Clinical Audit: Prescribing antipsychotic medication for people with dementia

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1 Clinical Audit: Prescribing antipsychotic medication for people with dementia Trust, team and patient information Q1. Patient's DIS number... Q2. Patient s residence: Home Residential Home Nursing Home Other *If other, please specify Q3. Patient's year of birth (yyyy)... Q4. Patient s gender Female Male Q5. Are NICE Guidelines being followed?: Yes No Q6. Patient's sub-type of dementia (ICD-10 category) (see guidance notes for further information) F00: Dementia in Alzheimer's disease F02: Dementia, other (incl frontotemporal dementia) F00.2: Dementia in Alzheimer's disease, atypical or mixed type F03: Unspecified dementia F01: Vascular dementia F02.3: Dementia in Parkinson's disease Sub-type not yet determined Unknown Q7. Severity of dementia (see guidance notes for further information) Mild Moderate Severe Not Known/not documented Q8. Other psychiatric diagnoses (tick all that apply) F05: Delirium F20-29: Schizophrenia spectrum disorder F32-39: Depression F32.3: Psychotic depression F70-79: Mental retardation/ learning disability None documented Other psychiatric diagnosis documented in clinical records please specify below * F31: Bipolar disorder F40-48: Anxiety spectrum disorder 1

2 Q9. Please tick all of the following medications the patient is currently prescribed. No dosage, administration or other information required (see guidance notes for further information) Regular Rx Dose PRN Rx Dose Analgesic Anticholinergic Antidepressant SSRI Antidepressant trazadone Antidepressant other Carbamazepine Cholinesterase inhibitors Lamotrigine Lithium Lorazepam Benzodiazepine other Melatonin Memantine Memory enhancing drug other Pregabalin Valproate Z-hypnotics * If other psychiatric medications are prescribed, but not listed above, please specify the type of medication Q10. Last medication review undertaken by GP: Q11. Is the patient currently prescribed an antipsychotic (regular and/or PRN)? Yes No! Stop here if the patient is not prescribed an antipsychotic 2

3 Clinical indications and antipsychotic prescribing Q12. Who initiated the most recently prescribed antipsychotic medication? Primary Care Secondary Care Unknown/unclear Q13. Who is currently prescribing this antipsychotic medication? Primary Care Secondary Care Unknown/unclear Q14. How long has this antipsychotic medication been prescribed? Less than 3 months 6 months 1 year 3 months less than 6 months Longer than 1 year Q15. What is the total duration of treatment with antipsychotics (regular and/or PRN) to date, including the one most recently prescribed? (see guidance notes for further information) Not previously prescribed an antipsychotic Less than 3 months 6 months 1 year Longer than 1 year 3 months less than 6 months Q16. Documented clinical indications/ target symptoms. Please record below all the clinical indications for the current antipsychotic medication(s) in this patient, as documented in the clinical records at the time of initiation or at subsequent review. Please tick all that apply Known psychotic illness such as schizophrenia, bipolar disorder, psychotic depression Evident or assumed psychotic symptoms (delusions/ hallucinations/ paranoia/ suspiciousness not due to known psychiatric illness as in the previous box) Depression/low mood Disturbed sleep Fear/anxiety Agitation Distress Verbal Verbal aggression aggression Physical aggression Disinhibited behaviour (e.g. removing clothes) Resisting help with activities of daily living such as hygiene, eating, drinking, dressing, etc. Wandering! Stop here if the patient has a diagnosis of F20-29: schizophrenia, F31: bipolar disorder 3 or F32.3: psychotic depression

4 Complete Q17-20 for all who do not have a diagnosis of F20-29: schizophrenia, F31: bipolar disorder or F32.3: psychotic depression and whose total duration of treatment with antipsychotic medication(s) is less than 3 months. Q17. Is there documented evidence that the following potential underlying causes of BPSD (behavioural and psychological symptoms in dementia) were considered? (see guidance notes for further information) Depression Anxiety Side effects of medication prescribed at the time Physical illness (constipation, UTI, chest infections, heart failure, etc) Other cause(s) Pain Q18. Is there documented evidence that any of the following non-pharmacological interventions were tried before an antipsychotic was prescribed? Please tick all that apply Engagement in social/personal activities Changes to staff approach (e.g. behavioural approach, distraction techniques) Changes to the environment (e.g. lighting, TV,availability of quiet areas, orientation aids) Other approaches (e.g. reminiscence therapy, aromatherapy, multi-sensory stimulation, therapeutic use of music and/or dancing, animal assisted therapy, massage) No documented evidence 'Watchful waiting'/ monitoring Q19. Is there documented evidence that a risk/benefit analysis regarding antipsychotic medication was carried out (severity of BPSD vs side effects, risk of stroke, etc.)? (see Yes No Q20. Is there documentation that the patient and/or carer(s) were consulted about the risks and benefits, prior to antipsychotic initiation. Please tick all that apply Patient consulted Care worker consulted Family carer consulted No documentation of patient/carer consultation 4

5 Complete Q21-24 for all who do not have a diagnosis of F20-29: schizophrenia, F31: bipolar disorder or F32.3: psychotic depression and whose total duration of treatment with antipsychotic medication(s) is more than 3 months. Q21. Is there documented evidence in the clinical records of a medication review addressing therapeutic response in the past 6 months? Please tick all that apply, leave blank if nothing is documented Medication review by primary care addressing therapeutic response Medication review by secondary care addressing therapeutic response Mobility Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Q22. Is there documented evidence in the clinical records of a medication review considering/addressing the following possible adverse events, in the past 6 months? Please tick all that apply, leave blank if nothing is documented Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Falls Sedation Low blood pressure Chest infection Anticholinergic side effects (e.g.constipation, blurred vision, urine retention, dry mouth) Q23. Is there documented evidence of the patient and/or carers being involved in any medication review conducted? Yes No Not applicable (e.g. neither patient or carer are able to participate due to no carer, carer unavailability, or patient lacking capacity) Q24. Is the outcome of the most recent medication review clearly documented (e.g. medication warrants continuation unchanged, change in dosage required, change of antipsychotic drug required)? Yes No No documented review 5

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