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Clinical Audit: Reviewing the use of antipsychotic medicines in older people

This audit helps health professionals in primary care to identify patients aged 65 years and older who are taking an antipsychotic to determine whether there is an appropriate reason for prescribing the medicine, non-pharmacological interventions have been discussed and treatment has been reviewed.

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Published: 4 May 2020

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Older people are particularly vulnerable to the adverse effects associated with antipsychotics, which are often prescribed off-label and sometimes for inappropriate indications, e.g. for insomnia. Non-pharmacological treatments should be used first-line and continued if an antipsychotic is initiated. These medicines should only be prescribed if they are likely to be beneficial for the condition being treated and the patient closely monitored for the development of intolerable or serious adverse effects. Treatment should be initiated as a trial at the lowest dose likely to provide therapeutic benefit. In most cases, indefinite treatment is not appropriate and should ideally not exceed three months duration.

Further discussion on the appropriate use of antipsychotic medicines in older people, including national antipsychotic prescribing data, is available from:

We recommended that this article is read before completing the clinical audit

This audit identifies patients aged 65 years and over who are taking an antipsychotic to determine if this prescribing is appropriate

Finding eligible patients

You will need to have a system in place that allows you to identify patients aged 65 years and over who are taking an antipsychotic. Many practices will be able to do this by running a “query” through their PMS.

Sample size

The number of eligible patients will vary according to your practice demographic. It is unlikely that a large number of results will be returned, but if so, take a random sample of 20–30 patients.

Criteria for a positive outcome

You will need to access and review the patients’ clinical notes to complete this audit. For a positive result, each patient’s notes should contain documentation of:

  • An appropriate reason for prescribing the antipsychotic, i.e. prescribed for a condition for which there is evidence that antipsychotics are effective and a recommended treatment
  • Discussion and implementation (if appropriate) of nonpharmacological interventions
  • Review of treatment effectiveness and adverse effects in the past three to six months. Ideally, patients should be reviewed frequently after an antipsychotic is first initiated and again at three months

Any patient whose notes do not contain the information described above should be flagged for review.

Data analysis

Use the sheet provided to record your data. A positive result is any patient taking an antipsychotic who has evidence in their clinical notes of an appropriate reason for prescribing the medicine, a discussion of non-pharmacological interventions and a treatment review. The percentage achievement can be calculated by dividing the number of patients with a positive result by the total number of patients audited.

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

  • What is the problem or underlying problem(s)?
  • Change it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • Identifying barriers can provide a basis for change
  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Monitoring change and progress

It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that the doctor completes the first part of the Audit of Medical Practice summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices complete the remainder of the Audit of Medical Practice summary sheet.

Claiming credits for Te Whanake CPD programme requirements

Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).

Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.

To claim points go to the RNZCGP website:

If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the RNZCGP website).

N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.

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