Psychotropic Drug Therapy in Adults with Learning Disability Steve Wilkinson
Outline and Aims of the Session Drug use in learning disability Two distinct areas of drug therapy I. Treatment of common psychiatric disorders in the learning disabled population II. Treatment of behaviour disturbance (challenging behaviour) in adults with learning disability
Drug Use in Learning Disability All surveys show that use is common in learning disability 20-45% on psychotropic medication (Deb 2006) 1/3 on anti-epileptics 1/3 on antipsychotics Remainder on mixture of antidepressants and anxiolytics
Drug Use in Learning Disability For antipsychotics 22-45% in hospital patients 20% use in community patients 14-30% of psychotropic medication is for behaviour problems 36% Adults with LD on psychotropic's did not have a diagnosed mental illness (Clark 1990) 71% on antipsychotic did not have recorded severe mental illness (Faculty ID report 2016) Polypharmacy common Medication is used for mental illness, epilepsy, sleep problems, hyperactivity, and behavioural problems
Drug Use in Learning Disability Evidence for use not in learning disabled population Indications for use in psychiatric illness the same as non LD population Main difference of use is in the area of challenging behaviour Problems with drug use Consent and Capacity Best Interests Compliance Prominent side effects Communication difficulties Misidentified side effects
Drug Use in Learning Disability Diagnostic difficulties sometimes lead to a therapeutic trial of drugs Starting drug dosage may be smaller than the BNF norm Low and Slow Improvement is often rated by carers, their impression can alter outcomes
Drugs in Specific Psychiatric Disorders Schizophrenia Affective Disorder Mood Stabilisers Anxiety Disorder Dementia
Drug Treatment: Schizophrenia Antipsychotic drugs are the mainstay Large doses still common, polypharmacy, side effects missed and wide overlap into challenging behaviour Increasing pressure to use antipsychotics to treat only a diagnosed mental illness Increased use of the atypical antipsychotics unless good reason not to, Risperidone is the most commonly used. Mostly case reports and handful of RCT's (Deb, 2006) Risperidone or Olanzapine are usually considered first-line Amisulpride or Quetiapine are alternatives
Drug Treatment: Schizophrenia Risperidone, RCT evidence of decreased aggression, but linked with weight gain and somnolence Hyperprolactinaemia problem Clozapine, effective in learning disabled individuals with resistant schizophrenia. 79% responded (Antonacci and de Groot, 2000). Reduces seizure threshold Olanzapine, somnolence, increased appetite, weight gain, glucose intolerance Quetiapine, good choice in Parkinson's and movement disorders
Drug Treatment: Schizophrenia Tardive Dyskinesia in 45-50% of those with learning disability on typical antipsychotics 29% transient dyskinesia on stopping (Gualtieri,1986) TD irreversible more so in LD as in elderly compared to young adults Increased prevalence of NMS in learning disability, twice as common Mortality higher, fluid intake critical Akathisia often missed
Drug Treatment: Affective Disorder Verhoeven (2001), 60% effectiveness of Citalopram in learning disability Langee and Conion (1992), retrospective audit showed 36% response rate to antidepressants in severe and profound LD Only 20% response in those with hyperactivity and self-injurious behaviour,? Treating undiagnosed mood disorder 10% subjects with LD get worse when treated with antidepressants
Drug Treatment: Affective Disorder Which drug to use? Tricylic Antidepressants Poor sleep Significantly reduced body weight Cost or availability Associated enuresis SSRI s Danger of self harm Excessive weight (fluoxetine) Cardiac risks, angina, cardiac conduction defects Sedation problems Poorly controlled epilepsy Obsessional syndromes Others Trazodone-useful for sleep problems and epilepsy Venlafaxine-useful for obsessional symptoms
Drug Treatment: Mood Stabilisers Lithium is effective in mood disorders but can be difficult to manage in LD Blood monitoring can be difficult in the learning disabled Carers often unaware of side effects and changes with physical illness Valproate and Carbamazepine widely used Lamotrigine increasingly used Improvement may be linked to treating epilepsy
Drug Treatment: Anxiety Disorder CBT and environmental manipulation. Don t jump in with medication SSRI s widely used for anxiety disorders May need high doses and be used for 3 months to show response Short course of benzodiazepines Negative effect on cognition, withdrawal problems Buspirone low potency and long onset of action
Drug Treatment: Dementia Donepezil for Alzheimers type mild to moderate dementia Main clinical problem is targeting use in early illness MMSE inappropriate tool in LD DLD (formerly DMR) Memantine use in moderate to severe dementia, some positive effect seen clinically
Drug Use: Challenging Behaviour Wide use of psychotropic drugs in behaviour disorders Antipsychotics are commonly used Move from typical to atypical antipsychotics Aggressive behaviour is the strongest predictor for use of medication Used as both treatment and prophylaxis Lower the IQ the harder it is to distinguish between behaviour disorder and mental illness
Drug Use: Challenging Behaviour 10-15% of people with LD in contact with services have challenging behaviour 2/3rds of those identified were male 2/3rds were adolescents or young adults 50% living with families More demanding behaviours seen in those with profound intellectual disability (Emerson et al, 2001)
Drug Use: Challenging Behaviour Prudhoe Hospital in 1987 (24%) of the hospital patients were receiving antipsychotic medication The most frequent diagnosis was behaviour disorder in 48% of the patients 19% had affective disorder; 13% had schizophrenia Fifteen different antipsychotics were prescribed although Chlorpromazine and Thioridazine were most frequently prescribed (Wressell SE et al, 1990)
Drug Use: Challenging Behaviour Psychotropic drugs are often used for unlicensed indications in people with behavioural challenges in LD Reasons include the management of sleep disturbance, increased arousal and self-injurious behaviour, and behavioural change resulting from epilepsy and dementia A cross-sectional survey of psychotropic drug prescribing in in-patients with intellectual disability found that 46.4% were receiving at least one psychotropic for an unlicensed indication, most typically in an attempt to manage behavioural problems or to stabilise mood (Haw & Stubbs, 2005)
Drug Use: Challenging Behaviour Antipsychotics, typical and atypical Benzodiazepines Anticonvulsants, particularly Carbamazepine and Valproate Antidepressants including Tricyclic, SSRI s and Trazodone SSRI s no controlled studies of effectiveness Buspirone Amantadine Beta-blockers
Drug Use: Challenging Behaviour Naltrexone used in self injury. 30-70% reduction in self-injurious behaviour (Sandman and Hetrick, 1995) Lithium, DBPCT 73% response rate in treatment of aggression (Craft, 1987 Tyrer S, 1984) Lithuim licensed for aggression and self injurious behaviour
Drug Use: Challenging Behaviour Antipsychotics very widely used but evidence-base for their use is poor Brylewski and Duggan (1999), reviewed over 500 citations for antipsychotics in challenging behaviour only 3 were sound RCT s. Uncertain evidence showing that antipsychotics benefit Trend to reduce antipsychotic drugs
Drug Use: Challenging Behaviour NACHBID Trial, Tyrer P et al, Lancet, 2008 Risperidone, Haloperidol and placebo in the treatment of aggressive and challenging behaviour in intellectual disability: randomised controlled trial
Drug Use: Challenging Behaviour Aggression declined dramatically with all three treatments by four weeks, with placebo showing the greatest reduction (79% vs 57% for combined drugs) The mean initial daily dosage for Risperidone was 1.07mg rising to 1.78mg, and Haloperidol 2.54mg rising to 2.94mg Adherence to prescribed medication was good Exclusion factors were high What we must conclude from our data is that the routine prescription of antipsychotic drugs early in the management of aggressive challenging behaviour, even in low dosage, should no longer be regarded as a satisfactory form of care
Drug Use: Challenging Behaviour Placebo/Hawthorn effect Trials in people with intellectual disability often reveal considerable improvement whenever a new treatment is tried The possible reasons for this include: Increased interest in the person being investigated A change in the environment in which the person is living Increased stimulation of the staff and positive changes in the care because of novelty Consequentially the drug is continued
Drug Use: Challenging Behaviour Withdrawal symptoms from antipsychotics include Dysphoria Nausea Vomiting Stomach pains Dizziness Tremor These symptoms have been found in volunteers In Learning Disability may be reasons for requests to continue Need motivated and well informed family and carers
Drug Use: Challenging Behaviour Effects of drug withdrawal Zuclopenthixol in adults with intellectual disabilities and aggressive behaviours: discontinuation study Of 49 patients responding to the treatment 39 took part in a randomised withdrawal trial. The placebo subgroup (20) showed more aggressive behaviour as indicated on the Modified Overt Aggression Scale than the continuing subgroup (19) This indicates that discontinuation of Zuclopenthixol in this population leads to an increase in aggressive behaviour. (Haessler, F et al. 2007)
Drug Use: Challenging Behaviour Thioridazine withdrawal In a population of 155 patients in Bristol, 18 patients were regularly taking Thioridazine at the time of the CSM directive. Only 3 of these patients had a diagnosis of schizophrenia. All 18 patients stopped Thioridazine following the Committee on Safety of Medicines' advice 7 experienced moderate or severe difficulties in the following three months (Davies, 2002)
Psychotropic Drug Prescribing for People With Intellectual Disability, Mental Health and/or Behaviours That Challenge: Practice Guidelines Faculty of Intellectual Disability- April 2016
Standards for Prescribing Indications for use clearly stated, along with off licence, high dose Consent to treatment or Best Interests (family/carer involvement) Monitor response 3 monthly along with side effects Review need to continue 3 monthly, maximum 6 monthly
Recommendations All initiations of psychotropic medications in people with intellectual disability should be by competent in the care of people with learning disability Secondary care initiation Prescribing seen as wider multi-disciplinary and holistic care plan Regular review A national audit of prescribing practice Use of standards by regulators and commissioners
Audit Tool Standards The indication(s) and rationale for prescribing the psychotropic drug should be clearly stated, including whether the prescribing is off-label, polypharmacy or high dose Key lines of enquiry Is the prescribing part of a wider multidisciplinary care plan? Is there documentation of the indication for prescribing? (This can include the diagnoses as well as the narrative account of the target symptoms.) If the prescription is only for behaviour that challenges, are the NICE guidelines being followed? (Psychological interventions have not produced a change within an agreed time period or treatment of coexisting mental and physical conditions have not led to a reduction or risk to the person or others is very severe and drugs are offered only with psychological or other interventions.) Is there off-label prescribing? If so, is the rationale explained? Is there polypharmacy? If so, is the rationale explained? Is there prescribing over British National Formulary maximum limits? If so, is the rationale explained? Audit standard rating Consent-to-treatment procedures (or best- interests decision- making processes) should be followed and documented Is there evidence of a capacity assessment? If the patient is deemed to lack capacity, is the best- interests process followed? Is there evidence that the patient s views about the drug treatment are being recorded? Is there evidence that the carers or family members views about the drug treatment are being recorded? If patient is detained (e.g. under the Mental Health Act 1983), are the legal requirements around consent to treatment satisfied? There should be regular monitoring of treatment response and side-effects (preferably every 3 months or less, at a minimum every 6 months) Review and evaluation of the need for continuation or discontinuation of the psychotropic drug should be undertaken on a regular basis (preferably every 3 months or less, at a minimum every 6 months) or whenever there is a request from patients, carers or other professionals Is there documentation about progress on the target symptoms for treatment? Is there evidence of objective evaluation of treatment response (e.g. use of standardised instruments)? Is there evidence of objective evaluation of side-effects (e.g. use of standardised instruments)? Is there evidence of objective evaluation of treatment response (e.g. use of standardised instruments)? Is there evidence of objective evaluation of side-effects (e.g. use of standardised instruments)? Is there evidence of regular review of the need for continuation or discontinuation of the drug? (This includes discussion of risks and benefits with the patient and/or carer.)
Drug Use: Challenging Behaviour Is there a need for long term medication for challenging behaviour? Identify, mental and physical health factors Treat these as priority Even if now well, if a history of affective disorder try a specific treatment for this Cyclical disturbance of behaviour, try a mood stabiliser
Drug Use: Challenging Behaviour Might epilepsy be a contributing factor? Is the EEG abnormal? If so, try an anticonvulsant Is the patent physically aggressive? If so, try Lithium Risperidone, Olanzapine, Carbamazepine or a -blocker Are there any signs of adrenergic over activity, such as tachycardia or tremor? If so, try a -blocker Is the patient s behaviour impulsive? If so, try an SSRI Is the patent self-injurious? If so, try an antipsychotic, SSRI or Lithium
Summary Try in all circumstances to work out why the person disturbed is behaving in an untoward way Alter the environment whenever possible if this is thought to contribute to the problem Too many people are on psychotropic medication If drugs are prescribed, use sparingly
Summary Have a good indication for use and be prepared to stop Most evidence for drug use on non LD population Beware of side effects being much more likely Low starting dose and increase very slowly and be proud to stop steve.wilkinson@danshell.co.uk