Rethinking psychotropics in nursing homes

To the Editor: The article by Hilmer and Gnjidic1 raises issues about the management of behavioural and psychological symptoms of dementia (BPSD)2 in residential aged care facilities (RACFs).

It is important to remember the context in which RACF residents’ care is provided. The federally managed aged care system is politically and organisationally perceived as supported accommodation, which is geared toward supporting or substituting for residents’ performance of basic and instrumental activities of daily living. This system is outside the state-based health care system. Health care, effectively an optional extra in this context, is provided by general practitioners, who may have no prior knowledge of the resident before admission.

RACF residents in high-level care are too sick and disabled, many suffering from moderate or severe dementia and in the palliative phase of their illness, to be supported by the state health system in the community. BPSD are an everyday fact of life that cause distress to those suffering them and their fellow residents and can make it impossible for carers to provide essential care safely.

Yes, BPSD can be managed by non-pharmacological methods.1 This requires skilled assessment, which goes significantly beyond diagnosis, and skilled intervention, which is much more than just prescription, by carers of all categories. Geriatrician or psychogeriatrician involvement is an obvious and necessary starting point. So why does it not happen when geriatric and psychogeriatric services exist in most regions of the country?

Unlike people living in their own homes, RACF residents are dependent on medical services coming to them, and my experience suggests that GPs are only too happy to refer patients for consultation. Are RACF residents invisible because they can’t come to us, and we won’t go to them?