Behavioural and Psychological Symptoms of Dementia (BPSD) include a range of neuropsychiatric disturbances such as agitation, aggression, depression, and psychotic symptoms. These common symptoms can impact patients’ functioning and quality of life. Antipsychotic medication can be prescribed to alleviate some symptoms, but this comes with significant risks including cerebrovascular events and increased mortality. We aimed to review antipsychotic prescribing of the Harrogate Older Adult Community Mental Health Team (CMHT); to measure compliance with NICE guidance and local policy and thus improve the prescribing and monitoring process.

Using electronic patient records, we identified all patients under the care of the CMHT with a diagnosis of dementia currently receiving antipsychotic treatment; a total of 55 patients. A random sample of 24 patients were reviewed; their records were hand searched for relevant information.

The standards measured were derived from the NICE Guideline (NG97) June 2018: ‘Dementia: assessment, management and support for people living with dementia and their carers’ as well as local trust guidance.

All 24 patients were receiving antipsychotics for severe distress or aggression. 88% of patients had an assessment of sources of distress before treatment was started, but only 42% had a non-pharmacological intervention before antipsychotic treatment was started. Once antipsychotic treatment had started this increased to 58%. For some patients, the reason for not receiving a non-pharmacological intervention was due to urgency of treatment or being on a waiting list for occupational therapy, but for most the reason was not explicitly documented.

For 63%, there was evidence of a discussion of the risks of treatment with the patient, carer or family member. 63% had initial baseline blood tests and 54% had a baseline ECG. Of the patients who did not have initial monitoring, a suitable reason was given for just over 60%. Only 33% of patients who had antipsychotic treatment for over 12 weeks had a trial of discontinuation or dose reduction. Less than 22% of patients had physical health monitoring at one year of treatment.

There were shortfalls in several areas including the offer of non-pharmacological interventions, regular review of the ongoing need for antipsychotics, and physical health monitoring.

Introduction of a checklist before antipsychotics are prescribed is recommended, to include discussion of risks and benefits, non-pharmacological interventions, and initial monitoring. Also recommended is a system to identify when monitoring and review of antipsychotics are due.

The impaired functioning of patients with dementia has economic, social and quality of life implications for individuals, carers and wider society. We audited the provision & uptake of psychosocial interventions to promote the cognition, independence and well-being of Later life Adults under Macclesfield Memory services, supported by Service and Involvement, Recovery and Wellness Centre at Jocelyn Solly Resource Centre, United Kingdom. Compliance with National guidance on psychosocial care for patients with dementia was assessed: 1. NICE guideline [NG97] “Dementia: assessment, management and support for people living with dementia and their carers.” 2. “Memory Services National Accreditation Programme Standards for Memory Services”

Electronic patient records were retrospectively reviewed. Clerical staff identified all patients with dementia reviewed at Jocelyn Solly Resource Centre from 1/4/22 – 31/07/22 (n=140) and data of referrals to, and engagement with, the Recovery College collected.

23/140 patients (16.4%) were referred to the Involvement, Recovery and Wellness Centre by a single referrer; 12 booked onto workshops, 4 declined, 1 was unable to attend due to lack of transport & 6 were not successfully contacted. 11.4% (n=16) of clinic letters documented referral and nil stated referral rationale. n=1 patient attended tai-chi and booked workshops included: Cognitive Stimulation Therapy (CST) (n=8), Living well with dementia (n=1), Living well with a long term condition (n=1), Anxiety Management (n=1). Compliance was 100% for: trained staff delivering workshops, patients and carers having access to psychosocial interventions for challenging behaviour and assessment and interventions for the emotional, psychological and social needs of carers. 99.3% of patients (n=139) were offered pharmacological intervention (or the exception documented). There was no access to individual/maintenance CST, art or creative therapies nor input from psychology or occupational therapy due to vacancies. No patients <65 were signposted to work, education or volunteering.

Though the Recovery college adequately trains and supervises staff and documents patient outcomes, there is capacity to improve the quantity of referrers, referrals & attendances to maximize existing resource utilisation. Implementing strategies to reduce access barriers and hiring a psychologist & occupational therapist would improve service quality. Documenting patient-defined goals and using multiple outcome measures would better enable staff to review progress and could heighten patients’ motivation to engage with services.

Recommendations to improve compliance include: amending clinic letter proformas to include patient-defined goals, psychological and social interventions; educating team members about services offered and referring to the Recovery college and implementing multidisciplinary review of recovery college referrals.

We set out to compare the physical health monitoring of patients established on Clozapine within our local mental health team (LMHT) to national and trust guidance. We also compared data collected in this audit with results from a similar audit conducted in 2018 to identify if improvements had been made to services. We then sought to present the findings to our LMHT to shape the formation of a newly set up pharmacy technician led Clozapine clinic.

National Institute for Health and Clinical Excellence (NICE) and Nottinghamshire Healthcare Trust (NHT) guidelines were reviewed to set criteria for the audit. Where NICE and NHT guidance stipulated similar recommendations, NICE guidance was used to set criteria. Criteria was found to be met if it had been collected within the last 12 months. Data were collected by a single clinician over the period of one month on review of electronic medical records.

30 patients were identified as established on Clozapine within our LMHT. 27 (90%) patients had a licensed diagnosis for Clozapine prescription. Smoking status was recorded in 26 (83.3%) patients and caffeine intake in 21 (70%) patients. Full blood count, liver function tests, urea and electrolytes all met the criteria at the 100% target however one patient was found to have Hba1c and lipid measurement outstanding. Weight was documented for 29 patients (96.7%) however waist circumference was documented in five (16.6%). This was the lowest scoring criteria. Pulse and blood pressure was recorded in 27 (90%) patients. Electrocardiograms were less consistently recorded as completed, with 22 (73.3%) recorded. Physical health monitoring was recorded for 27 (90%) patients, whilst 10 (33.3%) had a GASS-clozapine form completed. Percentages for all criteria that were measured in 2018 were found to be higher in the 2022 cycle.

Findings show that physical health monitoring for the patients prescribed Clozapine in our LMHT does not consistently meet guidance. Development of a ‘Clozapine clinic’ was already planned. Results from this audit were shared within the LMHT and recommendations were made as follows; i) a measuring tape to be placed in each room ii) data such as weight, blood pressure and heart rate to be entered in a way that it can be plotted over time iii)pharmacy technician to work with a healthcare assistant to ensure all criteria can be met in the designated yearly Clozapine clinic

The audit was undertaken to explore if inpatients with treatment resistant schizophrenia (TRS), or whose condition has not adequately responded to two antipsychotics of an optimal duration and dose, were offered clozapine as per NICE guidelines (CG178 1.5.7.2).

Data were collected retrospectively and anonymously from all electronic notes via the UK-CRIS analysis platform.

The inclusion criteria required patients, aged 18–64 years, to have a schizophrenia (ICD10 F20) diagnosis and to have been admitted to one of ten Trust inpatient wards between 01/01/2020 and 01/01/2021.

Patients were required to fulfil the criteria of treatment resistance, as having an inadequate response to two or more antipsychotic drugs, one of which was an atypical agent.

Patients who had previously tried or were currently on clozapine were excluded. Those with non-schizophrenia psychotic disorders were also excluded. 347,645 records were electronically screened according to the criteria, and 209 records were reviewed.

43 patients from the 209 patients reviewed were found to be eligible for clozapine. 28 (65%) were offered clozapine during their admission and 9 of these patients had started the titration process (21% of those eligible).

Of the 19 patients who declined clozapine when offered, 14 had refused the drug with the most common reason of not accepting the required blood monitoring (n=10).

Of the 15 eligible patients who were not offered clozapine, the clinical team had documented a consideration to offer clozapine in 6 patients (14%) but had rejected its, predominantly due to concerns of non-compliance.

For 3 patients (7%) the clinical team considered for but did not offer clozapine. There was no documentation regarding clozapine for 6 patients (14%).

This audit identified that most patients with TRS were offered clozapine during their admission. However, a proportion of patients were not offered the gold standard treatment for TRS and this may lead to poorer outcomes.

It demonstrated that a minority of eligible patients ultimately start the drug. There are barriers for eligible patients to accept clozapine, for instance around the regular blood monitoring required.

To re-audit whether community teams are requesting GPs to take over the prescribing of antipsychotic depots for patients who have been stabilised on treatment, in line with Shared Care Pathway protocols by Greater Manchester Medicines Management Group (GMMMG).

The sample size was 199 patients open to Rochdale, Heywood and Middleton community mental health team antipsychotic depot clinics. Information was gathered from depot cards, care records and clinical entries on Paris and imputed on an Excel spreadsheet. This was a prospective audit and data collection took place between 01/11/22 and 30/12/22 by the auditors. Microsoft Excel was used to carry out simple percentage analysis by the authors and presented using charts.

Transfer of prescribing responsibility for first generation antipsychotic had the highest compliance rate with 98% prescribed by GP on shared care protocol for stable patients followed by Paliperidone and Risperidone at 94%. Aripiprazole was the least compliant with 91% prescribed by GP for stable patients as against 100% target.

Overall compliance rate for all depot antipsychotics was 96% compared with 83% from original audit in 2020. In comparing the different community teams, one team was compliant by 99% overall in transferring prescribing responsibility to the GP for stable patients and 100% compliant with 1st generation antipsychotics, paliperidone and risperidone.

The data showed that CMHT prescribed higher proportion of 2nd generation antipsychotics when compared to original audit.

This re-audit has demonstrated that overall, there was significant improvement in compliance with GMMMG shared care guidelines by Rochdale community teams from 83% in 2020 to 96% in 2022. However, this does not meet the standard of 100% target for depot antipsychotics as per GMMMG guidelines. In other to ensure that target standards are met a 100%, secondary care prescribers should ensure appropriate transfer of prescribing responsibilities via the shared care protocol to the GP for stable patients are done and also shared with the new team particularly during the transition phase for patients transferred from one team to another who are stable on their current medication.

The psychiatry liaison team at Chelsea and Westminster Hospital (C&W) specialises in working together with different healthcare teams to improve patient outcomes. Following feedback received from ward teams who manage the patients that we support on a daily basis, we identified a need for an accessible and user-friendly document that could give some guidance towards safely managing patients on lithium, including lithium toxicity. We do not anticipate medical teams at C&W to initiate lithium therapy without liaison psychiatry input. The most likely scenario where staff will encounter lithium is in patients admitted whilst on established lithium therapy. The aim of the guidance document is to support our medical and surgical colleagues across the hospital site to safely continue to prescribe lithium.

To create this document, we reviewed joint Lithium Policies across several NHS Trusts in England. This policy has been adapted from Central and North West London's own policy to be more specific in supporting best practice for clinicians in initiating, monitoring and adjusting lithium therapy in a safe and timely way.

Junior doctors in liaison psychiatry wrote policy which was re-drafted with consultant support and input. Additionally, specialist advice was provided by mental health pharmacists for subsequent revisions. At present, the policy is awaiting discussion at a prescribing group meeting prior to starting the implementation process across the trust.

Multidisciplinary feedback from pharmacy has advised that this guidance is particularly useful because lithium patients are so infrequent (approximately 55 patients on lithium at C&W in a 12 month period). Ward teams are therefore unfamiliar with prescribing and managing lithium, and crucially, at recognising signs and symptoms of toxicity. The guidance is not only functional, but is incredibly accessible. It is well laid out and makes use of colour to make it user-friendly. It is an appropriate length and includes a one page overview that is ideal for printing or for quick-reference.

Developing this lithium policy has been a key patient safety project. We hope this document will be a useful and safe tool for ward teams to refer to. Liaison psychiatry continue to have an excellent relationship with our ward colleagues and we hope this policy represents our ongoing dedication towards service development.

During this process, we have been grateful for the expert help from our pharmacy colleagues and have learnt about how liaison psychiatry can support ward teams by creating a robust and easy to follow guideline.

Chemsex refers to the use of specific drugs before or during sex to sustain, enhance, disinhibit, or facilitate the sexual experience, primarily amongst gay, bisexual and other men who have sex with men. The main drugs associated with Chemsex are crystal methamphetamine, gamma-hydroxybutyrate/gamma-butyrolactone, mephedrone and ketamine. There are complex biological, psychological, and social factors that influence why someone may choose to engage in Chemsex that are yet to be fully elucidated. However, there are global concerns that such harm is increasing both in prevalence and complexity, including interfaces between the health, social care and criminal justice systems. Chemsex has been identified as a priority for the UK Home Office Drug Strategy since 2017; however, the response to date has lacked a coordinated approach between the multiple services and agencies where Chemsex can present.

West London NHS Trust hosted a day-long meeting of the Chemsex Expert Reference Group (ERG) on 27th July 2022 at the London School of Hygiene and Tropical Medicine. This comprised of a group of clinicians and academics across the NHS, criminal justice system and third sector, with the meeting focused on three main clinical questions: what do we need to know about working with this complex and vulnerable group of people?; What is the research needed to improve this?; What are the aspiration clinical pathways that should be developed?

The ERG identified several gaps in our knowledge including a paucity of epidemiological data, the importance of cultural competency around the health needs of LGBTQ+ people, inconsistencies in the knowledge of healthcare professionals on how to manage emergency presentations such as methamphetamine-induced psychosis, GHB withdrawal and GHB overdose and risk assessment and risk management for those who may also be a victim and/or a perpetrator of a criminal offence in the Chemsex context. The group's core values for service and pathway development were identified as to be authentic, competent, non-judgemental and that lived experience should be at the centre of service development, as well as being evidence-based and supported by national clinical guidelines.

What was apparent was the ambition and interest from across so many clinical specialities, and some incredibly positive work that is already ongoing. It is hoped that the outcomes of this ERG can help progress this to a more cohesive set of responses, and the development of an evidence-based, multi-agency approach to assessment and treatment for this complex group.

Women with bipolar disorder have a high recurrence rate in the perinatal period. However, the use of prophylactic medication can be a concern during pregnancy and breastfeeding. There are few studies looking at the impact of prophylactic medication on the risk of recurrence.The aims of this study are to describe the use of medication in women with bipolar disorder in the perinatal period and the impact of that prophylactic medication on the rate of postnatal recurrence.

The BDRN (Bipolar Disorder Research Network Study) is the largest individual network of individuals with bipolar disorder and related mood disorders in the world. The BDRN pregnancy study is a prospective observational study which took place in the UK. We collected sociodemographic, clinical and medication data from pregnant women with a diagnosis of bipolar disorder and who were euthymic entering the postpartum period. The clinical data were collected via interviews during pregnancy and the postpartum and access to clinical records where those were available.

Data were analysed for association using χ2 tests and logistic regression.

Our total sample for this analysis comprised of 103 women who met the criteria.

We found that 71 (70%) were taking medication at delivery: 43 (43%) antipsychotics, 9 (9%) antidepressants, 10 (10%) mood stabilisers, (6 lithium, 4 anticonvulsants and 9 multiple medication classes).

Of the total sample, 44 (43%) experienced a postpartum recurrence: 21 (20%) had an episode of postpartum psychosis, 15 (15%) of non-psychotic depression and 8 (8%) of hypomania. Of the postpartum psychotic episodes 11 were of mania with psychosis, 8 of mania without psychosis and 2 of psychotic depression.

There was no significant association between taking medication at delivery and postpartum recurrence χ2 (1)=0.116, p=0.73.

In a multivariable analysis there continued to be no association when adjusted for age, ethnicity, parity, severity (previous admissions, age at impairment, bipolar subtype) and previous psychotic symptoms aOR 1.35 95%CI [0.45; 4.00], p=0.59.

A high number of bipolar women are taking medication at delivery and in the majority, antipsychotics are prescribed. The postnatal recurrence rate in both medicated and unmedicated women is high.

Our findings align with recent electronic health records and observational studies, but differ from older clinical cohort and higher Lithium-prescribing sample studies. Limitations include the study design and confounding by indication. Further research in larger populations is necessary to inform clinical decision-making for women and their healthcare providers.

Benefit has been shown from testosterone therapy given to postmenopausal women experiencing reduced sexual desire. Specifically, an increased frequency of satisfying sexual encounters and intensity of sexual desire and better sexual response has been shown with testosterone therapy in a number of studies spanning more than 35 years. Androgen therapy has been related to improvement in energy, mood, well-being, self-perception, and some parameters of sexuality (libido, activity, sexual arousal, excitability and satisfaction.

In a group of 10 menopausal women applying Testogel 16.2mg/g at the dose of 20.25 mg every 3-4 days as part of their usual care together with oestrogen +/- progestogen HRT, we measured serum testosterone and free androgen index (FAI) pre-application of Testogel and 24 hours after its application. Testosterone was measured by mass spectrometry. The Female Sexual functioning Index (FSFI) was completed by the women.

The range of duration of treatment with testosterone was 6 months-23 years. All women subjectively reported an improvement in sexual function with testosterone administered most recently as Testogel.

Female Sexual functioning Index (FSFI) median score was 24.5/36 (25-75% interquartile range 18-28) with highest domain scores for sexual satisfaction and arousal (4.2/6) and moderate scores for orgasm and desire (3.6/6) with lowest domain score for lubrication (2.4/6) and no reported issues re pain on intercourse, All women subjectively reported an improvement in sexual function with testosterone supplementation.

Mean pre-Testogel administration testosterone level (corresponding to a trough level) was 0.85: 0.6-1.2 nmol/L (median: 25-75% interquartile range) rising at 24 hours post Testogel to 3.6: 1.9-4.8 nmol/L (median: 25-75% interquartile range) (Reference range for testosterone is women is up to1.4 nmol/L).

The rise in serum testosterone was not associated with any untoward effects in terms of hirsutism/acne.

All the women in our case series experienced benefit with testosterone gel in terms of sexual function. FSFI score indicated reasonable sexual function in this group of women treated with Testogel for HSDD.

The increase in serum testosterone level and FAI at 24 hours after application of Testogel was not associated with untoward reported / manifest consequences.

Testosterone supplementation is not approved for treatment of hypoactive sexual desire disorder (HSDD) in the UK / other parts of Europe. This matter needs to be addressed as a priority by all stakeholders so that this medication can be made more freely available.

Neuropsychiatric symptoms including depression, apathy and psychosis are experienced by the majority of patients with Parkinson's disease. A subgroup of patients develop cognitive impairment, which may increase the risk of falls due to reduced attention. Acetylcholine deficit is thought to contribute to neuropsychiatric symptoms in Parkinson's disease. The acetylcholinesterase inhibitor rivastigmine is beneficial in Parkinson's disease dementia (PDD), but the consensus for the use of rivastigmine earlier in the disease course is unclear. This systematic review aims to assess the evidence for rivastigmine in the treatment of neuropsychiatric symptoms in Parkinson's disease without dementia.

EMBASE, MEDLINE, PsychINFO, Cochrane CENTRAL, NGLC, NICE Evidence and medRxiv.org were searched for studies with terms relating to Population (Parkinson's disease) and intervention (rivastigmine).

1922 references were identified, of which 358 were duplications.

Inclusion criteria were: diagnosis of Parkinson's disease, rivastigmine intervention and the presence of neuropsychiatric symptoms or falls. Articles were excluded if they only related to patients with dementia.

Following title and abstract review, 1331 articles were excluded.

After full text review, 9 articles remained, which underwent a risk of bias analysis.

Outcomes were heterogenous, so were not suitable for meta-analysis. Therefore, the results are presented in narrative form. The articles included 6 Randomised Controlled Trials (RCTs), 2 open-label trials and 1 case-series.

Three of the studies focused on psychosis. Two of these studies indicated a benefit of rivastigmine on psychotic symptoms in Parkinson's disease. However, these studies were an open label trial and a case series, and the results were not reproduced during RCT.

One RCT indicated benefit of rivastigmine in rapid eye movement behaviour disorder (RBD).

One RCT showed improvements in apathy after treatment with rivastigmine.

Two RCTs demonstrated a reduction in falls with rivastigmine treatment compared to placebo.

One RCT showed a significant improvement on a performance-based measure of cognitive ability.

One study identified brain areas that were hypoactive in hallucinating Parkinson's patients, and the reduced activity could be restored with rivastigmine. This restoration of activity was associated with improved attention compared to baseline.

There is evidence that rivastigmine is beneficial for RBD and apathy in Parkinson's disease, independently from the presence of dementia. There is high level evidence that rivastigmine reduces falls, which may be due to improved attention. The impact of rivastigmine on psychotic symptoms is less clear, but is supported by current theoretical models which involve acetylcholine dysfunction in the generation of visual hallucinations in Parkinson's disease.

The use of clozapine demands regular monitoring of patients’ clozapine blood levels. Assays are usually performed in a central laboratory with results available only after several days. The South London and Maudsley NHS Trust wanted to implement a clozapine Point-of-Care (POC) capillary blood test that would provide the benefits of immediate results.

The MyCare Insite, a small (2.2 kg) tabletop analyser was used. The Insite can readily be connected to electronic health records. Insite device has been fully validated but to achieve the benefit of clozapine POC testing, other factors beyond the test validation needed to be considered. We developed tools, software, and processes to guide health professionals on why and when to measure clozapine blood levels, on what to do with test results, and systems for documentation and tracking of patients’ test results. In addition, the device supplier conducted staff training to ensure consistent and correct testing. Finally, users were certified as qualified based on demonstrated proficiency.

We have fully implemented POC capillary clozapine testing across four geographic sites.. Patients and staff preferred capillary finger stick testing over venous draws. Patients’ engagement with their results was better than with laboratory testing. Real-time testing for adherence was possible for patients admitted on clozapine. It was also possible to make rapid dose adjustments based on near immediate plasma level results. Patient safety was increased since toxic levels could be quickly detected. Clinical decision-making was expedited as results were available immediately (< 7 minutes). The utility of the testing meant that the length of hospital stays was reduced as discharges were not delayed pending a laboratory result.

Clozapine POC blood level testing was successfully implemented at our institution achieving the expected benefits of clozapine POC testing with near immediate results. The new process improves clozapine management, patient engagement and reduces inpatient bed stays.

To determine potentially significant drug interactions in an old age setting among inpatients with psychosis and medical comorbidities over the past 12 months

Study setting: old age inpatient functional ward

Sample size: 11

Inclusion criteria:

• • Inpatients on psychotropic medications with diagnosis ranging from F20 to F29 (ICD-10)

• • Comorbid chronic medical condition(s) requiring long term drug treatment

Exclusion criteria:

• • Patients with other/co-existing mental health diagnosis excluded

• • Antibiotics , OTC medications, herbal treatments, emergency treatments and other medications requiring short-term administration excluded from analysis

Study tools:

• • Lexicomp® interaction checker

  • ◦ Category X: Avoid combination

  • ◦ Category D: Consider therapy modification

  • ◦ Further categories (In order of decreasing risk ratings: C, B, A) excluded from the analysis

Out of the total 67 inpatients admitted between January 2022 and December 2022, 17 patients had diagnosis ranging between F20 and F29. 4 patients were excluded due to no medical comorbidities and 2 were excluded due to lack of data. Among the 11 patients included in the analysis, the most common medical comorbidities were, in decreasing order, hypertension, hypercholesterolemia and chronic pain. A total of 114 interactions were noted between psychotropic medications and other physical health medications, as follows:

No significant interactions: (category A, B, C): 103

Category D (consider therapy modification): 10

• • 7 of these interactions were associated with administering Buprenorphine with other medications (Flupentixol, Gabapentin, Nortriptyline, Olanzapine, Amisulpride, Aripiprazole and Pregabalin) leading to additive CNS depressant effects.

• • Interaction of codeine with Valproate and Flupentixol carried risk of CNS depression.

• • Carbamazepine interacted with Risperidone via CYP enzyme induction.

Category X (avoid combination): 1

• • The interaction between Flupentixol and Glycopyrronium was associated with risk of severe anticholinergic effects

This study is a preliminary investigation towards understanding the drug interactions in a population with long term mental health and physical health ailments. Awareness regarding the potential interactions can help avoid combinations with possible detrimental effects. The limitations of this study, in terms of sample size and quality of available data, can be overcome by conducting a planned study on a larger population.

Financial Sponsorship: none

Conflict of interests: none