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1
Welcome to the Right Care webinar programme

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2
The pharmacist contribution to the care of
people with dementia across health social
care

• Denise Taylor, Anne Child, Jonathan Mason

3
Speakers

• Chair Dr Denise Taylor Senior Lecturer,
  University of Bath and President of CMHP
• D.A.Taylor_at_bath.ac.uk
• Speaker 1 Anne Child, Head of Pharmaceutical
  Care Clinical Standards, Avante Care Support
• Anne.Child_at_avantepartnership.org.uk
• Speaker 2 Jonathan Mason, Clinical Adviser
  (Medicines) at NHS England London Region
• Jonathan.Mason_at_nhs.net

4
Our Objectives

• Scene setting
• - Getting medicines right for people with
  dementia
• CMHP, CPPE Royal Pharmaceutical Society
• Royal College of Psychiatrists
• Local research need for proactive medicines
  optimisation in dementia
• Pharmacist contributions to ensuring appropriate
  medicines use in people with dementia
• NHS England Perspective
• QA Time

5
Dementia

• a syndrome consisting of progressive impairment
  in two or more areas of cognition
• (memory language visuospatial perceptual
  ability thinking problem-solving personality)
• sufficient to interfere with work, social
  function or relationships

6
Local National

• Getting medicines right for people with dementia
• CMHP, CPPE Royal Pharmaceutical Society
• Royal College of Psychiatrists - liaison
• Secondary Care Prescribing of Antipsychotics

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Prescribing Antipsychotics for Older People with
Dementia

• CSM 2004 warning stroke increased by over 3-fold
  with risperidone or olanzapine and more than
  doubled with any other atypical antipsychotic
  agent.
• Two epidemiological studies in 2005 showed
  typicals had similar risk pattern
• Prime Ministers Challenge reduce by 2011
• Audit 2012 success story or.

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ANTIPSYCHOTIC RISK ASESSMENT IN DEMENTIA
(AID - Assess, Investigate and Deliver best care)
Patient ID

• DELIVER BEST CARE
• Complete a Capacity Assessment for informed
  consent to the treatment. If lacking proceed
  under Best Interest guidance (see Mental
  Capacity Act)
• Treat factors which worsen symptoms e.g. delirium
  pain
• Treat underlying thrombo-embolic risk factors ,
  dehydration, causes of sedation e.g. medication
  and infection
• Maximise mobility
• Consider VTE prophylaxis
• Review the need for an antipsychotic on a regular
  basis, initially daily
• Review the need for their continuing use prior to
  discharge
• If prescribed post discharge arrange a
  post-discharge review as soon as possible by
  primary care or specialist mental health services
• Do not give an antipsychotic to a patient with
  Parkinsons disease or Lewy Body dementia without
  advice from a psychiatrist or specialist
  physician experienced in their use. Do not use
  the drugs stated below
• Start with the lowest dose possible for clinical
  effect. Use oral risperidone (max 2mg daily) or
  when oral administration is not possible
  intra-muscular haloperidol (max 3mg daily).
• Do not use anticholinergic medication routinely
  for problematic side effect as they cause
  delirium in dementia as do other drugs with
  anticholinergic side effects. Reduce the dose or
  stop the antipsychotic
• Discuss with the patient their relative/carer
  the risks and benefits of their use. 1 in 3
  people will benefit. 1 in 100 will experience a
  CVA
• 1 in 100 will die as a result of their use

ASSESS Does the patient have dementia with
psychosis or exhibits severe physical aggression?

1
3
YES
NO - do not prescribe an antipsychotic
INVESTIGATE Look for factors which worsen
symptoms risk factors for thrombo-embolism
(CVA, DVT, PE, MI) Delirium (see NICE CG103
Delirium)

Pain
Dehydration

Sedation InfectionImmobility

VTE risk assessment
2
When completed Date
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Pharmacists Role

• Look for underlying causes ensure these are
  treated effectively
• Look for underlying medication precipitants
  withdraw if appropriate
• Ensure smallest effective dose used of
  non-anticholinergic AP (risperidone) monitor for
  effect
• Ensure withdrawn if ineffective or symptoms
  resolve

10
Possible care pathway for AD management in
patients with behavioural symptoms
Diagnosis of Alzheimers disease
Does the patient have challenging behavioural
symptoms?
Yes
No
Consider psychological and alternative therapies
Has there been a sufficient response?
Yes
No
Monitor
Pharmacological options
Short-term management
Longer-term management
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Rationale for Non-pharmacological interventions

• Liaison Services (eg. Ballard et al 2002)
• Clinical Psychologist (eg. Bird et al 2007/2009)
• Staff training (Fossey et al 2006, Chenoweth et
  al 2009)
• Social Interaction (Cohen-Mansfield et al 1997,
  2007, Ballard et al 2009)

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Aromatherapy, herbal remedies and food
supplements
Study Intervention Design Number Outcome
Holmes et al 2002 Lavender aromatherapy Double blind crossover, 10 days n15, NH severe dementia Significant improvement in agitation (p0.02)
Smallwood et al 2001 Lavender aromatherapy and massage Single blind RCT 2 weeks aromatherapy massage v massage only n21 In patients severe dementia 34 improvement in motor agitation (p0.056) with aromatherapy massage
Ballard et al 2002 Melissa aromatherapy Double blind RCT 4 weeks n72, NH severe dementia Significant improvement in CMAI (plt0.0001)
Burns et al 2008/9 Melissa aromatherapy Double blind 12 weeks n100 ESSENCE AD To be completed october 2008
Akhondzadeh et al 2003 Oral Melissa Single blind RCT n30 Agitation in 5 active v 40 placebo (p0.03)
Freund-Levi et al 2008 Oral omega-3 supplements Double blind RCT n174 No overall effect, but significant reduction of agitation with apoE4
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Recommendations for short-term antipsychotic use

• Non pharmacological Interventions and alternative
  pharmacological treatments need to be available
• Severity criteria need to be in place for the
  prescribing of Antipsychotics to people with
  dementia
• Relatives should receive full explanation
• Monitoring should be mandatory
• Treatment should not be continued beyond 12 weeks
  except in extreme circumstances - and this
  should be policed

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Neuropsychiatric symptoms in AD Potential
alternative therapies
Sodium valproate Meta-analysis (Lonergan et al 2008) Low doses ineffective, higher doses poor tolerability
Carbamazepine 2 small 4-6 week RCT focusing on agitation/aggression, both with positive outcomes (Tariot et al 1998, Olin et al 201). Meta-analysis shows significant benefit on CGIC and BPSD (Ballard et al 2009). New Norwegian study this week trend to improvement of agitation. Hollis 2007 no ? mortality.
Gabapentin Systematic review (Kim et al 2008) few small case series only
Trazadone Meta-analysis (Martinon-Torres et al 2008) 2 trials, 1 parallel group, 1 cross-over. Insufficient evidence to recommend as a treatment
Citalopram Two promising RCT, 1 v placebo, 1 v risperidone
Memantine Meta analysis suggests significant benefit for behaviour (2.76 points on NPI McShane et al 2008). Promising post hoc pooled analysis (Wilcock et al 2008)
Cholinesterase inhibitors Ineffective over 12 weeks (Howard et al 2007 CALM-AD). Meta-analyses and pooled analyses suggest 1.5-2 point advantage on total NPI over 6 months (Trinh et al 2003)
Not licensed for treatment of AD
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Assessment Tools

• Assessing cognition in older
• People a practical toolkit
• for health professionals.
• http//www.alzheimers.org.uk/cognitiveassessment

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Recent Research

• Pharmacist input
• concomitant medication
• swallowing difficulties
• compliance issues
• repeat prescribing problems, and
• lack of proactive information provision

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Potential Pharmacist Input

• Medicines management issues
• Concomitant medication
• Medicines use reviews
• Progression, and at any stage
• Proactive provision of information

See the RPS Practice Guidance for
dementia http//www.rpharms.com/public-health-reso
urces/mental-health.asp?
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Medicine Management Issues

• Counselling points
• All medication
• Cautions
• Side Effects
• Assessing Efficacy
• Withdrawal Issues all medication

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Concomitant Medication

• Check for anticholinergic load e.g oxybutynin
• antidepressants thioridazine
• Check for adverse CNS effects e.g. Long acting
• benzodiazepines, barbiturates opiates
  dopaminergics
• Check need for antipsychotics risperidone only
  licensed
• agent in aggression
• Any agent potentially causing confusion e.g. LA
• hypoglycaemics NSAIDs H2 antagonists e.g.
  cimetidine
• Ensure all CV and diabetic risks treated
  appropriately

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Medicines Use Reviewshttp//www.pm-modules.co.uk/
pm_modules/dem_pm0713.pdf

• Appropriate titration
• Check for side effects
• Cholinergic
• Cardiovascular
• Cramps
• compliance issues and repeat prescribing problems
• Other medicines question everything

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Compliance (Secondary Adherence) issues

• Large numbers of medicines
• Interactions or side effects
• Timing
• Remembering
• Strain on main carer/PWD living on own
• Repeat prescribing issues
• - stock, labelling issues, equal quantities of
  all medicines, formulation

22
Progression

• Swallowing difficulties
• Behaviour
• Dietary intake and fluid
• Bowels
• Palliation

23
Proactive Information

• On diagnosis
• signposting to support groups social service
  support
• Lifestyle changes to keep healthy
• healthy body is a healthy brain
• On receiving a medicine for dementia
• AE, compliance issues, concomitant medicines
• Social, ethical and legal issues
• - Advance Directives, wills, Power of Attorney
  etc
• Care end of life issues

24
Social Care Support

• CPN monitoring
• Psychiatric care support programme
• Care patient counselling/support/stimulation
• Day hospital services
• Social worker assessment
• Respite care
• End of Life Care hospice?

25
Why is this Important?

• Prolonged stress leads to poorer health outcomes
  for both carer and PWD and then
  institutionalisation
• Better quality of life for people if better
  adherence to their medicines
• Carers more supported in coping with supervisory
  medicines role

26
Public Health and Dementia?

• Lifestyle changes which
• improve cognitive reserve
• Better and continuing education occupation
• Physical activity and exercise
• Midlife obesity
• Alcohol intake
• Smoking cessation
• ?improved social networking

• Improved treatment or
• prevention of certain
• medical conditions
• Stroke prevention
• Diabetes control,
• midlife hypertension,
• Midlife hypercholesterolaemia
• Midlife fitness levels

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QUALITY OUTCOMES FOR INDIVIDUALS WITH DEMENTIA

• Anne Child
• Head of Pharmaceutical Care and Clinical
  Standards
• Avante Care and Support

28
HERE WE ARE! - WHERE ARE WE ?

• Challenges faced in delivering quality
  outcomes for residents with dementia
• Dementia is in itself a complex condition
  requiring a MDT approach
• Residents are often living with more than two
  other LTC that need close monitoring and
  co-ordinated management across specialisms
• There is a need to meet health and social care
  needs in order to promote overall well being

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IMPROVED INTEGRATION HOW THIS WOULD HELP WITH
MUR !

• Access to specialist input in home environment -
  GPs can access support i.e. ask consultants
• Is there a pathway where pharmacists could tap
  into specialist pharmacists and thus improve
  residents outcomes?

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Continued

• This could be used post review to enhance
  recommendations - more MDT working
• Facilitate medicines optimisation and or
  facilitate withdrawal of low dose antipsychotics
• how many community pharmacist would feel
  confident to initiate withdrawals?
• Improve professional understanding
• Help with management and positive care planning
  for residents

31

• Example of medication review outcomes
  

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POSITIVE CARE PLANNING I.E. LBD

• Pharmacist Input could be focused on the
  individual, not the drug profile
• Increase staff awareness to drug sensitivity of
  individuals with this diagnosis
• Increase risk of postural hypotension and falls,
  target this area in MURs
• Reduction in psychotropic medication by
  management of disease manifestations

33
Advanced care planning

• Adequate information for individuals and their
  relatives to support decision making
• Some areas have this well managed see PEACE
  pathway Kings College for last months of life
• Medway has the my wish register

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APPROPRIATE USE OF LOW DOSE ANTIPSYCHOTICS

• In practice at home level we apply best practice
• Watchful waiting - Psychosocial interventions -
  In some residents we have found it is appropriate
  to use this form of medication in line with the
  Banerjee report
• Regular review

35
OTHER HEALTH CARE PROFESSIONALSAvante is lucky
enough to have

• An Admiral Nurse who works with individuals,
  families and staff to improve understanding and
  manage expectations of care
• A Health and Wellbeing specialist who oversees
  nutrition and hydration

36
MORE THAN THE DRUGSOUTCOME LINKED

• Reducing avoidable hospital admissions linked to
  medication, falls, nutrition and hydration
• Personalisation of care and improved expectations
• Living well with dementia as opposed to suffering
  from dementia

37
Jonathan Mason

• Clinical Adviser (Medicines) at NHS England
  London Region
• Why dementia matters to me, and why it should
  matter to Pharmacy

38
Conclusions

• Dementia is a complex and life changing condition
• It affects spouses, partners, families and
  communities
• Needs are multiple and varied
• Medicines can play an important role in delaying
  progression and Improving behaviours
• Pharmaceutical Care for people with dementia and
  their carers needs to be proactive

39
Questions

• Today we have briefly looked at how
• pharmacists are and can help support
• people living with dementia
• in any care sector.
• We would value your questions or
• comments

40
Dementia Action Alliance.

• If you would like to join DAA for support in your
  practice in dementia please join here
• http//www.dementiaaction.org.uk/join_the_alliance
  
• There are further resources after the the next
  slide

41
Thank you

• The Dementia Action Alliance will send you an
  invitation to join our Linkedin network over the
  coming weeks.
• For todays slides and any other resources from
  past webinar events please visit
  http//www.dementiaaction.org.uk/rightcarewebinars
  

42
Alzheimer's Society

• Assessing cognition in older people a practical
  toolkit for health professionals.
  http//www.alzheimers.org.uk/cognitiveassessment
• Reducing the use of antipsychotic drugs A guide
  to the treatment and care of behavioural and
  psychological symptoms of dementia
• http//www.alzheimers.org.uk/site/scripts/download
  _info.php?fileID1133

43
Mortality risks typical and atypical
antipsychotics
Risks Typical Atypical References
Death Ballard, Rochon, Gill, Schneeweis, Schneider, Wang
Stroke () () Gill, Hermann, Rochon, Kleijer, Douglas
Heart death Ray, Wang
Pneumonia Knol
44
Responses to atypical antipsychotics

• Response based on CGIC score at 12 weeks
• 32 Olanzapine group
• 26 Quetiapine group
• 29 Risperidone group
• 21 placebo group
• Overall comparison p0.22

A response was defined as continued treatment
with the original phase 1 study drug and at least
minimal improvement on the CGIC.
Schneider L et al. NEJM 2006 3551525-38.
45
Differential Survival
Ballard C et al. Lancet Neurol 2009 8(2)151-7.
46
Psychotropic drugs and BPSD
40-60 people with dementia in NH are taking
antipsychotics1
Drugs None (n13) Delusions (n28) Agitation (n72) Depression (n35)
Neuroleptics 4 (31) 13 (46) 38 (72) 16 (46)
Benzodiazepines 0 (0) 4 (14) 10 (14) 5 (14)
Antidepressants 2 (15) 6 (21) 17 (24) 13 (37)
Other psych 1 (8) 1 (4) 3 (4) 0 (0)
Table adapted from Ballard et al 2001
47
Stopping antipsychotics Impact on QoL
n42 Baseline (sd) Follow-up Follow-up Evaluation (Baseline v Follow-up)
n42 Baseline (sd) FITS (sd) Control (sd) Evaluation (Baseline v Follow-up)
Social Withdrawal 6.64 (8.96) -5.24 (13.56) -1.29 (5.42) T 2.1 p0.04
Daytime sleep -20.69 (23.24) -6.20 (24.58) -1.29 (24.38) T 1.1 p0.27
Type 1 Behaviours 34.74 (19.53) 13.44 (23.73) 1.47 (24.29) T 2.3 p0.03
Wellbeing 0.65 (0.69) 0.34 (0.59) 0.15 (0.98) T 2.2 p0.03
CMAI 42.88 (14.57) 0.75 (22.35) 5.29 (12.74) T 0.83 p0.41
48
Further Information- general

• Mental Health Resources http//www.rpharms.com/sup
  port-tools/mental-health-resources.asp
• Pharmaceutical care Guidance in Mental health
  http//www.rpharms.com/public-health-issues/mental
  -health.asp
• Alzheimers Society http//alzheimers.org.uk/
• College of mental health pharmacy
  http//www.cmhp.org.uk
• CPPE Focal Point on Dementia http//www.cppe.ac.u
  k/learning/Details.asp?TemplateIDDementia2DW2D0
  1FormatWID174EventID-
• CPPE Mental health http//www.cppe.ac.uk/learning/
  programmes.asp?formateID47theme11
• CPPE http//www.thelearningpharmacy.com/
• Taylor D.A. Medicines Use Reviews in Dementia.
  CPD Module. Pharmacy Magazine June 2013.

49
Living with Dementia

• Living with dementia
• http//www.youtube.com/watch?vWR74FEyc9KYfeature
  related
• Communication
• http//www.healthtalkonline.org/Nerves_and_brain/C
  arers_of_people_with_dementia/People/Interview/839
  /Category/144/Clip/4016/dementia-communicationdem
  entia-communication

50
Dementia Video Clips

• Alz Pt 1 of 4
• http//www.youtube.com/watch?v_OD0z0u93swfeature
  channel
• Alz Pt 2 of 4
• http//www.youtube.com/watch?vVHxdAYmMfK4feature
  channel
• Stan 3 of 4
• http//www.youtube.com/watch?vyykeknxMozkfeature
  channel
• Mum 4 of 4
• http//www.youtube.com/watch?vnl9xqm_9KbENR1
• Living with dementia
• http//www.youtube.com/watch?vWR74FEyc9KYfeature
  related
• Dementia tour (what its like to live with
  dementia) http//www.youtube.com/watch?v3hROU6f5T
  UQ

51
Carer Views on Medication

• Over-sedated
• http//www.healthtalkonline.org/Nerves_and_brain/C
  arers_of_people_with_dementia/People/Interview/833
  /Category/160/Clip/3519/dementiadementia
• Problem in giving medication
• http//www.healthtalkonline.org/Nerves_and_brain/C
  arers_of_people_with_dementia/People/Interview/830
  /Category/102/Clip/3693/dementia-medicationdement
  ia-medication
• Availability of medication
• http//www.healthtalkonline.org/Nerves_and_brain/C
  arers_of_people_with_dementia/Topic/2075/