Setting

This audit is particularly useful in old age psychiatry. Patients could be selected from in-patient and out-patient settings.

Background

Around 800 000 people in the UK have dementia, of whom 80% will be expected to have behavioural changes or psychological symptoms in the course of their illness (Overshott & Burns, 2005). The three main types of difficult-to-manage behaviours are associated with:

ᐅ agitation/aggression

ᐅ psychosis

ᐅ mood disorder.

The National Institute for Health and Clinical Excellence (NICE) (2006) and the Drug and Therapeutics Bulletin (2007) have published guidelines on the treatment of behavioural problems in patients with dementia. However, there are no medications currently licensed in the UK for these indications.

Standards

Based on the above guidance, the following standards were obtained:

ᐅ If patients are prescribed an antipsychotic medication, there should be documentation of their severe distress or of immediate risk of harm to themselves or others.

ᐅ Before a patient is started on or switched to an antipsychotic medication, there is documentation of the fact that the prescriber has considered important comorbid conditions such as cerebrovascular disease, diabetes mellitus, Parkinson's disease and hypercholesterolaemia.

ᐅ Discussion with the patient and/or carer is documented of the rationale behind starting on or switching to an antipsychotic medication, as well as discussion of its side-effects.

Method

Data collection

A list was obtained of all patients seen by older people's mental health services within the stipulated time frame for the audit. From this, those who were diagnosed with dementia were shortlisted, and those who were started on or switched to an antipsychotic medication were identified. All documentation (hand-written, computerised and printed) was examined.

Data analysis

The proportion of case notes with appropriate documentation was noted. A standard of 100% was set. A computerised database was used to tabulate and analyse the data.

Resources required

People

It is advisable to involve at least two people for the data collection, especially where there are large numbers of case notes involved.

Time

Data collection can be a time-consuming task when examining case notes.

Results

Among 307 patients screened, only eight were started on or switched to an antipsychotic medication within the audit duration of 2 months. Quetiapine was the preferred antipsychotic. Documentation was reasonably good, although 100% compliance was not achieved.