Psychotropics in aged care: where are the alternatives?

A DEARTH of alternative strategies for addressing changed behaviour associated with dementia is driving high rates of antipsychotic medication use among elderly Australians in the lead-up to and after admission to residential aged care facilities, says a leading psychiatrist.

Professor Gerard Byrne, Head of the Discipline of Psychiatry within the School of Clinical Medicine at the University of Queensland, said improved staff training and a focus on patient-centred care would help to reduce a reliance on psychotropic medications in managing challenging behaviour associated with dementia.

“Residential aged care facilities quite often do not allocate sufficient time for person-centred care for older people with dementia who exhibit challenging behaviour,” Professor Byrne said. “This is really a by-product of the business model. There are insufficient trained or experienced staff who can assess someone’s mental health needs and develop a sophisticated and personalised intervention strategy.”

He said even strategies such as modifications to the built environment of facilities could improve the mental wellbeing of residents by reducing crowding, the risk of absconding and the risks of residents accidentally entering the rooms of other residents.

Professor Byrne was commenting on a retrospective national cohort study of more than 320 000 aged care residents, published in the MJA, that found that 21% received at least one antipsychotic, 31% at least one benzodiazepine and 38% at least one antidepressant in the first 3 months after admission to an aged care facility. The researchers further found that 46% of those dispensed antipsychotics, 39% of those dispensed benzodiazepines and 20% of those dispensed antidepressants had not received them in the year before entering care.

“Although dispensing had also increased during the year before entering residential care, the rise was greater during the first 3 months of care and the increased level of dispensing was maintained during the first year of care,” they reported.

• Podcast with MJA research coauthor, Associate Professor Craig Whitehead

The findings come after the interim report of the Royal Commission into Aged Care Quality and Safety named the “significant over-reliance on chemical restraint” (including psychotropic medications) in aged care, as an area in which immediate action could be taken.

Dr Juanita Breen, Senior Lecturer at the Wicking Dementia Research and Education Centre at the University of Tasmania, said the study highlighted not only a marked increased in psychotropic medicines prescribing after admission to a residential aged care facility, but also an increase in drug use in the months leading up to admission.

“Up to now, we have been mostly concentrating on use in aged care, whereas there is evidence here that there are people in the community who are using quite a lot of psychotropic medications even before they go in,” Dr Breen said. “We should be also looking at examining what is driving this type of prescribing. Is it because family or formal caregivers can’t cope? Is it the go-to strategy for GPs who prescribe these drugs before other interventions are tried? It appears that greater support and training is needed for community caregivers.”

She said the transition to aged care was often a point at which changed behaviour may escalate and strategies were needed to prevent and address this before reaching for drugs.

“People with dementia who are having trouble living and coping with their home environment are then put into a new strange environment and their reaction to that can be increased anxiety and agitation,” she said. “We keep on hearing [that medication] should be a measure of last resort, but this study is showing that this is not the case and they are starting on these drugs very quickly.”

Dr Ludomyr Mykyta, geriatrician and author of the book Dementia is different, said it was important to recognise that a person’s admission to a residential aged care facility often came at a “crisis point”, and therefore, some increased prescribing of psychotropic medications was justified.

“The very act of admission is an extreme stressor, that means that whatever was happening before was escalated and the disturbed behaviour is a common trigger for placement,” he said.

“Basically, the partner gets worn out and, at times, is at risk of violence, so what you have in a residential facility are people with advanced dementia and all of its complications.”

Dr Mykyta said people transitioning into residential aged care may experience paranoia, delusional beliefs and severe anxiety and distress. “These are not happy feelings,” he said.

“A lot of these people have never had a comprehensive assessment and I am often the one who says ‘this is not only severe dementia, this is palliative, this is heading towards the end of that person’s life’,” he said. “So, it’s not surprising that many of these people were on antipsychotic medications prior to [admission to aged care] because they needed that to be able to remain in the community without destroying their partner.”

Professor Byrne said while some increased prescribing of some psychotropic drugs might be appropriate, much would not be.

“Some [prescribing] is likely to be appropriate, particularly the low dose antipsychotic prescribing in people with marked agitation and psychotic symptoms in the context of their dementia,” Professor Byrne said. “However, I am not sure all the antipsychotic prescribing is appropriate, and I am not sure that all the antidepressant prescribing is appropriate, and I am pretty sure that not all the benzodiazepine prescribing is appropriate.”

Dr Breen said the fact that the research showed continued use of these medications in the 12 months after admission, showed that prescribing was not all about the stressors associated with admission.

For patients who were already taking psychotropic medications before entering an aged care facility, she said it was crucial to identify possible underlying causes of distress.

“It’s really important to have a look at their medication to start with and not just automatically continue and add to it,” Dr Breen said.

“The first step is to do a proper medical assessment because often people are aggressive, agitated, very anxious due to underlying problems like pain. They might have an infection, like a urinary tract infection, or other infections that they can’t tell you about,” she said. “And, ironically, some of the medications that are given for mental health conditions can worsen behaviour. These include psychotropic medications like antipsychotics and benzodiazepines that are mentioned in the study.”

Dr Breen added that communication and creating a home-like environment in the residential aged care facility were vital in reducing the stress associated with the move.

“Acknowledge that it is an adjustment period, it’s a period of loss; they have lost their home, their routines. Some homes do this very well, but in others, this transition stage is more likely to be managed with medication.”

Dr Breen said the federal government’s 2018 budget allocation of $82.5 million to improve access to mental health services in aged care was a positive step in providing psychological support at the time of transition into aged care.

“Other services such as the Dementia Behaviour Management Advisory Service should also be consulted before reaching for the script pad.”

Professor Byrne agreed that access to psychological services for residents of aged care facilities was improving.

“It’s better than it was, but it’s coming from a very low base, so it’s got a long way to go.”