“Doing damage in delirium the hazards of antipsychotic treatment in elderly people”

This paper was published in the Lancet in late last year. It is a two page article that is worth reading in full. All screenshots below are from this paper:

The authors commented that:

The authors were of the view that:

Scottish Government figures confirm that prescribing of antipsychotics is rising in our elderly. It thus seems important to consider why this may be. The authors continue:

There is always the risk in times of austerity, and when staffing levels are not ideal, that:

The authors state:

The promotion of off-label use of antipsychotic medication was instrumental in my petition to the Scottish parliament for a Sunshine Act:

The authors continue:

But what does the evidence have to say? The authors state:

The authors continue:

The authors ask:

The authors conclude with Dr William Osler:

There is a risk that “brief screening tools” result in “pathways” being followed that, despite good intentions, lead to greater prescribing of antipsychotics in our elderly. I am aware that currently “brief screening tools” are being promoted in Scottish NHS hospitals.

I wish to conclude with one recent example of many: an elderly woman, with terminal cancer returned to her GP after a recent period in hospital. She asked her GP “But why am I on this anti-schizophrenic drug?”

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The following pathway was introduced across NHS Scotland:

This is a complicated pathway. This  is a close-up on the treatment section:

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Hospital prescribing of Haloperidol in your NHS Health Board area

The following Freedom of Information request was sent to all 14 NHS Boards in Scotland.  The responses, including tables of statistics, can be read here.

7 November 2014.

Dear NHS Board,
I am writing as part of a Freedom of Information request regarding statistical details of the prescribing of the antipsychotic medication generically called HALOPERIDOL. It may be that the all of the information that I request is already available through a publicly accessible database and if so could you please direct me to this.

The reason I write is that I am aware that Hospital Guidelines/Protocols for acute agitation, psychosis, behavioural or psychological disturbance generally seem to include Haloperidol as the first-line pharmacological treatment of choice, given either orally or intramuscularly.

This week in the British Medical Journal the following paper has been published: “Change Page: “Don’t use antipsychotics routinely to treat agitation and aggression in people with dementia” This refers to individuals who may be diagnosed with dementia, but I am aware that prescribing of Haloperidol, as part of Hospital Guidelines/Protocols is also part of management of Delirium.

I am aware that prescribing of Haloperidol is also routinely part of protocols in those aged under 65 for acute or chronic agitation, psychosis, behavioural or psychological disturbance.

Could you please answer the following questions as completely as possible:

1. For the last 5 years (2009 to 2013 inclusive) could you confirm the quantity of Haloperidol issued to cover all acute and community hospitals in your NHS Board area as per each strength:

ORAL TABLET HALOPERIDOL
0.5mg,
1.5mg,
5mg
10mg
20mg

ORAL LIQUID HALOPERIDOL
1mg/ml
2mg/ml

INJECTABLE HALOPERIDOL
5mg/ml

2. Can you supply any protocols/guidelines in place for your NHS Board area that include Haloperidol as part of a treatment pathway.

• Can you confirm if you have a protocol for Delirium and if it includes recommendation of Haloperidol?
• Can you confirm if you have a protocol for Dementia and if it includes Haloperidol as a treatment option for “BPSD” (Behavioural and Psychological Symptoms of Dementia)
• Can you confirm when each protocol was first issued?
• Can you confirm if Haloperidol is ever prescribed in those under 16 years of age?

I am grateful for your help.
Yours faithfully,

Peter J Gordon

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‘Improvement Science’ and the potential for harmful consequences:

On Friday the 25th of November 2016 I gave a talk for the Scottish Philosophy and Psychiatry Special Interest Group. My subject was “Improvement Science”. If you click here you can read my presentation: