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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.
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.”
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Moving into aged care and the corresponding adjustment to this new stage in life and unfamiliar environment would invoke behavioural and psychological symptoms in many older people. Judging from the rapid escalation of psychotropic use reported in this article it seems that the first response is prescribing. Isn’t psychotropic use supposed to be the last resort? Isn’t that what we are all saying we do? Instead its: Flat mood – sertraline; anxiety – oxazepam; agitation – quetiapine.
Does anyone talk to these residents, guide them through this transition stage? Is a thorough assessment conducted? In 2018, $80 million was allocated to PHNs to provide psychological care for aged care residents, with services targeted at that early transition stage. What has happened to this funding?
Most presentations of depression and anxiety in old age are mild to moderate. In many mild to moderate cases psychotropic medication provides limited benefit but increases the rate of falls, confusion, hyponatremia (SSRIs) and drug interactions. Non-drug strategies work as well or better. Our older residents deserve more than just being doped up with psychotropic agents – and we know once they are on them – they stay on them for much longer periods than recommended. And are they actually working? Is monitoring for effect taking place? AIHW 2019 data shows 49% of residents show signs of depression – yet over 41% take antidepressants.
And justifying prescribing psychotropic use because there is not enough staff is a cop out. Often used as an excuse to prescribe and not to assess, check the support provided to that person, request counselling or wait and see if the resident settles in and adjusts to their new life.
We can RedUSe psychotropic use but a large part of this issue is also thinking twice when its initiated. If absolutely necessary (i.e. last resort) please prescribe with an exit plan. Especially benzodiazepines.
Not mentioned by the authors and commentators is the fact that one of the reasons that patients are finally placed in aged care is that their dementia condition has deteriorated to a level of disturbance that the family or carer cannot any longer look after them at home. So it is not surprising that the frequency of psychotropic prescribing increases prior to residential aged care placement. And when placed in care patients can be disorientated, confused and more behaviourally disturbed until they become more familiar with their surroundings and new staff carers. So again no surprise that prescribing frequency can increase in the time soon after placement. The big issue is that Alzheimer dementia moderating drugs like cholinesterase inhibitors are underused in this population and when used serve to reduce behavioural and psychological symptoms of dementia. Also, it is so important to review the psychotropic use of patients in aged care facilities regularly in order to see if they are still needed. Behavioural disturbance can have a phase-like pattern and some psychotropics that are helpful in some stages are not needed in others. This assessment requires general practitioners and other specialists to keep in mind whether ongoing psychotropic treatment is needed when reviewing patient progress.
Our patients are already have more advanced dementia on admission to RACFs, so often medication to manage their BPSD initially is required after ruling out the 6 Ps: pee, poo, pus, pain and pills and then pathology .
Ideally , staff are available and well trained in dementia , but funding is lacking for this.
Mental health services are lacking too.
Psychiatric services take months to visit , DBMAS is not that helpful for staff , and psychological services are yet to be rolled out in most RACFs , yet started in 2018!
Perhaps we need to put Scomo in Aged Care to get some funds as he has short term memory loss .
It takes up to 40 minutes to refer someone to DBMAS from personal experience. We don’t get paid for that. We then leave it to the staff at the facility to do it instead and they may or may not do it, because it also takes them time.
We hardly needed a Royal Commission to find that there is over-reliance on chemical restraint in aged care. Professor Byrne suggests improving staff training with a focus on patient-centred care and developing sophisticated and personalised intervention strategies together with modifications to the built environment. These are all excellent and appropriate.
Many operators of aged care facilities would give their eye teeth to be able to afford such luxuries.
Individualised music therapy is likewise an intervention of proven benefit but also draws on precious human resources. Australia is unique in the world in having a specifically designed live broadcast service called “Silver Memories” delivered to nursing homes via satellite and to individuals via an app. Check it out before hitting the prescribe key. https://www.silvermemories.com.au/
If we accept that antidepressant and/or antipsychotic medications may be helpful during the transition to aged care, we are still faced with the question of why these medications are still being prescribed one year following admission, and longer.
In addition to remediation of staffing levels and mix in residential aged care, regulatory bodies need to address off-label use of antipsychotics.
The data came from the Registry of Senior Australians. There was NO information on the indications for psychotropic therapy, the dose prescribed, or the frequency of use (eg constant or prn. There was no clarity to define whether psychoactive medications were initiated in the aged care facility or from a hospital admission. There was limited clinical information regarding the clinical picture outside the 2 mental health issues of dementia and schizophrenia. The high rate of death in the first year may reflect palliative care rather than simple aged care.
I think we should use extreme caution in interpreting limited datasets, and the findings of this study
instead they will just send them by ambulance to the Emergency departments whenever they cause trouble
There is a definite time and place for antidepressant and antipsychotic medication in aged care
It is a pivotal point in a person’s life, and suffering should be addressed behaviourally and if needed with medication.
In my experience it is a time often for reducing other medication severely
National legislation on use of psychotropics in aged care facilities.
All aged care providers much formally acknowledge such.
Strict monitoring of compliance during audit visitations
Strict enforcement of legislation