Psychotropic Medication Prescribing to Patients with Dementia Admitted to Acute Hospitals in Ireland.

Abstract

Psychotropic medications are commonly prescribed to people with dementia (PwD) for non-cognitive symptoms of dementia (NCSD), but have significant risks. A national audit was performed in acute hospitals in the Republic of Ireland (ROI) to establish baseline practice prior to the launch and implementation of a National Clinical Guideline on the appropriate prescribing of psychotropic medications for NCSD. The objective of this study was to analyse psychotropic prescribing patterns and compare these with international data and with existing (limited) data from a previous audit round. The pooled anonymous dataset from the second round of the Irish National Audit of Dementia Care (INAD-2) was analysed. The audit had collected retrospective data from 30 random healthcare records from each of 30 acute hospitals in 2019. Inclusion criteria were a clinical diagnosis of dementia of any type, hospital stay of 72 hours or more, and discharge or death within the audit period. Most hospitals (87%) self-audited their healthcare records, but a random sample of six healthcare records (20%) from each hospital were re-audited by a highly trained healthcare auditor. The audit tool was based on a tool used in the England and Wales National Audit of Dementia audit rounds (Royal College of Psychiatrists), adapted to the Irish healthcare setting and national priorities. In total, 893 cases were included, as one hospital could not retrieve 30 cases even within a more prolonged audit period. The sample comprised 55% females and 45% males; the median age was 84 years (interquartile range 79-88 years) and the majority (89.6%) were >75 years of age. Only 52% of healthcare records specified the type of dementia; within these, the most common diagnosis was Alzheimer's disease (45%). Most PwD (83%) were receiving psychotropic medication on admission; 40% were prescribed new or increased psychotropic medication during admission, mainly for medical indications, including end-of-life care and delirium. Anticonvulsants or cognitive enhancers were rarely prescribed for NCSD in hospital. However, new/increased antipsychotic medication was prescribed for NCSD in 11.8-17.6% of the total cohort, while 4.5-7.7% were prescribed a benzodiazepine for anxiety or NCSD. Overall, there was poor documentation of risk/benefit, or of discussion with the patient/family, and apparently inadequate review for efficacy and tolerability. Concurrently, acetylcholinesterase inhibitors appeared to be underused for cognitive impairment in the community. This audit provides baseline data on psychotropic medication prescription for NCSD in Irish hospitals prior to a specific Irish guideline on this topic. Reflecting this, most PwD were receiving psychotropic medications on admission, and many were prescribed new/increased psychotropic medication in hospital, often without evidence of appropriate decision making and prescribing processes.