formulary and clinical guideline document · (see anxiety disorders clinical guideline document),...

Mersey Care Clinical Guideline / Formulary Document Updated: Jan 2017

Learning Disabilities Next Review: Jan 2019 1 |

Clinical Guideline / Formulary Document Pharmacy Department Medicines Management Services

LEARNING DISABILITIES AND AUTISM SPECTRUM DISORDERS

Introduction

There is an increased prevalence of mental health problems among people with learning disabilities (LD), compared to the general population. In addition to mental illness, people with LD may often suffer from coexisting developmental disorders, physical health conditions and sensory impairments. It is important to take these other problems into account when assessing, diagnosing and managing any mental health problems.

Diagnostic assessment can be difficult in LD partly because of the complexity of the presentation but also communication difficulties. People with LD may be unable to give informed consent or communicate symptoms or co-operate with assessments.

The physical needs of the person with LD, including presence of brain damage, epilepsy, sensory deficits, dysphagia, nutritional problems, profound multiple learning disability, complex physical and intellectual disabilities and communication difficulties should be considered as part of developing a person-centered care plan.

An annual health check should be carried out for people with learning disabilities that includes a mental health review, including any known or suspected mental health problems and how they may be linked to any physical health problems and a review of all medication and related side effects, adverse events, interactions and adherence. (NICE NG54).

Primary and secondary care should agree monitoring responsibilities, including who will carry out blood tests and other investigations.

Develop and agree a mental health care plan with each person with learning disabilities and a mental health problem and their family members, carers or care workers (as appropriate), and integrate it into their other care plans. (NICE NG54). Record all the information provided and include when the medication will be reviewed and plans for reducing or discontinuing the medication, if appropriate.

All legal requirements including those arising from the legislation on mental health, mental capacity, disability discrimination and human rights should be fulfilled.

Information, treatment and care should be culturally appropriate and tailored to the needs of the individual and provided in a manner that is accessible to the person with LD and/or physical or sensory disabilities and/or limited competence in speaking or reading.

Prescribing and Use of Medication in Learning Disabilities

Psychotropic medication is commonly prescribed for people with learning disabilities to treat a range of psychiatric disorders such as psychotic illness, affective disorders, anxiety disorders, attention deficit hyperactivity disorder, autism, insomnia etc. and challenging behaviours. However, systematic controlled research on the clinical use of drugs in the LD population is limited. Therefore, information to guide the use of psychotropic medication in LD is mainly based on clinical experience and consensus.

In general, the efficacy of medication in LD can be assumed to be the same as in the

general population and therefore pharmacological management of psychiatric conditions is broadly similar to treatment in the non-LD population.



The management of mental health problems in people with learning disability should follow the guidelines described in the relevant NICE guidance.

Before prescribing medication, there should be a clear diagnosis or target problem and a person-centered treatment plan. Capacity to consent to treatment should be assessed.

The potential impact of medication and other health conditions on the person should be

taken into account. People with learning disabilities may be more susceptible to the side effects and drug interactions because of the complexity of their condition and due to reduced drug metabolism, reduced drug clearance and reduced plasma protein binding. Interactions with any other prescribed drugs should therefore be excluded.

Therefore, when using psychotropic medication, lower doses and slow titration to the lowest effective dose may be required. The dose and duration of treatment should be within currently recommended limits from the BNF or manufacturer product information.

People with LD may be unable to report side effects due to difficulties in communication. Consequently, prescribing and monitoring of psychotropic medication in LD requires specialist multidisciplinary team input and service user and/or carer involvement.

If unlicensed medication is to be used, there should be a clear rationale and supportive evidence for use. Where possible, consent should be obtained and documented.

Monitor and review the benefits and possible harms or side effects, using agreed outcome measures and taking into account communication needs. Medication should be regularly reviewed, ideally every three months and particularly when polypharmacy exists.

Prescribers should record all medication prescribed, indications, information provided and review plans in the patient record. There should be an annual record of the reasons for continuing prescriptions. NICE NG54

Non-Pharmacological Therapies in Learning Disabilities

Psychosocial interventions are also commonly used interventions for mental health problems in people with learning disabilities.

Other approaches are also used, including educational, occupational and developmental approaches, and promotion of healthy lifestyles.

Managing Behaviour that Challenges in People with Learning Disabilities

A significant number of people with LD also display behaviour problems that may be described as challenging, including aggressive behaviour directed towards others, stereotyped behaviours, self-injurious behaviour, offending behaviour, and a range of other socially unacceptable behaviours. Commonly, behaviour problems are a reflection of limited communication but they may also be due to physical disorders (e.g. infection, earache, dehydration, toothache and indigestion) as well as epilepsy or side effects of medication.

Many studies have shown that despite limited evidence for effectiveness and safety, psychotropic medications, particularly antipsychotics antidepressants, mood stabilisers and sedatives, are widely overprescribed off-label for the management of challenging behavior in LD, often without adequate review and management of the underlying cause.

Medicines are mostly used to reduce excitation and aggression, despite lack of evidence There are very few studies comparing different medications for the management of

specific behaviour problems, making it difficult to make specific evidence-based recommendations.

Functional analysis of the challenging behaviour and positive behaviour support should be implemented before medication unless the potential risks are severe.

A diagnosis, formulation and treatment plan should be recorded before initiating any pharmacological treatments for challenging behaviour in LD.

Pharmacological treatment of challenging behaviour should only be initiated following a thorough process of assessment in situations where there is:



lack of response to non-pharmacological interventions treatment for any coexisting mental or physical health problem has not led to a

reduction in the behaviour or significant risk or evidence of harm and/or distress to the service user and others

Medication should be an integral part of a comprehensive intervention strategy and should be regarded as adjunctive or complementary to psychological or other non-drug interventions targeted at the challenging behaviour.

Antipsychotic medication should initially be prescribed and monitored by a specialist taking into account the person's preference (or that of their family member or carer, if appropriate), side effects, response to previous antipsychotic medication and interactions with other medication.

There should be regular review of the benefits of medication and side effects. NICE NG11 states that antipsychotics effectiveness and any side effects should be

reviewed after 3–4 weeks and medication should be stopped if there is no indication of a response at 6 weeks.

If there is a positive response to antipsychotic medication, conduct a full multidisciplinary review after 3 months and then at least every 6 months covering all prescribed medication.

Follow-up assessments should always consider withdrawal of medication and use of non-drug managements in individuals with challenging or problem behaviours. Prescribers should only continue medicines that have shown a benefit.

If the behaviour problem is resolved or treatment is deemed ineffective after an adequate trial, treatment should be carefully withdrawn to minimise secondary problems, e.g. withdrawal reactions, side effects, toxicity.

Rapid tranquillisation (RT) should follow the Trust Policy SD11 on violence and aggression. The use of RT should be accompanied by a documented review.

Following the use of pharmacological interventions for challenging behaviour, feedback should be provided to the service user and/or family/carers, wherever possible.

Relevant NICE Guidance

NICE. Mental health problems in people with learning disabilities: prevention,

assessment and management NICE guideline [NG54]

https://www.nice.org.uk/guidance/ng54

NICE quality standard (QS142). Learning disabilities: identifying and managing mental health problems. January 2017. https://www.nice.org.uk/guidance/qs142

NICE: Key therapeutic topic. Psychotropic medicines in people with learning disabilities

whose behaviour challenges Published: 16 January 2017: nice.org.uk/guidance/ktt19

NICE NG11. Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges (NG11). May 2015. https://www.nice.org.uk/guidance/ng11

NICE quality standard. Learning disabilities: challenging behaviour (QS101). October

2015. https://www.nice.org.uk/guidance/qs101


https://www.nice.org.uk/guidance/qs142




Learning Disabilities Review: Jan 2019 4 |

Learning Disabilities - Anxiety Disorders (GAD)

General Anxiety Disorder (GAD)

Notes

First Line: Sertraline £ Second Line Alternative SSRI or SNRI £-£££ Other agents Benzodiazepines (short-term) £ Pregabalin £££ Buspirone ££ Antipsychotic (refractory GAD) £-£££

People with GAD who have a mild learning disability or mild acquired cognitive impairment may be treated with the same interventions as for other people with GAD (see Anxiety Disorders clinical guideline document), adjusting the method of delivery or duration of the intervention if necessary to take account of the disability or impairment.

Anxiety disorders may cause behaviour problems in people with learning disabilities.

Pharmacological interventions for people with GAD and a moderate to severe learning disability or moderate to severe acquired cognitive impairment should be initiated with the advice of a specialist.

Short-term use of short acting benzodiazepines or buspirone or small doses of antipsychotic should be reserved for managing refractory symptoms. Consultant advice should be sought.

Psychotherapy approaches may be helpful but these approaches may need to be adapted, for example to cope with any communication and/or cognitive difficulties.

Obsessive Compulsive Disorder (OCD)

Notes

First Line SSRI £-££

Second Line Alternative SSRI £-££ Clomipramine £ Other agents Venlafaxine £-££ MAOIs £ Anxiolytics (short term use) £

Treatment of OCD in learning disabilities should follow similar guidelines as described in the Anxiety Disorders clinical guideline document.

Offer appropriate psychological therapy (eg CBT), if appropriate, adjusting the method of delivery or duration of the intervention if necessary to take account of the disability or impairment.

Carry out an ECG and measure blood pressure before prescribing clomipramine, citalopram /escitalopram

Combined treatments may be considered and initiated by specialists only (e.g. SSRI + clomipramine or SSRI + mirtazapine; SSRI + small doses of haloperidol, risperidone or olanzapine). Monitor closely – risk of additive side effects and toxicity.

Only consider benzodiazepines for short periods in severe anxiety.

Only consider MAOIs for atypical obsessive symptoms; Dietary restrictions and interactions limit use of MAOIs



Learning Disabilities - Other Anxiety Disorders

Panic Disorder (PD)

Notes

First Line SSRI £-££

Second Line Imipramine £, Clomipramine £ Venlafaxine £-££

Other Propranolol £-££

Treatment of Panic Disorder in learning disabilities should follow similar guidelines as described in the Anxiety Disorders clinical guideline document.

Offer psychological therapy and self help, if appropriate, adjusting the method of delivery or duration of the intervention if necessary to take account of the disability or impairment.

When using pharmacological therapy, start with low doses and increase the dose slowly with monitoring

Propranolol can help with somatic symptoms but it can cause bradycardia and hypotension and is contraindicated in asthma, heart block, heart failure and peripheral vascular disease

Benzodiazepines and antipsychotics should not routinely be prescribed for panic disorder.

Post-Traumatic Stress Disorder (PTSD)

Notes

First Line SSRI – Paroxetine £ (liquid ££) Sertraline £, Mirtazapine £-££

Second Line Amitriptyline £, Phenelzine £

Others Hypnotic

Treatment of PTSD in learning disabilities should follow similar guidelines as described in the Anxiety Disorders guideline document.

Offer trauma-focussed therapies, if appropriate, adjusting the method of delivery or duration of the intervention if necessary to take account of the disability or impairment.

Amitriptyline and phenelzine should only be initiated under specialist advice (risk of side effects/interactions)

Combination of drugs and psychotherapy may be useful when there is significant comorbidity

Hypnotics may be appropriate for short-term use only in PTSD where lack of sleep is a major problem.

Social Anxiety Disorder (SAD)

First Line SSRI (escitalopram £ or sertraline £) Second Line Alternative SSRI or SNRI £-££ Other MAOIs £, Benzodiazepines £-££

Treatment of SAD in learning disabilities should follow similar guidelines as described in the Anxiety Disorders guideline document.

Offer psychological therapies (CBT), if appropriate. Role of psychotherapy may be limited where there are communication difficulties and limited cognitive abilities

SSRIs (escitalopram, sertraline, paroxetine, fluvoxamine (off-label) have proven efficacy in social anxiety disorder for acute and maintenance treatment.

Benzodiazepines may be useful for short-term use only for severe anxiety as an augmentation strategy



Learning Disabilities - Attention Deficit Hyperactivity Disorder [ADHD)

ADHD Notes

First Line Methylphenidate £ M/R ££ (Schedule 2 controlled drug)

Second line Atomoxetine £££ Alternative stimulant Dexamfetamine £ (Schedule 2 controlled drug)

Lisdexamfetamine £££ (Schedule 2 controlled drug)

Other agents Antidepressants £-£££ Clonidine £ Risperidone £-£££ Aripiprazole £-£££ Quetiapine £-£££ Olanzapine £-£££

Treatment of ADHD in individuals with autism or learning disabilities should follow similar guidelines as described in the Attention Deficit Hyperactivity Disorder guideline document. Current BAP ADHD guidelines (2014) state that stimulants and risperidone are the drugs with more evidence in LD patients. Atomoxetine is second-line, although there is less evidence for it. Psychological therapies can be added to drug treatments but more research is required to clarify their role in comorbid learning disability with ADHD.

Levels of ADHD are higher in people with learning disabilities than in the general population.

Adults with learning disability who have ADHD have been shown to be more severely affected by mental health problems and less likely to improve over time than other people with ADHD.

ADHD in learning disabilities is associated with increased incidence of challenging behaviour, stereotypies, self-harm, anxiety, oppositional defiant disorder, tic disorders and sleep problems.

Cardiovascular risk in some types of learning disability is increased due to congenital malformations, and this risk needs to be assessed prior to treatment.

There also needs to be careful assessment prior to the decision to use medication, because of the increased risks posed by concurrent neurological and other physical health needs.

Treatment may need to be more cautious and side effects monitored carefully. There may be a reduced tolerance of stimulants in patients with comorbid learning disability and higher rates of adverse effects such as motor tics, social withdrawal, irritability and loss of appetite, etc. Stimulant treatment should be started at lowest possible dose (e.g. 2.5mg-5mg BD) and increased very slowly due to higher rate of side effects.

In people who have difficulty communicating, careful consideration needs to be given to enabling them to take part in discussions about medication and also to monitor the effects of the medication.

Carers will have a pivotal role in carefully monitoring and looking for any evidence of side effects in those service users who are unable to discuss their medication fully.



Learning Disabilities – Autism Spectrum Disorders

Notes

General information

Core features of autism are described by NICE guidelines as qualitative differences and impairments in reciprocal social interaction and social communication, combined with restricted and stereotyped interests and activities, and rigid and repetitive behaviours.

Medication should not be prescribed first line to address the core symptoms of autism because drug treatments have been shown to be ineffective and also carry significant potential risks. NICE guidelines state that anticonvulsants, antidepressants, antipsychotics, drugs designed to improve cognitive functioning (for example, cholinesterase inhibitors) and exclusion diets should not be used for managing of core features of autism.

Autism is commonly associated with a number of comorbid neurodevelopmental and psychiatric disorders (e.g. anxiety, depression, obsessive compulsive disorders, tics, ADHD, bipolar disorder, psychosis etc.) that can affect the individual’s presentation and management. Comorbid disorders autism should be appropriately managed.

Educational and psychosocial interventions and environmental changes are recommended first line for core features of autism, depending on the person’s specific needs.

Pharmacological treatments may be appropriate in exceptional circumstances, e.g. for the short-term treatment of challenging behaviour or for treatment of comorbid psychiatric and physical health disorders.

People with autism may show an unpredictable response to psychotropic drugs, with increased and decreased sensitivity in different individuals, as well as more frequent and unusual adverse effects. Therefore, medication should be introduced at a low dose and increased cautiously, with careful monitoring.

Treatment of common coexisting mental health disorders in autism.

For adults with autism and coexisting mental disorders, pharmacological treatments of specific disorders should be similar to those of the general population.

ADHD: BAP guidelines state that positive effects have been described with methylphenidate first-line and atomoxetine as second-line treatments. Risperidone, carbamazepine and clonidine have also been used (off-label use). There may be more side effects with stimulants in people with autism, the most likely being increased irritability and exacerbation of ritualistic behaviours and stereotypies.

Depression and anxiety disorders should be treated with psychological interventions and/or antidepressants (e.g. SSRIs)

Epilepsy should be treated for the general population. Management should not be influenced by the presence of autism.

Psychosis - Early treatment with antipsychotics is important to the prognosis. Low doses of second generation ‘atypical’ antipsychotics may be preferred due to increased sensitivity and risk of side effects.

Sleep disorders - Sleep hygiene is recommended first line. Pharmacological interventions to aid sleep (in conjunction with non-pharmacological interventions) should be prescribed by specialists only for short term use when sleep disorders are persistent and having a negative impact on the service user/carer(s). There is evidence to suggest that melatonin (2-10mg) may be effective in reducing sleep disturbances in autism. Regular review of ongoing benefits and side effects is necessary.



Learning Disabilities – Autism Spectrum Disorders

Notes

Challenging or Problem behaviours in Autism e.g. aggression, irritability, hyperactivity and self-injury.

Possible triggers, including physical, mental health and behavioural problems and environmental factors that provoke the behaviour problems should be identified and addressed. NICE recommends that a functional analysis of behaviour should be a core component of treatment.

First-line interventions for behaviour that challenges should be appropriate psychosocial interventions or specific interventions to address any identified triggers (including any coexisting mental disorders) for the behaviour

When psychosocial or other interventions are not sufficient on their own, or cannot be delivered because of the severity of the behavior, psychotropic medication may be tried off-label in an attempt to manage the challenges behaviour. Due to an atypical response to medication and increased risk of side effects, it is important to use the lowest effective dose.

Second-generation antipsychotics may be considered to reduce irritability, hyperactivity and behavior that challenges in people with autistic spectrum disorders in the short term. There is a limited amount of research evidence to suggest that antipsychotics (e.g. risperidone, olanzapine and aripiprazole) may be beneficial for the short term treatment of significant behaviour problems in autism, including hyperactivity, aggression, and self-injurious behaviours. Aripiprazole may be beneficial for the treatment of hyperactivity, irritability, aggression, mood swings and repetitive behaviours in some young people on the autism spectrum, when other treatments and therapies have not worked. Limited evidence from adults with autism suggests that risperidone may have a modest effect in the treatment and management of challenging behaviour. There is a significant amount of research evidence to suggest that risperidone may be beneficial for the treatment irritability, repetitive behaviour, and hyperactivity in autism. Risperidone is also sometimes used to treat problem behaviours in autistic people, including aggression, self-injurious behaviours and sudden mood changes. Risperidone has been widely used in children with comorbid conduct disorder. Choice of antipsychotic medication should be influenced by a consideration of the side-effect profile, the service user’s personal preferences and any past experience of taking the drug. There should be regular review of the benefits of the drug after 3-4 weeks, any side effects, adherence and physical health. Treatment should be discontinued if there is no indication of a clinically important response at 6 weeks

Stimulants like methylphenidate can reduce hyperactivity, impulsivity and inattention in some people with autism.

Antidepressants may be considered by specialists for the treatment of people with autism who have other problems, such as repetitive behaviours or social deficits but NICE does not recommend their use in autism due to insufficient evidence.

Anticonvulsants may sometimes be used to reduce symptoms such as social and communication difficulties and repetitive, compulsive behaviour but the evidence is limited. NICE does not recommend routine use of anticonvulsants for core symptoms or behavioural problems in autism.



Learning Disabilities - Bipolar Affective Disorder (BPAD)

BPAD Notes

Manic /Hypomanic Episodes Antipsychotics, e.g. risperidone £-££, olanzapine £-£££, quetiapine £-£££ OR Antipsychotic + Lithium ££-£££ Antipsychotic + Valproate ££-£££ Depressive Episodes Fluoxetine £ + Olanzapine £-£££ or Olanzapine alone £-£££ or Quetiapine £-£££ or Lamotrigine £-££ OR Add lithium to quetiapine, olanzapine or lamotrigine £-£££ Other Antidepressants £-££ Maintenance treatment Lithium £ or Valproate £-£££ or Quetiapine £-£££ alone or in combination Rapid Cycling Same interventions as above

People with bipolar disorder who have learning disabilities should receive the same range of treatments and services as other people with bipolar disorder, taking into account the risk of interactions with any other medication that they are prescribed (see Bipolar Affective Disorders clinical guideline document).

Studies have shown that people with learning disabilities are at high risk of developing co-morbid serious mental illness, including bipolar disorder.

Mania and hypomania may be associated with behavioural problems including uncontrollable overactivity, impulsiveness and recklessness, irritability, sexual disinhibition, aggression and violence.

Psychological interventions developed specifically for bipolar disorder or high-intensity psychological interventions should be offered.

Choice of pharmacological treatment depends on the phase of bipolar illness and current treatments being taken. Service user factors should be considered.

Rapid cycling bipolar disorder is often associated with severe behavioural problems particularly self-injurious behaviour (SIB). People with rapid cycling bipolar disorder should be offered the same interventions as people with other types of bipolar disorder.

When using drug treatments in people with learning disabilities, the following should be considered: o Lithium has been used successfully in learning disabilities but regular blood monitoring may prove

difficult due to limited understanding and cooperation. People with learning disabilities may have limited capacity to consent to tests

o Consider risk of neurotoxicity when using antipsychotics in combination with mood stabilisers o Consider risk of interactions with carbamazepine

In learning disabilities, be aware that anticonvulsants and lithium may have multiple indications (epilepsy, mood stabilisation, aggression, SIB, neuropathy)



Learning Disabilities - Dementia

Notes

Mild to Moderately severe Alzheimer’s Disease Donepezil £ Galantamine £ Rivastigmine £ Moderate to Severe Alzheimer’s disease Memantine £ Mild to moderately severe dementia in idiopathic Parkinson's disease Rivastigmine £ NB: Proprietary formulations, liquid, orodispersible forms and patches ££-£££

People with dementia and learning disabilities should receive the full range of assessments and interventions as other people with dementia including appropriate use of dementia medications (see Dementia clinical guideline document), taking into account the risk of interactions with any other medications prescribed.

People with learning disabilities have a higher risk of developing dementia compared to the general population and at a much earlier age, with a significantly increased risk for people with Down’s syndrome.

Carrying out investigations may be difficult in learning disabilities and decisions may have to be made using information from history, physical assessment and direct observations and carer’s input.

Guidelines on assessing capacity must be followed, where investigations are considered necessary and the person is unable to consent and cooperate.

When using assessment scales to determine the severity of Alzheimer’s disease, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the results and make any adjustments they consider appropriate.

The risks and benefits of treating with medication should be considered carefully and discuss with service users and carers

Depending on the diagnosis, a specialist in LD may initiate treatment with donepezil, galantamine, or rivastigmine at a minimum possible dose and titrate up gradually if tolerated. Monitor at 4-6 weeks, 12 and 24 weeks, or more frequently as appropriate.

Anti-dementia medications can also be used in the management of behaviour/psychological problems in people with Alzheimer’s and Lewy body dementia where psychological/environmental measures alone are not successful.

The effects and adverse drug reactions of medication should be closely monitored. Acetylcholinesterase inhibitors can cause nausea and vomiting (common) and muscle cramps, decreased heart rate (bradycardia), decreased appetite and weight, and increased gastric acid production (less common). Common undesirable effects of memantine are dizziness, headache, constipation, somnolence and hypertension.

It is important to use the skills of the full multi-disciplinary team to support people with LD and dementia.



Learning Disabilities - Behavioural and Psychological Symptoms of Dementia (BPSD*)

BPSD Notes

Management See Dementia clinical guideline document for further information

People with BPSD and learning disabilities should receive the same care as other people with dementia, taking into account concurrent conditions and risk of interactions. Psychotropic medications have only a limited role in the management of neuropsychiatric symptoms in people with learning disabilities and dementia and should only be considered if other psychosocial or environmental approaches have produced only very limited or no benefit and the risk from the symptoms is high.

Develop individually tailored care plans that address BPSD.

Be aware that challenging behaviours may be a way of communicating an unmet need.

Treat any underlying contributory problems (e.g. infection, pain, drug side effects)

Treat any coexisting emotional disorders (e.g. depression and/or anxiety and sleep disturbances).

For non severe BPSD, use non-pharmacological interventions (e.g. music, dance, aromatherapy, cognitive stimulation, massage, multisensory stimulation, exercise, creative therapies) or watchful waiting.

Pharmacological interventions, often in conjunction with non-pharmacological interventions, should only be used in cases of severe distress or when there is immediate risk of harm to the service user and/or others. Consultant guidance should be sought.

Acetylcholinesterase inhibitors and memantine may also be considered in the management of BPSD where psychological/environmental measures alone are not successful. Specialist advice is required.

Specialists should only consider antipsychotics for BPSD if other interventions have been unsuccessful due to limited benefits and increased risk of stroke/TIAs, chest infections, falls and mortality.

Only risperidone is licensed for the short term treatment (up to 6 weeks) of persistent aggression in moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others

The decision to prescribe an antipsychotic should be taken on an individual basis after full consideration and discussion with the service user and/or carer about the risks and benefits

Where an antipsychotic is prescribed, use low initial dose and titrate up gradually; monitor for side-effects. Prescriptions should be time limited and reviewed at least every 3 months or according to clinical need.

At each review, consider reducing or gradual withdrawal of antipsychotic treatment

*BPSD include agitation, aggression, extreme anxiety, shouting, changes in behaviour, delusions and hallucinations



Learning Disabilities - Depression

Depression Treatment Notes

First Line Generic SSRI e.g. sertraline £ or Mirtazapine £ Second Line Alternative SSRI £ or SNRI £-££ or better tolerated newer-generation antidepressants Third Line TCAs £-££££, MAOIs ££ Refractory symptoms Augmentation ££-£££ Combination treatment ££-£££ NB: Proprietary, M/R, liquid, orodispersible formulations ££-£££

People with a learning disability or acquired cognitive impairment with a diagnosis of depression should receive the same interventions as for other people with depression (See Depression clinical guideline document), adjusting the method of delivery or duration of the intervention to take account of the disability or impairment if necessary.

People with learning disabilities are less likely to complain of mood changes due to communication difficulties.

In people with learning disabilities, depressive illness may be associated with a variety of problem behaviours. Depression may be associated with apathy, withdrawal and self-neglect or it may lead to severe agitation, irritability and repeated attempts at self-harm or suicide.

NICE advises that when assessing a person with suspected depression, be aware of any learning disabilities or acquired cognitive impairments, and if necessary, and consider consulting with a relevant specialist when developing treatment plans and strategies.

There are no systematic controlled drug trials on treatment of depression in people with learning disabilities; however, case reports suggest that antidepressants are as effective in LD as in the general population

SSRIs are preferred because of the reduced side effect burden. However, be aware that antidepressants with a specific serotonin action should be used with caution in people with learning disability as they can cause agitation, physical aggression and self-injurious behaviour (SIB) and sleep disturbance related to the role of serotonin in autistic symptoms.

An adequate trial of antidepressants (e.g. 8-12 weeks) at the optimum dose is recommended.

Concerns with use of antidepressants are akathisia, lowered seizure threshold, hyponatraemia; hypomania and increased behavioural problems.

Offer psychological treatments; many people with mild learning disability may benefit from psychological therapy



Learning Disabilities - Epilepsy

Epilepsy Treatment

Notes

Commonly prescribed treatments Sodium valproate £-£££ Carbamazepine £-££ Lamotrigine £-££ Other agents Clobazam £ Liquid £££ Ethosuximide ££ Gabapentin £ Levetiracetam £ Liquid ££ Oxcarbazepine £ Liquid ££ Topiramate £ PRN PR Diazepam £-£

Epilepsy is associated with an increased risk of falls and injuries and a higher mortality rate in people with learning disabilities. Behaviour problems are also common in people with learning disabilities and epilepsy. The management of epilepsy in people with LD is no different than that for the general epilepsy population and NICE guidance on the management of epilepsy makes it clear that people with learning disabilities should be offered the same services, investigations and therapies as other people with epilepsy. There is no evidence to suggest that efficacy of drugs differs for this population.

Neurologist referral or advice is essential to allow accurate diagnosis of seizure type. Local neurological support is very good and highly recommended.

The choice of antiepileptic drugs is based on the presenting epilepsy syndrome. Valproate, carbamazepine and lamotrigine are usually used first line. Other antiepileptics are recommended within their licenced indications where first line treatments not suitable or beneficial. See http://www.nice.org.uk/guidance/cg137.

Use of a single anti-epileptic medication is recommended wherever possible. Antiepileptic drug treatment should be initiated at low doses and titrated up slowly to the appropriate maintenance dose.

Due to differences in bioavailability and potential loss of control of seizures, consistent supply of the same brand, branded generic or specified generic antiepileptic drug (AED) preparation is recommended.

Careful monitoring of seizures and side effects by staff and carers is important. Immediate action should be taken if side effects are reported. Investigations and monitoring may be difficult due to capacity to consent issues and non-cooperation. Serum level monitoring should be done only when clinically indicated.

Rescue medications are usually rectal diazepam or buccal midazolam, if initiated by a neurologist.

The main side effects of sodium valproate are weight gain, gastrointestinal problems, and cognitive dysfunction. The main side effects of lamotrigine are skin rashes and gastro-intestinal side effects. Common side effects of carbamazepine include dizziness, drowsiness, skin reactions and ataxia.

Prescribers should be aware of the contraindications to prescribing carbamazepine to some people of Han Chinese or Thai origin, the teratogenic risks of antiepileptics, especially sodium valproate, the risk of interactions especially with oral contraceptives. Importance should be placed on cognitive and behavioural effects of antiepileptic drugs as it may be more difficult to assess and treat in this population.

Antipsychotics and antidepressants can lower seizure threshold and caution is required when used together

Withdrawal of antiepileptic drugs should be managed by or under the guidance of a specialist

http://www.nice.org.uk/guidance/cg137



Learning Disabilities - Schizophrenia

Antipsychotic treatment Notes

First Line: An oral antipsychotic in conjunction with a psychological intervention (family intervention and individual cognitive behavioural therapy (CBT) is recommended by NICE guidelines for treatment of first episode psychosis or for treatment of acute exacerbation or recurrence of psychosis or schizophrenia. Drug choice should be informed by the like benefits, relative impact of side effects and informed service user preference Refractory symptom Clozapine ££ Clozapine augmented with a second generation antipsychotic ££-£££

The principles of treatment of schizophrenia in LD are the same as those for the general population, as described in the Psychosis and Schizophrenia clinical guideline document. In people with coexisting learning disabilities, the diagnosis of schizophrenia is difficult especially in those with moderate to severe/profound learning disabilities and reduced communication skills. Schizophrenia may be commonly associated with epilepsy, negative symptoms and memory impairments. The lower the IQ, the greater the likelihood of unexplained aggression, bizarre behaviours, mood lability, or increased mannerisms and stereotypical behaviour (i.e. behavioural equivalents)

The choice of antipsychotic should be determined by the service user’s current symptoms, previous clinical response and side effects, past medication history, comorbidities, concurrent treatments and individual preferences (including advance statements about treatment and carer views, if appropriate).

Depot or long-acting injectable antipsychotic medication may be considered for maintenance treatment of schizophrenia if preferred after an acute episode or where clinically indicated to avoid covert non-adherence

A detailed cardiovascular risk history is necessary before prescribing antipsychotic. Physical health parameters (e.g. ECG, BP/pulse, FBC, U&E, LFTs, lipids, glucose and weight/BMI) should be monitored at baseline and periodically thereafter, or more often if using high dose or combination treatment.

People with learning disabilities may be more likely to suffer metabolic, neurological side effects, cardiac side effects (QTc prolongation), cognitive impairments and other side effects. Antipsychotics can lower seizure threshold and should not be prescribed routinely in dementia due to increased risk of stroke and death.

Lower doses of antipsychotic medication may be more suitable; Treatment should start with low doses and be titrated up slowly - use of the lowest effective dose with regular monitoring and review is advised

Use of high dose antipsychotics or combinations of antipsychotics should be avoided altogether due to increased risk of side effects, particularly cardiac effects. If high dose or combination antipsychotics are used, the decision must be made by a consult psychiatrist in consultation /multidisciplinary team. Any prescription of high-dose antipsychotic medication should be seen as an explicit, time-limited individual trial with a distinct treatment target. There should be a clear plan for regular clinical review including safety monitoring.

Antipsychotics for schizophrenia should be continued as clinically appropriate, but for minimum of 1-2 years to reduce risk of relapse. For people with learning disabilities who are taking antipsychotic drugs and not experiencing psychotic symptoms consider reducing or discontinuing long-term prescriptions of antipsychotic drugs gradually with close monitoring, documenting at annual checks the reasons for continuing the prescription if it is not reduced or discontinued. Investigations and monitoring may be difficult due to lack of capacity/consent and non-cooperation



Learning Disabilities - Sleep Disorders

Hypnotics Notes

Non-pharmacological measures should be considered before drug therapy for insomnia. First Line Zopiclone £ Suspension ££ Second line Zolpidem £ Third line Temazepam ££ Other Melatonin M/R £££

Sleep difficulties are common in people with learning disabilities. They can cause considerable distress and may be associated with subsequent challenging behaviours. People with a learning disability and sleep disorders should receive the same interventions as for the general population, see Sleep Disorders clinical guideline document.

Before considering hypnotics, there should be a thorough assessment to exclude co-morbid mental health problems, psychological issues substance misuse, physical health problems, side-effects of medication and poor sleep hygiene.

Any associated physical or psychological problems should be appropriate managed.

Sleep hygiene and behavioural strategies should be first line in the management of insomnia

Medication should only be used if other approaches have failed or risks are significant

Hypnotics including Z-drugs and temazepam should be largely reserved for refractory cases or severe insomnia

Use hypnotic medication on an ‘as and when necessary’ basis, PRN (every second or third night if required) rather than on a regular basis.

When a hypnotic is used it should be for a short period of time (no longer than 4 weeks) only in strict accordance with the licensed indications.

Melatonin may be of value for treating sleep onset insomnia and delayed sleep phase syndrome in learning disabilities. It has some evidence of benefit in sleep disorders in people with visual impairment, learning disabilities and in autism spectrum disorders and conditions such as visual impairment, cerebral palsy, ADHD and autism. The usual dose range is 2mg-10mg before bedtime. NB: Doses of melatonin above 2mg are off-label.

Be aware of additive side effects especially with other sedative medication.

Advise of the side effects including day-time sedation, falls and sundowning (confusional state in the evening) and impact of driving, operating machinery or performance of skilled tasks.



Learning Disabilities - Managing Challenging or Problem Behaviours

Challenging Behaviour Notes

General principles

A comprehensive assessment that addresses both the individual and their behaviour, in the context of any underlying cause of the behaviour and its consequences, along with a formulation, is an absolute prerequisite in managing any problem behaviours i.e. functional analysis / positive behaviour support.

Following assessment, specific psychiatric and physical disorders and contributory social and environmental factors should be addressed.

Psychosocial interventions (including a broad range of therapies, such as communication interventions, applied behaviour analysis, positive behaviour support and cognitive behavioural therapy) may be used for the short- and long-term reduction and management of behaviour that challenges

Behavioural strategies should be considered before medication except when the behaviour occurs frequently or is so severe and intense that delay in treatment would be dangerous to the individual or others.

In severe behavioural disturbance (aggression, anxiety, agitation) requiring urgent intervention for the protection of the individual or of others, rapid tranquillisation may be necessary.

Medication should be complementary to other non-drug interventions delivered by a multidisciplinary team

Any medication prescribed should have a clear rationale or target symptom and should be prescribed at the lowest effective dose and for the minimum duration with clear assessment of outcome and side effects.

Where an antipsychotic is used, the choice of agent should be based on consideration of the side effect profile, the service user’s past experience of use and personal preference.

Antipsychotics may be helpful when psychotic symptoms (e.g. hallucinations and delusions) are present or when psychological approaches and other interventions have been unsuccessful in managing behaviour or where the symptoms are so severe that they pose risk to the service user and others (caution in epilepsy)

People with LD are more sensitive to the effects and side effects of antipsychotics. Antipsychotics are associated with adverse effects, such as weight gain, diabetes, increased prolactin levels, extrapyramidal side effects, tardive dyskinesia and lowering of seizure threshold.

Effectiveness and possible adverse effects of prescribed medication should be monitored at regular intervals

Review the effects of the medication after 3–4 weeks and discontinue it if there is no indication of a clinically important response at 6 weeks.

Withdrawal of medication and use of non-pharmacological management strategies should always be considered at regular intervals.




Agitation

Notes

Antidepressants £-££ Anxiolytics £-££ Mood stabilisers £-£££ Low Dose Antipsychotics £-£££

Medication should only be used if environmental, psychosocial and behavioural interventions have proved unsuccessful. Any factors that trigger or maintain the behaviour should be identified and addressed (functional analysis).

Antidepressants e.g. SSRIs, mirtazapine and trazodone may be useful in managing agitation

Short-term use of benzodiazepines (e.g. lorazepam) and buspirone can help manage high levels of underlying anxiety. Beta blockers can control anxiety with physical symptoms but contraindications must be checked.

Mood stabilisers such as lithium, carbamazepine or sodium valproate are sometimes used for managing challenging behaviour but the evidence base is limited and they carry a risk of side effects and interactions.

Antipsychotics should be reserved for extreme agitation where there is risk of harm to self and others and should be used alongside psychosocial interventions for challenging behaviour. Limited evidence suggests that risperidone may be effective in improving a range of behavioural disturbances including agitation. Consultant advice should be sought. Antipsychotics should be reduced and stopped once symptoms are under control.

Aggression

Notes

Low Dose Antipsychotics £-£££ Anticonvulsants £-££ Lithium £

Medication should be used as a last resort to control aggressive behaviour. The efficacy of all interventions should be assessed against specific target symptoms. Any factors that trigger or maintain the behaviour should be identified and addressed (functional analysis).

Aggression secondary to agitated depression may be successfully treated with an antidepressant, whereas aggression secondary to command hallucinations in schizophrenia may require antipsychotics

Antipsychotics should not routinely be used first line but may be used as a last resort in severe behaviour problems. Low dose second generation antipsychotics used on a PRN basis may need to be considered first due to lower risk of extrapyramidal side effects. The dose of antipsychotic should be reduced, and treatment stopped once symptoms are under control.

Lithium has some efficacy in reducing severe aggression but investigations and monitoring may be difficult.

Anticonvulsants have been used to decrease aggression and impulsivity, although the evidence is limited.

Beta blockers may be useful in controlling heightened arousal and anxiety states causing aggressive behaviour.




Self Harming / Self-Injurious Behaviour (SIB)

Notes

SSRIs Tricyclics e.g. clomipramine £ Antipsychotics e.g. risperidone £-££ Opioid antagonists, e.g. Naltrexone / Naloxone ££-£££

People with learning disabilities who self-harm should be offered the same quality of care and range of treatments as any others bearing in mind that self harming may occur as secondary features of psychiatric and physical disorders among people with severe learning disability. There is very little research on the management of self-harm in people with a learning disability and so the evidence base for pharmacological treatments for self-harm is extremely limited. Pharmacological interventions that are sometimes used for challenging behaviour include various antidepressants, antipsychotics, mood stabilisers, beta blockers (e.g. propranolol) and opioid antagonists like naltrexone or naloxone and sedatives/hypnotic agents (melatonin).

A comprehensive assessment by a mental health specialist followed by psychological and behavioural strategies provided with respect and privacy by appropriately trained staff should be first line management.

There is limited evidence that opiate antagonists such as naltrexone and naloxone may reduce the rate and intensity of repetitive self-injurious behaviour and stereotypy in some people with learning disabilities. This is an off-label use of naltrexone and would need to be conducted in the context of a therapeutic trial starting with a low dose, with appropriate and regular monitoring and review the effects of the medication.

There is also growing evidence that serotonergic drugs (SSRIs e.g sertraline) may be effective in reducing SIB.

Lithium and carbamazepine have some support for use in SIB. Lithium is licensed for the control of aggressive behaviour or intentional self-harm; appropriateness for blood tests should be assessed.

Clomipramine has been shown to improve the rate and intensity of SIB and stereotypy

Among antipsychotics, there is limited evidence for risperidone and possibly olanzapine in the management of aggressive and self-injurious behaviour in people with moderate to profound learning disability. If a depot is indicated, flupentixol and zuclopenthixol have been tried.

Sexual Offending

Notes

Cyproterone acetate ££ Medroxyprogesterone £ Benperidol £££

Antilibidinal drugs (e.g. cyproterone acetate and medroxyprogesterone) which reduce testosterone levels may be considered as an adjunct in service users with LD who show inadequate response to psychological and behavioural strategies alone.

Benperidol is licenced the control of deviant antisocial sexual behaviour. It may be appropriate to consider an ECG and electrolyte monitoring before treatment and periodically during treatment.

SSRIs have also been beneficial for people with less severe paraphilias including exhibitionism. In practice, high dose fluoxetine at 60mg/day may significantly reduce libido and may be useful to manage sexual offending.



References

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formulary and clinical guideline document · (see anxiety disorders clinical guideline document),...

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