Antipsychotic prescribing to people with dementia during COVID-19
Authors: Robert Howard, Alistair Burns, Lon Schneider
Journal: The Lancet Neurology (2020)

Antipsychotic drugs are used to treat agitation, aggression, and psychosis in dementia when alternative strategies have failed. Their use has been reduced because of concerns about safety and limited efficacy.1Ballard C Howard R Neuroleptic drugs in dementia: benefits and harm.Nat Rev Neurosci. 2006; 7: 492-500Crossref PubMed Scopus (231) Google Scholar The English National Health Service publishes monthly data on patients registered with a dementia diagnosis in England, including those who have been prescribed an antipsychotic.2NHS DigitalRecorded Dementia Diagnoses—July 2020.https://digital.nhs.uk/data-and-information/publications/statistical/recorded-dementia-diagnoses/july-2020Date: 2020Date accessed: September 24, 2020Google Scholar From March, 2020 (470 292), to April, 2020 (453 377), the number of registered people with dementia fell by 3·60%. There was a similar 3·34% reduction when comparing April, 2019 (469 025) with April, 2020 (453 377). According to the Office of National Statistics, 17 316 patients died in England in April, 2020, with "dementia and Alzheimer's disease" recorded on their death certificate.3UK GovernmentExcess mortality in England: weekly reports.https://www.gov.uk/government/publications/excess-mortality-in-england-weekly-reportsDate accessed: August 26, 2020Google Scholar This number of deaths was nearly three times more than expected, compared with the 5-year mean for April (appendix). Although the absolute number of antipsychotic prescriptions for people with dementia decreased this year from March (45 554) to April (45 286), May (43 374), June (42 664), and July (42 964), reductions in the overall number of registered patients meant that the proportion of patients who have been prescribed antipsychotics substantially increased. Similar to the overall number of people with dementia, the proportion of patients who have been prescribed antipsychotics had tended to be constant, between 9·28% and 9·47%, throughout 2018 and 2019. In March, 2020, this percentage increased to 9·69% (95% CI 9·60–9·77) and in April to 9·99% (95% CI 9·90–10·08); it was 9·80% (95% CI 9·67–9·85) in May, 9·66% (95% CI 9·57–9·75) in June, and 9·74% (95% CI 9·65–9·83) in July. Rates in March, April, and May, 2020, were substantially higher than in the same months in 2018 (increased by 4·40%, 6·95%, and 5·22%, respectively) and 2019 (increased by 4·28%, 7·34%, and 4·87%, respectively). These data support anecdotal reports of increased antipsychotic prescribing to people with dementia during the COVID-19 pandemic.4Wang H Li T Barbarino P Gauthier S Brodaty H Molineuvo JL Dementia care during COVID-19.Lancet. 2020; 395: 1190-1191Summary Full Text Full Text PDF PubMed Scopus (394) Google Scholar People with late-stage dementia and those within care facilities, who would be the group most likely to be prescribed antipsychotics, were over-represented among the additional deaths in April, 2020, and the effects of loss from the register by death of at least 20 000 such people would have been expected to reduce the proportion of patients receiving these drugs.5Graham NSN Junghans C Downes R et al.SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes.J Infect. 2020; 81: 411-419Summary Full Text Full Text PDF PubMed Scopus (166) Google Scholar The register does not record specific indications for antipsychotic prescribing, and it is possible that some of the increase related to delirium management or palliative care, although most of the increase was probably in response to worsened agitation and psychosis secondary to COVID-19 restrictions (eg, care-home residents confined to their bedrooms, cessation of communal activities and family visits). Longer follow-up will show whether systems of caring for people with dementia can adapt to the continued threat of COVID-19 without increased use of antipsychotic drugs and whether we can continue to reduce the use of these drugs when the risks of infection have passed. RH reports grants from the English National Institute of Health Research, outside the submitted work; and is Trustee of the charity Alzheimer's Research UK. AB reports being National Clinical Director for Dementia at the National Health Service England, and receiving personal fees from National Health Service England, personal fees from International Journal of Geriatric Psychiatry, personal fees from various lectures and talks, personal fees from occasional court reports, other from Driver and Vehicle Licensing Authority, outside the submitted work. LS reports grants and personal fees from Eli Lilly, personal fees from Avraham Pharmaceuticals, personal fees from Boehringer Ingelheim, grants and personal fees from Merck, personal fees from Neurim, personal fees from Neuronix, personal fees from Cognition, personal fees from Eisai, personal fees from Takeda, personal fees from vTv Therapeutics, grants and personal fees from Roche/Genentech, grants from Biogen, grants from Novartis, personal fees from Abbott, grants from Biohaven, grants from Washington University of St. Louis, grants from Dominantly Inherited Alzheimer Network Trial Unit of the National Institute on Aging, and personal fees from Samus, outside the submitted work. Download .pdf (.14 MB) Help with pdf files Supplementary appendix