and folate levels

6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

Inhaler use
Single use plastics
Medicines waste
- over-ordering
- disposal
Water pollution

Person specific issues to address

All medicines are formulary choices
Ensure appropriate disposal of medicines as per hospital standard operating procedures
Advised to dispose of medicines no longer required through the community pharmacy
Advised to only order what is needed, do not stockpile medicines

7. Person-centredness: Is the person willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

is the medication in a form they can take?
is the dosing schedule convenient?
what assistance is needed?
are they able to take medicines as intended?

Agree and communicate plan

discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
include lifestyle and holistic management goals
inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete PROMs (Questions to answer after medicines review) after their review

Agreed plan

Delirium:

Agreed treatment of underlying medical causes
Stop Agreed to treat underlying cause of delirium and use non-pharmacological options in the first instance. Review regularly, if no improvement following non-pharmacological management and symptoms causing significant distress to patient, or if threat to patient, carers or others, consider pharmacological options. Refer to local guidance
Stop: solifenacin, hydroxyzine, atorvastatin, perindopril, donepezil
Start: laxatives; folic acid/vitamin B12
Covert administration in place for one week. Review need regularly
Aspirin, folic acid and laxatives are currently being given covertly as per agreements within signed policy
Worsening cognition and function over past three months: discussion of benefit and risks of cholinesterase inhibitors, if to restart (stopped due to potential cause of bradycardia)

Key concepts in this case

Acute onset in mental status or new onset confusion? THINK DELIRIUM
Use TIME bundle:

Triggers: identify potential triggers (e.g. constipation, anticholinergics)

Investigate: record national early warning system (NEWS), screen for infection, take bloods

Manage: document diagnosis of delirium, causes and plan

Engage: engage with patient/family/carers, complete “what matters to me”. If patient does not have capacity to consent to care, complete Adult With Incapacity (AWI) documentation

Use non-pharmacological options such as environment (e.g. quiet room), verbal and non-verbal escalation techniques
Anticholinergic medications can cause symptoms such as dry mouth, constipation and urinary retention. Exposure to anticholinergic agents has been linked to impaired cognition and physical decline. They may also be associated with falls, increased mortality and cardiovascular events. The anticholinergic effect of individual medicines varies greatly between individual patients, and the effect of multiple medicines are cumulative
Covert administration: requires a formal agreement between healthcare professionals and carers (it should only be completed for patients who lack capacity to agree to treatment). See Mental Welfare Commission for Scotland: Covert medication good practice guide. Refer to local policy and procedures. Set a date for review of the continued need for covert administration
Cholinesterase inhibitors: stopping established treatment may lead to loss of cognition or function, which may not be regained if the medication is restarted. The risks and benefits of deprescribing should be considered carefully