Psychotropic drugs are often used to control the behaviour of people with dementia in aged care.
Credit: Harry/Flickr, CC BY-NC.
Psychotropic drugs are being over-used in Australian aged-care facilities to chemically restrain residents, according to both researchers and several government reports. But despite all this attention, little is being done to reduce their use.
What’s worse, these drugs are widely used despite their known harms. For a start, older people more sensitive to the sedating effects of these drugs. They also experience more side effects than younger people, including movement disorders, confusion, falls and infections.
Most importantly, though, we now know one of the classes of psychotropics, antipsychotics, increase the risk of early death in people with dementia by 60% to 70%.
High rates of use may stem from health practitioners being unaware of their limited benefits and significant risks. But aged-care facilities may also suffer from inadequate staffing and resources, a lack of information about alternatives, management issues and inadequate review practices.
The latest government report about the issue came from the Senate Committee on Community Affairs, in late March. Care and management of younger and older Australians living with dementia and behavioural and psychological symptoms of dementia (BPSD) refers to an “overreliance on medication to manage the behaviour of residents”.
This was not the first government inquiry to look into the issue. A Senate committee reported on the topic in 1995, and in 1997, a <a href="http://trove.nla.gov.au/work/7586182?q=" _cke_saved_href="http://trove.nla.gov.au/work/7586182?q=" +nursing+homes+complaints+against"&c="book&versionId=8734269"">NSW Ministerial Taskforce</a> looked into psychotropic use in nursing homes.</p> <p> Both reports recommended measures such as pharmacists reviewing psychotropic medication and staff education on alternate ways to manage behavioural problems.</p> <h2> Inappropriate use</h2> <p> Psychotropic medications affect mental function and behaviour. There are three main classes – antipsychotics, such as risperidone, benzodiazepines, such as diazepam and antidepressants, such as fluoxetine.</p> <p> The psychotropic class of most concern are antipsychotics. Although these drugs were developed to treat severe mental illness such as schizophrenia, studies <a href="http://www.academia.edu/1023310/Psychiatric_drug_prescribing_in_elderly_Australians_Time_for_action" _cke_saved_href="http://www.academia.edu/1023310/Psychiatric_drug_prescribing_in_elderly_Australians_Time_for_action">show very high rates of use</a> among older Australians. People over 60 are given the drugs most of all, with highest rates in those between 80 and 95 years old.</p> <p> Increasing use with age parallels the rise in dementia rates after age 60, and prescribing in many aged-care facilities up to ten times higher than the community rate. <a href="https://ama.com.au/media/antipsychotic-and-antidepressant-medication-rise-sydney-nursing-homes" _cke_saved_href="https://ama.com.au/media/antipsychotic-and-antidepressant-medication-rise-sydney-nursing-homes">Current data</a> suggests around one in three people in Australian aged-care facilities are given antipsychotic medication and usage rates appear to be increasing.</p> <p> The drugs are mainly used to manage what are known as the behavioural and psychological symptoms of dementia, which include physical aggression, delusions, wandering, and screaming. Over 90% of people with dementia display <a href="https://www.ranzcp.org/Files/Publications/A-Handbook-for-NSW-Health-Clinicians-BPSD_June13_W.aspx" _cke_saved_href="https://www.ranzcp.org/Files/Publications/A-Handbook-for-NSW-Health-Clinicians-BPSD_June13_W.aspx">behaviour like this at some time</a>, and symptoms can be distressing for the person and their carer, as well as putting the former at risk.</p> <p> <a href="https://www.ranzcp.org/Files/Publications/A-Handbook-for-NSW-Health-Clinicians-BPSD_June13_W.aspx" _cke_saved_href="https://www.ranzcp.org/Files/Publications/A-Handbook-for-NSW-Health-Clinicians-BPSD_June13_W.aspx">Guidelines</a> for responding to such behaviour say the first step should be to consider possible underlying causes. Is the person in pain, for instance, does she have an infection, or is he reacting to a noisy or otherwise unfamiliar environment?</p> <p> They suggest simple non-drug behavioural strategies unless symptoms are severe. If they’re not easily manageable, psychotropic medications should be prescribed with caution – for as short a time as possible. And effectiveness and side effects should be closely monitored.</p> <p> Apart from side effects, the problem with using antipsychotics to manage wayward behaviour is they only have modest efficacy. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15687315" _cke_saved_href="http://www.ncbi.nlm.nih.gov/pubmed/15687315">International studies</a> show the drugs only reduce aggression in one in five people with dementia.</p> <p> <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003476.pub2/full" _cke_saved_href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003476.pub2/full">Evidence is mixed</a> regarding their effect on delusions and hallucinations and the <a href="http://www.ncbi.nlm.nih.gov/pubmed/16437455" _cke_saved_href="http://www.ncbi.nlm.nih.gov/pubmed/16437455">drugs are not effective</a> for managing other behaviours, such as wandering, screaming, hoarding and apathy.</p> <h2> Better ways</h2> <p> What’s more, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/22952073" _cke_saved_href="http://www.ncbi.nlm.nih.gov/pubmed/22952073">recent review of other strategies</a> for managing these behaviours showed they were at least as effective as antipsychotics for mild to moderate symptoms.</p> <p> These strategies include providing activities for residents to engage in such as crafts, gardening, music and simple exercise classes. Aromatherapy and pet therapy have also been shown to be effective alternatives.</p> <p> Mostly, it’s important to try and address residents needs, often by simply providing one-to-one attention; a resource in very short supply in most staff and resource strapped aged care facilities.</p> <p> The Senate Committee on Community Affairs made <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Dementia/Report/Report" _cke_saved_href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Dementia/Report/Report">six well-considered recommendations</a> directly addressing antipsychotic prescribing in aged care. They include a three-monthly review of use; recording why antipsychotics are used and attempts to reduce use; annual psychotropic audits and better education for prescribers and aged-care staff about managing difficult behaviour.</p> <p> Such measures have worked in <a href="http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=548" _cke_saved_href="http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=548">the United Kingdom</a> and <a href="http://www.medscape.com/viewarticle/810513" _cke_saved_href="http://www.medscape.com/viewarticle/810513">the United States</a>, which have made significant inroads to reducing antipsychotic use in aged-care facilities.</p> <p> Hopefully, Australia can follow suit and eliminate the need for yet another government inquiry on the inappropriate and dangerous use of these drugs in aged care.</p> <p> <em>Dr Juanita Westbury is leading the Reducing Use of Sedatives in Aged Care Facilities (RedUSe) project which is funded by the Australian Government Department of Social Services under the Aged Care Service Improvement and Healthy Ageing Grant Fund.</em></p> <p><em> This article was originally published on <a href="http://theconversation.com" _cke_saved_href="http://theconversation.com">The Conversation</a>. Read the <a href="http://theconversation.com/antipsychotic-drugs-harm-older-people-lets-reduce-their-use-24941" _cke_saved_href="http://theconversation.com/antipsychotic-drugs-harm-older-people-lets-reduce-their-use-24941">original article</a>. Follow all of the Expert Voices issues and debates — and become part of the discussion — on <a data-ls-seen="1" href="https://www.facebook.com/expertvoices" _cke_saved_href="https://www.facebook.com/expertvoices">Facebook</a>, <a data-ls-seen="1" href="https://twitter.com/Expert_Voices" _cke_saved_href="https://twitter.com/Expert_Voices">Twitter</a> and <a data-ls-seen="1" href="https://plus.google.com/u/0/b/102966466858233835249/102966466858233835249/posts" _cke_saved_href="https://plus.google.com/u/0/b/102966466858233835249/102966466858233835249/posts">Google +</a>. The views expressed are those of the author and do not necessarily reflect the views of the publisher. 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