E in the Scottish data examined in this analysis over the

E in the Scottish data examined in this analysis over the same period (reflecting Scotland’s better historical recording of dementia in GP records [23]). Changes in rates of antipsychotic use over time have to be treated with caution because of the shifting denominator of `recorded dementia’.Interpretation of the FindingsIn an observational design of this nature, it is not possible to definitively ascribe causality to the statistical associations seen in segmented regression models of the kind used here. However, the 2004 risk communication was associated with a large change in prescribing consistent with the Title Loaded From File nature of the warning disseminated urgently to all prescribers (table 1). On the background of previously rising trends in the use of both, risperidone and olanzapine prescribing more than halved in the quarter following the risk communication (from 12.5 of older people with dementia to 5.6 for risperidone, and from 3.3 to 11967625 1.5 for olanzapine), with only partial immediate replacement by other antipsychotics. Our interpretation is that the 2004 risk communication prompted widescale review of people with dementia prescribed antipsychotics, with large changes in prescribing. Interpretation of the impact of the 2009 risk communication is more ambiguous. There was no immediate change in antipsychotic prescribing, although we observed a statistically significant decline in antipsychotic use subsequently. This reduction in antipsychotic use was associated with a decline in 1315463 initiation, was consistent with the 2009 risk communication which only highlighted caution in initiation as a specific action for prescribersRisk Title Loaded From File communications and Antipsychotic PrescribingFigure 4. Hypnotic, anxiolytic and antidepressant prescribing in people aged 65 years with dementia. doi:10.1371/journal.pone.0068976.g(table 1). However, it is important to note that other publications at around the same time also highlighted concern about antipsychotic use in older people with dementia, including the European Medicines Agency report in December 2008 that prompted the 2009 risk communication, [5] the English National Dementia Strategy in February 2009, [17] and the English Department of Health `Time for Action’ report about antipsychotic use in older people with dementia published in November 2009 [13] (although the latter two did not strictly speaking apply in Scotland, they may still have affected practice). It is therefore possible that the observed statistically significant association between the 2009 risk communication and changes in antipsychotic prescribing is spurious. Our interpretation is that the impact of the 2009 risk communication was small at best, in contrast with the changes associated with the 2004 risk communication. Although causality cannot be proven, our interpretation is that the data is consistent with the two risk communications having an impact which reflected differences in the nature and dissemination of the two risk communications. The 2004 risk communication made very explicit statements of the magnitude of risk, had specific recommendations to avoid, review and stop named drugs, and was urgently disseminated directly to all prescribers. In contrast, the 2009 risk communication made a less clear recommendation to be cautious in initiation, did not explicitly recommend review or stopping, and was disseminated via a limited circulation routine bulletin (table 1). While it is impossible to know what the `right’ level of antipsychotic.E in the Scottish data examined in this analysis over the same period (reflecting Scotland’s better historical recording of dementia in GP records [23]). Changes in rates of antipsychotic use over time have to be treated with caution because of the shifting denominator of `recorded dementia’.Interpretation of the FindingsIn an observational design of this nature, it is not possible to definitively ascribe causality to the statistical associations seen in segmented regression models of the kind used here. However, the 2004 risk communication was associated with a large change in prescribing consistent with the nature of the warning disseminated urgently to all prescribers (table 1). On the background of previously rising trends in the use of both, risperidone and olanzapine prescribing more than halved in the quarter following the risk communication (from 12.5 of older people with dementia to 5.6 for risperidone, and from 3.3 to 11967625 1.5 for olanzapine), with only partial immediate replacement by other antipsychotics. Our interpretation is that the 2004 risk communication prompted widescale review of people with dementia prescribed antipsychotics, with large changes in prescribing. Interpretation of the impact of the 2009 risk communication is more ambiguous. There was no immediate change in antipsychotic prescribing, although we observed a statistically significant decline in antipsychotic use subsequently. This reduction in antipsychotic use was associated with a decline in 1315463 initiation, was consistent with the 2009 risk communication which only highlighted caution in initiation as a specific action for prescribersRisk Communications and Antipsychotic PrescribingFigure 4. Hypnotic, anxiolytic and antidepressant prescribing in people aged 65 years with dementia. doi:10.1371/journal.pone.0068976.g(table 1). However, it is important to note that other publications at around the same time also highlighted concern about antipsychotic use in older people with dementia, including the European Medicines Agency report in December 2008 that prompted the 2009 risk communication, [5] the English National Dementia Strategy in February 2009, [17] and the English Department of Health `Time for Action’ report about antipsychotic use in older people with dementia published in November 2009 [13] (although the latter two did not strictly speaking apply in Scotland, they may still have affected practice). It is therefore possible that the observed statistically significant association between the 2009 risk communication and changes in antipsychotic prescribing is spurious. Our interpretation is that the impact of the 2009 risk communication was small at best, in contrast with the changes associated with the 2004 risk communication. Although causality cannot be proven, our interpretation is that the data is consistent with the two risk communications having an impact which reflected differences in the nature and dissemination of the two risk communications. The 2004 risk communication made very explicit statements of the magnitude of risk, had specific recommendations to avoid, review and stop named drugs, and was urgently disseminated directly to all prescribers. In contrast, the 2009 risk communication made a less clear recommendation to be cautious in initiation, did not explicitly recommend review or stopping, and was disseminated via a limited circulation routine bulletin (table 1). While it is impossible to know what the `right’ level of antipsychotic.