By Linda Belardi.

Psychotropic medications are being used in residential aged care to excess, in dangerous combinations and without adequate consent, according to a series of damning editorials published in the Medical Journal of Australia.

Geriatrician and Clinical Pharmacologist Associate Professor Sarah Hilmer and NHMRC Early Career Fellow Dr Danijela Gnjidic, said that a shift to non-pharmacological management of behavioural and psychological symptoms of dementia in aged care facilities was urgent.

The authors said that while research supports use of psychotropics (antipsychotics, hypnotics, anxiolytics and antidepressants) in some clinical scenarios, they are being used “too often and for too long” at high doses in residential aged care with harmful effects.

In their article ‘“Rethinking psychotropics in nursing homes” first published in February, they said there was limited data supporting the efficacy of psychotropic medications in residential aged care residents, and in most cases antipsychotics could be safely withdrawn from nursing home patients with dementia, with stable or reduced symptoms in most.

Growing evidence has also linked psychotropic use in residents with increased risks of falls, pneumonia, hospitalisation and even death.

“Increasing exposure to psychotropics, with respect to dose, duration and number of drugs, is associated with more adverse events,” they said. 

Hilmer and Gnjidic called for economic evaluations of pharmacological and non-pharmacological therapies for residents and increased investment in recruitment and training of staff.

While non-pharmacological management options often showed similar effects to pharmacological management, these strategies require skilled nursing and allied health staff, which is limited in aged care, they said.

In a second editorial published on Monday, Hilmer and Gnjidic said staff education alone was insufficient to address the complex issues affecting psychotropic drug use in nursing homes and better access to GPs, geriatricians, psychogeriatricians, psychologists, pharmacists and nurses or nursing aids was needed.

Provision of these services in aged care may require changes to healthcare and funding models, they said.

In a reply, also published on Monday, Dr Juanita Westbury from the University of Tasmania’s school of pharmacy and Professor Gregory Peterson, said they were alarmed by the extent of the problem.

Westbury and Peterson said they had recently completed a national psychotropic audit of over 9000 nursing home medication reviews from 2011–12, which showed that more than a quarter of residents reviewed (27%) were taking antipsychotic medication.  

They said an overestimation of the efficacy of psychotropic medications and limited awareness of their adverse effects was contributing to high levels of prescribing.

Westbury and Peterson said that through local audits, benchmarking and nurse education in 15 Tasmanian nursing homes, antipsychotic and benzodiazepine use had been reduced significantly over a 6-month period.

Westbury and Peterson are currently involved in RedUSe, a national project which aims to reduce the use of sedatives in residential aged care, targeting 150 homes over three years. The project is currently being rolled out in partnership with the Department of Health and Ageing (DoHA), the National Prescribing Service and the Pharmaceutical Society of Australia.

Glenn Rees, CEO of Alzheimer’s Australia called on the federal government to do more to protect the legal and human rights of nursing home residents.

“We need to ensure that more funding is targeted to those with complex care needs, and that it results in better trained staff and better designed facilities,” he said.

“We know that well-designed facilities with adequate numbers of staff trained to use psychosocial approaches such as Montessori techniques can provide personalised care to people with dementia. This can avoid many of these problems and keep people safe,” said Rees.

See the May-June edition of Australian Ageing Agenda 2013 for an in-depth report on the overuse of antipsychotics in aged care.

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  1. the key to this is decent funding for appropriate staffing levels so that calming strategies can be implemented. The continuing cuts to ACFI & expectations of increased documentation consumming additional staff time taken from direct care is blatant elder abuse.
    limited staffing hours result in rushing with consequences of challenging behaviours. Not only are residents at risk but staff who sustain life long injuries from kicks, punches etc from aggressive residents

  2. I don’t believe that there is anyone within the age service industry that would not agree that medications including psychotropics need to be regularly reviewed for intended use and benefit. Medication reviews are required on a quarterly basis within residential care. It does appear a shame however that nursing homes are labelled in such a way when there is no nursing home in my experience that can prescribe medication of any type. Comments from ill-informed and sensationalist lawyers about class actions, and likewise ill-placed comments by high profile people such as Ita Buttrose about naming and shaming nursing homes involved do nothing to address the real issues. Glenn Rees is correct to point that that having an appropriate number of suitably educated and experienced people helps to reduce or even eliminate the use of psychotropics. The funding reality in Australia is that is not even factored into consideration – extra supplements are simply redirection of existing inadequate funding. There is a clear need for a broad-based inclusive focus on the issue of the use or mis-use of psychotropics, but let’s do this in an atmosphere of issue resolution, not blame, or “naming an shaming” – not an approach likely to get engagement for a solution. It may just be good for headline grabbing though, and surely to resolve such an important issue we need to rise above that….

  3. The training of staff in solid competency to observe, understand, analyse and plan to manage the complex and challenging behaviours that present in the individual elderly person is the key to successful Non Pharmacological treatment an management. I myself have proven this through EBP in the JBI that this is the case and with professional application and team work it is achievable. One factor that impacts is of course money. money for training and money for care, not to mention the money for pay. We currently pay these dedicated care workers the lowest pays in the country to manage one of the most complex psychosocial issues of today. Understanding and managing the complex behaviours of the human being is one thing, then add the age, illness, dementia, the institutional issues, the family, no funds, and the list goes on. I find it difficult to watch that society has created this mess and now wants to complain about it. Again the experts out there have the knowledge and tools. when are we going to action reform and real change.

  4. I totally agree, funding is so wrong, nursing homes claim on ACFI meaning as long as they have paper work that shows/meet ACFI they get funding, how about having the nursing, on the floor hours that would be able to cope with the needs of the residents. Less medication and more hands on care, so many nurses now sitting doing ACFI and so few actually providing the care 🙁

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