Doctors groups are calling on aged care and health professionals to adopt new recommendations aimed at reducing the amount of unnecessary drugs and treatments given to older Australians.
The guidelines recommend against using antipsychotics as first-line treatment for behavioural and psychological symptoms of dementia (BPSD), and against using benzodiazepines or other sedative-hypnotics as first-line treatment for insomnia, agitation or delirium.
The new recommendations for medications use among older people have been developed through the Choosing Wisely Australia campaign, which is led by Australia’s medical colleges and societies and facilitated by NPS MedicineWise.
The use of medications, particularly antipsychotics and antidepressants, is a long-standing issue in residential aged care.
In March, Australian Ageing Agenda reported that a practice guide found the use of antidepressants in the treatment of depression in people with dementia was ineffective, while those with mild to moderate BPSD should not usually be prescribed antipsychotics due to the increased risk of adverse events.
The latest recommendations, which were released today, said that many seniors may not be aware they were on a “prescribing cascade” where they took one medicine and had an adverse reaction, only to be prescribe another medicine.
“One common example is when a patient is prescribed a non-steroidal drug for pain, and is then prescribed a proton pump inhibitor (PPI) to reduce the risk of stomach side effects caused by the first prescribed medicine,” they said.
The recommendations urge professionals to recognise and stop the prescribing cascade, to avoid adverse drug reactions in older people; to reduce the use of multiple medicines; and not prescribe medicines without conducting a drug review in order to avoid adverse outcomes for people on 5 to 20 medications.
They also call for medicines to be stopped when they show no further benefit will be achieved, particularly for older people with a limited life expectancy where the treatments are unlikely to prevent disease.
Recommendations from the Australian and New Zealand Society for Geriatric Medicine include:
- do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia
- do not prescribe benzodiazepines or other sedative-hypnotics as first choice for insomnia, agitation or delirium
- do not prescribe antibiotics for asymptomatic bacteriuria in older adults
- do not prescribe medication without conducting a drug regimen review
- do not use physical restraints to manage older adults with delirium.
President of the Royal Australasian College of Physicians Dr Catherine Yelland highlighted the recommendation not to use antipsychotics as the first choice in treating BPSD, including aggression, resistance to care and disruptive behaviour.
“The use of antipsychotics is of dubious benefit and can lead to serious side effects that can be life-threatening. We recommend trying non-drug interventions first as they are an effective option. Ensuring a workforce is trained to be able to deliver non-pharmacological interventions is critical to being able to provide high quality care,” said Dr Yelland.
Professor Jennifer Martin from the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists said that research had confirmed a significant association between polypharmacy and adverse outcomes among older people and an association with decreased physical and social functioning; increased risk of falls, delirium, hospital admissions and death.
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