Setting

This audit is relevant to psychiatrists working in the field of old age psychiatry. It can relate to either in-patient or out-patient settings, but would be of particular relevance to memory clinics.

Background

Anti-dementia medications are not without significant side-effects, and close monitoring is necessary to ensure that anticholinesterase (AchE) inhibitors are being used appropriately. In November 2006, the National Institute for Health and Clinical Excellence (NICE) revised its guideline on prescribing and monitoring the use of AchE inhibitors (donepezil, rivastigmine, galantamine and memantine) in Alzheimer's dementia. These guidelines limited the use of these medications to patients with moderate Alzheimer's disease, defined as those with scores of 10–20 (out of 30) on the Mini-Mental State Examination (MMSE) (Folstein et al, 1975).

Standards

Standards were obtained from the NICE (2006) guideline on prescribing and monitoring the use of AchE inhibitors. Of particular relevance were:

ᐅ Medications can be prescribed only by specialists in elderly care (psychiatrists, neurologists and physicians specialising in care of the elderly) for patients with an MMSE score between 10 and 20.

ᐅ Carers’ views should be sought at baseline.

ᐅ Patients who continue the drug should be reviewed at 6-monthly intervals by means of MMSE score, along with a global, functional and behavioural assessment.

ᐅ Carers’ views should be sought regarding the patient's condition at followup.

ᐅ The drugs should be continued only while the patient's MMSE score remains at or above 10 points and his or her global, functional and behavioural condition remains at a level where the drug is considered to be having a worthwhile effect.

ᐅ Prescribing can occur outside these guidelines, but clear documentation outlining these clinical decisions is necessary.

Method

Data collection

The medical notes of patients who had been in the service since November 2006 and who were currently prescribed AchE inhibitors were selected. Notes were examined to ascertain documented evidence of the following:

ᐅ type of dementia diagnosed (Alzheimer's disease, mixed-type, vascular, etc.)

ᐅ the clinician who initiated treatment

ᐅ type of medication begun (i.e. donepezil, galantamine or rivastigmine)

ᐅ baseline recordings of MMSE score, carers’ views and assessments of functioning

ᐅ frequency of follow up, evidence of ongoing MMSE assessment, carers’ views and assessments of the patient's global, functional and behavioural condition