Medications

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The Northern Ireland Medicines Optimisation Quality Framework (March 2016) outlines what needs to be done at each stage of the patient pathway within the acute hospital setting to ensure people gain the best possible outcomes from their medicines. People living with dementia should be supported to achieve these same outcomes at each stage.

• Admission

On admission patients, family or carers should be encouraged to bring in the person's own medicines from home so that they can be checked and used where possible. Within 24 hours of admission or sooner if clinically necessary, patients should have their medicines reconciled in accordance with the Trust policy for Medicines Reconciliation.

Presumptions should not be made that people living with dementia cannot participate in gathering information or making decisions about their medicines. Every effort should be made to adapt this task to meet the needs of the person.

At the point of admission staff should identify the normal medicines routine/approach. This should consider if the person self-manages their medicines at home, or whether they are supported or assisted by family or friends and in what way. Information of the medication routine should be clearly documented at the point of admission to help inform prescribing decisions, medicines administration and effective discharge plans.

People with dementia admitted to the acute setting should have a comprehensive review of the appropriateness of their medicine regimen. Medicines review should consider the patient's preferences, priorities and values whilst considering how medicines impact on their overall health goals with respect to functionality, life expectancy and frailty.

Prescribers should always consider the potential increased risk of adverse effects when doses are increased or new medicines are commenced in people with dementia. Patients and their families or carers should be involved in decisions to start any new medicines and receive appropriate, tailored information on the medicines and the expected health outcomes.

• Acetylcholinesterase (AChE) Inhibitors (Donepezil, Rivastigmine and Galantamine):

AChE inhibitors used to reduce memory and cognitive decline in dementia should not be stopped abruptly on admission to hospital.

If the admission is considered to be related to the use of the AChE inhibitor, staff must discuss the ongoing need to prescribe with a Geriatrician or Old Age Psychiatrist within the Trust.

In the late stages of dementia, AChE inhibitors and Memantine are no longer used as a means of reducing decline in memory and cognitive functions. Instead their role is to support basic psychomotor processes required to help caregivers deliver basic care.

The benefits may also extend to reducing antipsychotic usage.

Abrupt withdrawal can adversely impact on these benefits.

In patients progressing to very advanced dementia, the overall benefit of these agents should be assessed in conjunction with a Geriatrician or Old Age Psychiatrist before considering discontinuation.

• Antipsychotics

Antipsychotics are known to have limited benefits in treating behaviours that challenge, but can cause significant harm by placing the patient at increased risk of sedation, falls, accelerated cognitive decline, stroke and death.

All antipsychotic therapy in use in people with dementia should be continually reviewed.

Staff must complete the needs assessment for patients with dementia who were receiving antipsychotics before admission and also for those who are to be started on antipsychotics during their hospital stay.

Non-pharmacological approaches are considered first line treatment for the management of behaviours that challenge. People with dementia should only be offered antipsychotics if they are severely distressed or if there is an immediate risk of harm to the person or others.

Before being prescribed an antipsychotic, the patient and/or family should be provided with written and verbal explanation of the risks and benefits for the use of antipsychotics. Any discussion should be written in the patient's medical notes.

Risperidone is the only antipsychotic licenced for the short term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others. The reasons to prescribe and antipsychotic 'off-licence' should be clearly documented in the medical notes.

Any new prescription for antipsychotic therapy should have documented target symptoms, planned duration of treatment and communication of when and who will review the effectiveness and ongoing need.

• Analgesia

Effective pain management and the prescribing of appropriate analgesia in people with dementia can be challenging because of the presence of comorbidity and polypharmacy.

The lack of recognition of pain particularly in the non-verbal person is one of the main reasons for poor levels of analgesic prescribing. The use of traditional pain scales can be difficult to administer because of communication barriers.

Staff should administer the modified Bolton pain scale on admission and throughout the in-patient stay.

Coupled with comprehensive assessment and pain history (gathered from patient or their family), the scale should be used to prompt prescribing in accordance with the guidance for the use of analgesia in older people (currently under development).

A risk factor of delirium is the adverse effect of medicines. Staff should review all prescribed medicines with the aim of reducing or stopping medications known to cause or increase the risk of delirium in older people.

Medicines with anticholinergic activity can increase the risk of cognitive impairment and delirium in people with dementia. These medicines are also known to directly negate the effects of the AChE inhibitors used to treat dementia. Staff should review the use of anticholinergics affecting cognition in all people with dementia, delirium or cognitive impairment with the aim of stopping or switching to a medicine with lower anticholinergic burden.

• Administration

The administration of medications may be one task which results in the person living with dementia exhibiting behaviours that challenge. These behaviours can be a result of the change in the regular routine and approach to medication administration. Where this is identified, all efforts should be taken to clarify and implement the normal routine and to support supervised administration where possible by the patient or family.

Staff must ensure a comprehensive medication review involving the patient and their family has been undertaken by the medical team or pharmacist. This review should aim to minimise distress to the patient and family by ensuring the total number of medicines to be administered are kept to a minimum and the most appropriate choice, dose, route and formulation is used.