Laxative use in adults with intellectual disabilities: development of prescribing guidelines.

BACKGROUND: Constipation is overrepresented in people with intellectual disabilities. Around 40% of people with intellectual disabilities who died prematurely were prescribed laxatives. A quarter of people with intellectual disabilities are said to be on laxatives. There are concerns that prescribing is not always effective and appropriate. There are currently no prescribing guidelines specific to this population. AIMS: To develop guidelines to support clinicians with their decision-making when prescribing laxatives to people with intellectual disabilities. METHOD: A modified Delphi methodology, the RAND/UCLA Appropriateness Method, was used. Step 1 comprised development of a bespoke six-item, open-ended questionnaire from background literature and its external validation. Relevant stakeholders, including a range of clinical experts and experts by experience covering the full range of intellectual disability and constipation, were invited to participate in an expert panel. Panel members completed the questionnaire. Responses were divided into 'negative consensus' and 'positive consensus'. Members were then invited to two panel meetings, 2 weeks apart, held virtually over Microsoft Teams, to build consensus. The expert-by-experience group were included in a separate face-to-face meeting. RESULTS: A total of 20 people (ten professional experts and ten experts by experience, of whom seven had intellectual disability) took part. There were five main areas of discussion to reach a consensus i.e. importance of diagnosis, the role of prescribing, practicalities of medication administration, importance of reviewing and monitoring, and communication. CONCLUSIONS: Laxative prescribing guidelines were developed by synthesising the knowledge of an expert panel including people with intellectual disabilities with the existing evidence base, to improve patient care.

Chronic constipation in people with intellectual disabilities in the community: cross-sectional study.

BACKGROUND: One-third to half of people with intellectual disabilities suffer from chronic constipation (defined as two or fewer bowel movements weekly or taking regular laxatives three or more times weekly), a cause of significant morbidity and premature mortality. Research on risk factors associated with constipation is limited. AIMS: To enumerate risk factors associated with constipation in this population. METHOD: A questionnaire was developed on possible risk factors for constipation. The questionnaire was sent to carers of people with intellectual disabilities on the case-loads of four specialist intellectual disability services in England. Data analysis focused on descriptively summarising responses and comparing those reported with and without constipation. RESULTS: Of the 181 people with intellectual disabilities whose carers returned the questionnaire, 42% reported chronic constipation. Constipation was significantly associated with more severe intellectual disability, dysphagia, cerebral palsy, poor mobility, polypharmacy including antipsychotics and antiseizure medication, and the need for greater toileting support. There were no associations with age or gender. CONCLUSIONS: People with intellectual disabilities may be more vulnerable to chronic constipation if they are more severely intellectually disabled. The associations of constipation with dysphagia, cerebral palsy, poor mobility and the need for greater toileting support suggests people with intellectual disabilities with significant physical disabilities are more at risk. People with the above disabilities need closer monitoring of their bowel health. Reducing medication to the minimum necessary may reduce the risk of constipation and is a modifiable risk factor that it is important to monitor. By screening patients using the constipation questionnaire, individualised bowel care plans could be implemented.

A retrospective observational study of the use of gastroprotection for patients on dual antiplatelet therapy.

Dual antiplatelet therapy is recommended for secondary prevention of ischaemic events in coronary artery disease. Some patients, who may be at high bleed risk if other factors are present, should be considered for gastroprotection. In our survey, we assessed whether gastroprotection was prescribed for hospital inpatients, especially high-risk patients, who were receiving dual antiplatelet therapy at discharge, and the type of gastroprotection prescribed. We found that over 13 months, a total of 1,693 patient episodes were prescribed dual antiplatelet therapy at discharge, of which 71% also received gastroprotection. Of the patient episodes who were not prescribed gastroprotection, 46% (223/483) met the criterion of age as a risk factor for gastroprotection. A further 30 episodes met other risk criteria of certain concomitant drugs or prior comorbidity. There is a need among clinicians and pharmacy teams within the hospital for recognition and management of this opportunity to improve the care of these patients.

UK psychiatrists' experience of withdrawal of antipsychotics prescribed for challenging behaviours in adults with intellectual disabilities and/or autism.

BACKGROUND: A high proportion of adults with intellectual disabilities are prescribed off-licence antipsychotics in the absence of a psychiatric illness. The National Health Service in England launched an initiative in 2016, 'Stopping over-medication of people with a learning disability [intellectual disability], autism or both' (STOMP), to address this major public health concern. AIMS: To gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours. METHOD: An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225). RESULTS: Half of the 88 respondents stated that they started withdrawing antipsychotics over 5 years ago and 52.3% stated that they are less likely to initiate an antipsychotic since the launch of STOMP. However, since then, 46.6% are prescribing other classes of psychotropic medication instead of antipsychotics for challenging behaviours, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11.4% reported deterioration in challenging behaviours in over 50% of patients on withdrawal and the same proportion (11.4%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid carers' concern, lack of multi-agency and multidisciplinary input and unavailability of non-medical psychosocial intervention are key reported factors hampering the withdrawal attempt. CONCLUSIONS: There is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.

General practitioners' and psychiatrists' attitudes towards antidepressant withdrawal.

BACKGROUND: There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects. AIMS: To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms. METHOD: Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert. RESULTS: Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned. CONCLUSIONS: Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines.

A structured programme to withdraw antipsychotics among adults with intellectual disabilities: The Cornwall experience.

BACKGROUND: Antipsychotic medications are used among 19%-58% of adults with intellectual disabilities to manage challenging behaviour against the NICE guideline recommendations. Studies show that it is possible to completely withdraw antipsychotics in about one third of adults with intellectual disabilities and a dose reduction of 50% or more in another third. METHOD: In Cornwall, over three years the present authors developed a structured pathway to withdraw antipsychotics among adults with intellectual disabilities which involved people with intellectual disabilities and their carers, GPs, community learning disability team members and pharmacists. RESULTS: The present authors managed to withdraw antipsychotics totally among 46.5% (33/71) and reduced over 50% of dosage in another 11.3% (8/71) of adults with intellectual disabilities. At three months follow-up no one required hospital admission or change in placement. CONCLUSION: It is possible to withdraw/reduce antipsychotics in a high proportion of adults with intellectual disabilities if a concerted effort is made involving all stakeholders from the outset.

Accuracy of pharmacist electronic discharge medicines review information transmitted to primary care at discharge.

Background The poor quality of discharge summaries following admission to hospital, especially in relation to information on medication changes, is well documented. Hospital pharmacists can record changes to medications in the electronic discharge note to improve the quality of this information for primary care. Objective To audit the pharmacist-completed notes describing changes to admission medication, and to identify improvement opportunities. Setting 750-bed teaching district general hospital in England. Methods An evaluation of pharmacist written notes was conducted at a 750-bed teaching district general hospital in England. A sample of notes was analysed in three consecutive years, 2016-2018. Analyses were performed using descriptive statistics. Main outcome measure The number of discrepancies in the note compared to the discharge summary medication list. Results Notes were analysed for 125, 120 and 120 patients in 2016-2018 respectively. We saw an overall improvement in the accuracy of our notes from 12% of patients having an inaccurate note in 2016 to 4.2% in 2017 and 5.8% in 2018. The percentage of discharge medicines affected by these discrepancies reduced from 1.7% (2016) to 0.6% (2017) and 0.9% (2018). Conclusion Discrepancies were due to changes in the patient's medicines journey not being fully captured and documented. The overall reduction of discrepancies over the three consecutive audits was felt to be largely due to formalisation of the discharge medicines reconciliation process and reminding staff on how to complete a note. We are planning to utilise informatics surveillance tools along with system developments to sustain this elimination of out of date notes being transmitted to primary care.

Valproate MHRA Guidance: Limitations and Opportunities.

Recent publication of the Medicines and Healthcare products Regulatory Agency (MHRA) in the United Kingdom has strengthened the regulatory measures for valproate medicines. It highlights the importance of making women of childbearing age with epilepsy aware of the teratogenic risks of valproate and encourages the withdrawal of it from those currently prescribed. While a significant directive, it raises concerns of not having considered the impact on special populations such as women with Intellectual Disability (ID). While it is important that women with ID are not excluded from such safety initiatives, due caution needs to be taken on a case by case basis preferably, to ensure their best interests are central to the decision making. Many women with moderate to profound ID cannot have informed consented sexual relationships not to mention cognitive incapability to make informed choices on medication suitability. These women are at potential risk of having their epilepsy control undermined due to the MHRA directives. Around 30% of people with moderate to profound ID have seizures of which 60% are considered treatment resistant. In this vulnerable population changes to medication without clear clinical and social insights could lead to increased harm levels. This paper enumerates the challenges of application of the new directive to these special populations and proposes a pathway based on individual cognitive ability to provide informed consent to facilitate the continuation or removal of valproate. It is important not to lose sight of individual circumstances and the importance of working collaboratively toward providing person center care.

Improving knowledge of psychotropic prescribing in people with Intellectual Disability in primary care.

PURPOSE: People with Intellectual disability (ID) are likely to be prescribed psychotropic medication particularly antipsychotics without a clear clinical indication. This has given rise to a national initiative in the UK to stop overprescribing medication in this vulnerable population. While the goals are simple it is unclear if specialist ID services or primary care services in the UK should look to lead. Further, it is uncertain if primary care practitioners (GPs) can be systematically educated of the latest good practice developments and concerns in this specialised area. This study surveyed the knowledge level of a sample of GPs in Cornwall UK (county of 538,000) post a structured tutorial on psychotropic medication and people with ID. METHODS: A 21 item questionnaire was delivered in meetings organised for all the county GPs a year after a talk given to the same demographic. The questionnaire conducted an assessment of the knowledge of national guidance on use of psychotropic medication in ID based on the subjects covered in the tutorial. RESULTS: Of the 60 expected GP participants the tutorial was attended by 44 GPs (73%) and the follow up meeting by 42 (70%). Ninety percent GPs in the follow up meeting filled the questionnaire. For 16 questions, more than 80% GPs gave correct responses whereas five questions attracted a correct answer from less than 80%. Majority of the GPs felt psychotropic medication management in people with ID should be specialist led. CONCLUSIONS: GPs' knowledge of issues relevant to prescribing in people with ID benefitted from the tutorial. However a clear need for the psychotropic medication management to be delivered via specialist care emerged. This raises issues of resource allocation and debate on whether people with ID require specialist provision due to lack of ability in main stream primary care to manage their needs.

Going down the tubes! Impact on seizure control of antiepileptic medication given via percutaneous feeding tubes.

BACKGROUND: Long-term feeding by percutaneous endoscopic gastrostomy tube (PEG) is uncommon but can present significant issues when both nutrition and medication have to be fed down the same tube. This is especially important in people with epilepsy where the dose and bioavailability of antiepileptic drugs are critical to maintain adequate seizure control. This group with long-term PEG tubes is particularly vulnerable and dependent on their carers to provide high standard of care. Indeed, approximately half of the people with long-term feeding tubes suffer from severe intellectual disability which requires careful coordination of all members of the multidisciplinary team. It is all the more important when consideration is given that around 50% of people with severe ID have seizures, mostly treatment resistant. METHOD: A detailed literature review was conducted with the focus on the numerous factors that can affect medication delivery and absorption with the potential to destabilize seizure control in people with PEG. Issues concerning the site of drug absorption, excipients and dilution, interaction between antiepileptic drugs and the nutritional feed, bioavailability, and problems with the PEG tube are considered. RESULTS: There is limited research in this area and the studies are often based on small numbers, healthy volunteers or in vitro findings. CONCLUSION: In the absence of sound research data, seizure control in each patient with a PEG needs to be considered on an individual basis. Establishing a baseline by measuring the serum levels prior to the tube insertion may be helpful, followed by checking the levels after PEG insertion.

Omitted doses as an unintended consequence of a hospital restricted antibacterial system: a retrospective observational study.

OBJECTIVES: The objective of this study was to determine the frequency of omitted doses of antibacterial agents and explore a number of risk factors, including the effect of a restricted antibacterial system. METHODS: Antibacterial data were extracted from a hospital electronic prescribing and medication administration system for the period 1 January to 30 April 2014. Percentage dose omission rates were calculated. Omission rates for the first dose of antibacterial courses were analysed using logistic regression to identify any correlation between first dose omission rates and potential risk factors, including the antibacterials' restriction status and whether or not they were ward stock. RESULTS: The study included 90 761 antibacterial doses. Of these, 6535 (7.2%) were documented as having been omitted; omission of 847 (0.9% of 90 761) was due to medication being unavailable. Non-restricted, ward stock antibacterials had the lowest frequency of omission, with 6.2% (271 of 4391) first doses omitted. The prevalence was 10.4% (27 of 260) for restricted, ward-stock antibacterials (OR = 1.6, 95% CI = 1.0-2.4, P = 0.027) and 15.5% (53 of 341) for non-restricted, non-ward stock antibacterials (OR = 2.7, 95% CI = 2.0-3.7, P < 0.001). Restricted, non-ward stock antibacterials had the highest frequency (30.7%, 71 of 231; OR = 6.2, 95% CI = 4.5-8.4, P < 0.001). CONCLUSIONS: Antibacterials not stocked in clinical areas were significantly more likely to be omitted. The prevalence of omitted doses increased further if the antibiotic was also restricted. To achieve safe, effective antimicrobial use, a balance is needed between promoting antimicrobial stewardship and preventing unintended omitted doses.