Rethinking psychotropics in nursing homes

The potentially inappropriate use of psychotropic medications (antipsychotics, hypnotics, anxiolytics and antidepressants) in residential aged care facilities (RACFs) is of considerable community concern. It is of practical and ethical importance to assess the use of these medications and the feasibility of reducing their use, and to devise alternative strategies to improve the care of vulnerable people living in RACFs.

A recent survey of 2465 Sydney nursing home residents found that about half were prescribed psychotropic medications.1 Common indications included behavioural and psychological symptoms of dementia (BPSD), depression, sleep disorders, anxiety and schizophrenia. About half of Australian RACF residents have dementia, and a quarter have another mental illness.

While research supports use of psychotropics in some clinical situations, we tend to use them too often, for too long, at doses that are too high, in dangerous combinations with other medications and without adequate consent. A study of residents in low-level RACFs in Sydney found that 60% were exposed to anticholinergic or sedative medicines (mostly psychotropics), and 10% took three or more.2

The first step in Quality Use of Medicines (QUM), a central objective of Australia’s National Medicines Policy, is selecting management options wisely. Non-pharmacological management options have some evidence of efficacy, often with similar effect sizes to pharmacological management, particularly for BPSD,3 depression and sleep disorders, and do not carry the risks of psychotropic medications. However, non-pharmacological management is constrained by requirements for more intensive, skilled nursing and allied health staff — limited resources in the aged care sector.

There are limited data supporting the efficacy of psychotropic medications in RACF residents. Antipsychotic medications may be more effective than placebo for reducing aggression in patients with dementia.4 However, antipsychotics can be safely withdrawn from nursing home patients with dementia, with stable or reduced symptoms in most.5 There is very little evidence supporting the use of antidepressants in patients with dementia.6

There is growing evidence on the risks associated with psychotropics in RACF residents, including falls, pneumonia, hospitalisation and mortality. The increased risk of mortality in patients with dementia was first recognised with antipsychotics and is also observed with other classes of psychotropics.7 Increasing exposure to psychotropics, with respect to dose, duration and number of drugs, is associated with more adverse events. It is difficult to monitor medication safety and efficacy in individual RACF patients because adverse drug reactions present atypically as highly prevalent multifactorial geriatric syndromes, there are significant placebo effects, and the symptoms being treated fluctuate over time.

Ethically,8 particularly for management of BPSD, a shift towards non-pharmacological care is likely to give similar beneficence and less maleficence. Respect for patient autonomy requires residents or their surrogates to make informed, free choices about management.

We must determine the best strategies to prevent inappropriate use of psychotropics in RACF residents. QUM strategies, primarily pharmacist reviews and educational interventions, have been moderately successful in reducing psychotropic use, but there is little evidence of clinical impact.9 The pattern of psychotropic use in RACFs is similar across the developed world, despite differences in registration and legislation around their use.1

We need high-quality health economic evaluations of non-pharmacological and pharmacological management options for RACF residents with a range of conditions, to determine the effects and total costs of each approach. If costs align with appropriate use of psychotropics, the answer is likely to be education and training, but if costs favour inappropriate use, more complex policy solutions are required. Appropriate psychotropic use could be achieved through carefully considered financial incentives to equalise the costs of different management strategies. Investment could be made in recruiting and training staff to provide non-pharmacological therapies, and in research to develop better pharmacological and non-pharmacological management strategies to prevent and treat dementia, sleep disorders and mental illness in frail older people.