Dr. Ken Courtenay FRCPsych MRCGPDr. Ken Courtenay FRCPsych MRCGP ([email protected]) Consultant...
Transcript of Dr. Ken Courtenay FRCPsych MRCGPDr. Ken Courtenay FRCPsych MRCGP ([email protected]) Consultant...
Dr. Ken Courtenay FRCPsych MRCGP ([email protected])
Consultant Psychiatrist in Intellectual Disability
London UK
EAMHID Zagreb 27.4.2018
Overuse of Medication in People with ID
Clinical Background
Case Vignettes
Prescribing Practice
Challenges
Classes of Psychotropics
Antipsychotics
Antidepressants
Mood Stabilisers
Stimulants
Non-stimulants
Hypnotics
Clinical Indications
• Psychosis - Risperidone
• Mood Disorders – Olanzapine; Valproate
• Anxiety – Pregabalin; Fluoxetine
• ADHD – Atomoxetine; Methylphenidate
Role of Psychiatrist
• Mental Disorder - assess, diagnose, treat
• Medication - prescribe / monitor
• Risk - assess / manage
• Liaise / Advise - carers, service-users, families, GP, colleagues
• Legislation - MHA / MCA
‘Challenging Behaviour’
• NICE Guidance NG11 (2015) / QS101 (2015)
• ‘Challenging Behaviour – a Unified Approach’ (2016) RCPsych & BPS
• NICE Guidance NG54 (2016) / QS142 (2017)
Case 1: Challenging Behaviour?
28 year old woman Smith-Magenis Syndrome Aggression / ‘Trantrums’
Hypomania
Case 1: Drug Regimen
2006 2009 2010 2016 Benperidol Haloperidol Lithium
Carbonate Lithium Carbonate
Quetiapine Lithium Carbonate
Olanzapine
Haloperidol PRN
Clonazepam
Semi-Sodium Valproate
Lorazepam PRN
Case 2: Diagnoses
33 year old man in Supported Living
Schizo-affective Disorder? (2004)
Tourette’s Syndrome (childhood)
Autism (2012)
ADHD (2012)
Case 2: Drug Regimen
2006 2016
Risperidone Atomoxetine (ADHD)
Semisodium Valproate Pregabalin (Anxiety / ASD)
Haloperidol Olanzapine (Tic Disorder)
Lorazepam Intensive Support Team PBS
Adverse Effects
Metabolic
• Weight Gain • Dyslipidemia • Hypertension • Elevated Prolactin
Amenorrhoea Gynaecomastia
Motor
Extrapyramidal Effects • Oculgyric effects • Tremor • Dystonias
Tardive Dyskinesia
Case 3: Adverse Effects
73 year old man
Institutional care Supported Living
‘Molesting’ female support workers
Restless – not sitting still
Monitor Adverse Effects
• Rating Scales
Metabolic – GASS (Glasgow Antipsychotic Side effect Scale)
Motor – LUNSERS (Liverpool University Neuroleptic Side Effects Rating Scale)
Challenges to Psychiatrist
Psychiatrist
Mental Illness?
Prescribe?
Reduction / withdrawal Substitution?
Withdrawal period
Others
Change in behaviour
Resistance
Resources to monitor changes
Impact of Medication
• Person Clinical Effectiveness Quality of Life – impact of side effects
• Prescriber Monitoring of drug regimens
• Health Service Expenditure on medication
Clinical Practice
• Clinical Discussion – service-user; family; carer; colleagues
• Clear explanation – ‘Reasonable Adjustment’; ‘easy-read’
• Time to consider
• Agree desired outcome
• Clinical Review
• Measurement - clinical effects / side effects
Clinical Practice
• ‘Operationalise’ - CB Care Pathway
• Alternatives to medication – support plan
• ‘Everyone’s business’ – professionals; carers; families; service-users
Why is it important?
• Prevalence rates of mental disorders (SCZ 3%) • High rates of physical disorders • Medication use in People with ID • Polypharmacy • Clinical effectiveness • Adverse effects
What we know
• Glover (2015): GP data Antipsychotics 17% Antidepressants 16% Mood stabilisers 7%
• Sheehan (2015): THIN Database ‘Disproportionate use of Psychotropics in People with ID’
What does it mean in Clinical Practice?
• Mental Disorder or Challenging Behaviour?
• Drug reduction / withdrawal? (Sheehan 2017)
• Terminology: Withdrawal; Optimisation; ‘Deprescribing’
• Resources in Clinical Services
Whose Business Is It?
• Psychiatrists
• Clinical Teams
• Primary Care
• Pharmacists
• Families / Carers
• People with ID
Clinical Practice
• Clinical Discussion service-user; family; carer; colleagues
• Clear explanations
• Time to consider
• Agree desired outcome
• Clinical Review
• Measurement - clinical effects / side effects
• Care and Treatment Reviews
Summary
• Role of Psychiatrist
• Challenging Behaviour / Mental Disorder?
• Managing medication
• Alternatives to medication
• Working with others especially the person
Dr. Ken Courtenay FRCPsych MRCGP ([email protected])
Consultant Psychiatrist in Intellectual Disability
London UK
EAMHID Zagreb 27.4.2018