Antipsychotic prescribing to people with dementia during COVID-19

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.¹ 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.² 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.³ 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.⁴ 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.⁵ 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.