Retrospective Analysis of a Single Centre Experience of the Pharmacological Management of Patients With Intellectual Disability & Challenging Behaviour Across Three Audit Cycles

Abstract

Aims

To investigate adherence to NICE and STOMP guidelines for the pharmacological management of patients with intellectual disability (ID) and challenging behaviour (CB) in a large acute mental health trust over three audit cycles

Methods

The electronic records of a purposive sample of patients with ID and CB under the care of the ID Team at a large acute mental health trust were retrospectively reviewed over three audit cycles (conducted in 2013, 2014 and 2021).

Results

The sample sizes were 31 (2013), 17 (2014) and 35 (2021). Over the three cycles, most patients had moderate (35%, 47%, 49%) or severe ID (42%, 35%, 31%). Common co-diagnoses included autistic spectrum disorder (45%, 47%, 69%), mood disorders (23%,18%,17%) and epilepsy (16%, 24%,31%).

Target behaviours for intervention were aggression (42%, 27%, 49%), agitation (10%, 40%, 40%) and self-injurious behaviour (28%, 20% and 20%).

Medications used for CB were antipsychotics (61%, 24%, 62%), benzodiazepines (20%, 29%, 42%), antidepressants (13%, 35%, 42%) and mood stabilizers (6%, 12%, 9%)

The number of patients on multiple medications to manage CB declined over the years, with an increasing number receiving singular drug therapy (19%, 35%, 34%).

Over the three audited years, there were improvements in risk assessment (68%, 94%, 100%), descriptions of the nature of targeted behaviours (74%, 100%, 100%), metabolic monitoring (0%, 0%, 95%), documentation of successful and unsuccessful interventions (48%, 65%, 86%).

Adherence to certain standards however declined over time or remained difficult to achieve: complete evaluation of mental (87%, 94%, 60%) and physical health (61%, 88%, 60%), documentation of consent (19%, 76%, 46%), documentation of discussions regarding potential side effects (32%, 47%, 50%) and 6 weeks’ review of medications’ efficacy (52%, 65%, 50%). A positive behaviour support care plan was available in 75% of cases in 2021 and had not been audited in previous cycles.

Conclusion

This retrospective analysis highlights a reduction in the use of polypharmacy to manage CB in patients with ID over time. Adherence to standards remains patchy across the years with improvements in risk assessments and metabolic monitoring. Standards necessitating outpatient intervention such as review of medication efficacy, evaluation of mental and physical well-being were hard to achieve, in part explained by service changes and pressures related to the COVID-19 pandemic. Future improvements may require increased pharmacy-led reviews.