Psychotropic drug use in aged care facilities: a reflection of a systemic problem?

The use of psychotropic drugs in residential aged care facilities (RACF) in Australia is a topical and controversial issue.1 The potential overuse of drugs in RACF may arise from wider systemic problems with managing the considerable burden of psychiatric illness in such facilities.

Providing care and treatment for people with mental illness and behavioural and psychological symptoms of dementia (BPSD) in aged care facilities is problematic.2 The prevalence of psychiatric morbidity in this population is significant.3 Targeted pharmacological and non-pharmacological interventions may be effective for BPSD in RACFs,4,5 but training and structural issues can limit the ability of staff to implement them.2 Moreover, there is evidence that an appropriate culture and physical environment in RACFs can positively influence behaviours and quality of life.6-8 When mental illness combined with BPSD is considered a purely medical problem, there is insufficient attention to instituting non-pharmacological interventions. For these reasons, improving the mental health care of people in RACFs is likely to require a systemic approach.2

A systematic review has shown considerable psychiatric morbidity in RACFs: the prevalence of dementia is 58% and, among those affected, 78% have BPSD, 10% have major depression and 28% have depressive symptoms.3 Morbidity at such high levels demands substantive treatment rather than therapeutic nihilism,9 leavened by an understanding of the practicalities of medical and nursing care in RACFs.

Providing mental health care in RACFs necessarily involves comprehensive medical and nursing evaluation, and appropriate implementation of behavioural and pharmacological therapies. Judicious, targeted and careful use of medication is possible. Targeted non-pharmacological therapy is possible. However, mental health care in RACFs often falls short of best practice.2

There is some evidence for the effectiveness of acetylcholinesterase inhibitors, antidepressant and antipsychotic medications in treating BPSD in RACFs, although we acknowledge that there are substantial risks that need to be weighed carefully in considering the use of these agents.4,5,10,11 A Cochrane review concluded that, while there are few trials of antidepressant treatment for BPSD, two selective serotonin reuptake inhibitors modestly reduced symptoms of agitation and psychosis.10 Psychotic symptoms, particularly when associated with agitation and aggression, can pose a serious risk to the person (with or without dementia) and to carers. A Cochrane systematic review on use of antipsychotics in BPSD concluded that there is modest evidence for the efficacy of antipsychotic medications in BPSD, although it notes significant risks of adverse effects and argues that antipsychotics should be used only when there is severe distress or risk of physical harm to the patient or others.11 For depression in people with dementia, there is very limited evidence in total,9 but there is evidence that discontinuing antidepressant therapy can result in worsening or re-emergence of depression.12

Providing targeted pharmacological care depends on medical support in RACFs. Much of this is provided by general practitioners, who have to manage multiple medical problems in a complex patient group13 while being poorly remunerated.14 These are significant barriers to the provision of effective medical care and act as disincentives to attend RACFs at all.14 Specialist aged care consultation–liaison psychiatry services to RACFs may help GPs and facility staff to provide mental health care,2,15 but specialist recommendations are also often frustrated by systemic factors. Improved models of care are necessary to provide effective medical and mental health care in RACFs,2 and these might best be nurtured by embedding them within the standards of accreditation for RACFs, to ensure that this becomes intrinsic to the culture of care.

There is burgeoning evidence for the efficacy of non-pharmacological psychosocial and nursing strategies,4 and these should be the basis of mental health care in RACFs. However, the staffing levels in RACFs and mental health skills of most carers (nursing assistants, enrolled nurses, personal carers) may be inadequate to implement such strategies.16 Thus, there needs to be a focus on providing appropriate numbers of skilled nursing and allied health staff to meet the mental health and other complex needs of residents in RACFs.2 Psychologists, experienced aged care mental health nurses, diversional therapists, volunteers and family members may provide additional psychosocial skill and support, as may similar services accessed through non-government organisations. Personalised care and appropriately increased autonomy may lead to improved quality of life and reduced vulnerability to mental illness.7

Substantial improvement in the overall provision of mental health care in RACFs is needed. Research into mental health interventions in RACFs is growing rapidly, but would benefit from more funding and rigour.4 There has been considerable exploration of innovative models for providing mental health care in RACFs.2 Some proposals for improvement include:

• prompt assessment of residents with mental illness by consultation–liaison mental health services, GPs, nurses, and allied health professionals visiting RACFs;2

• use of telemedicine approaches to support assessment;

• education and upskilling of care staff to collaboratively implement interventions;17

• training in the use of assessment instruments (observation scales/questionnaires) for common mental health problems for skilled care staff;2

• changes in the design and organisational culture of RACFs aimed at improving the mental wellbeing of residents;6-8,18 and

• coordination of all of the above.2

We do not suggest that we have canvassed all of the systemic solutions, given the limited research evidence base in this area and the complexity of factors involved in providing care in the RACF environment in Australia.

Any reforms to improve the treatment of mental illness and BPSD in RACFs will need to begin with considering the physical design, staffing and skills of staff within RACFs. This could be influenced by federal government legislation and accreditation and by consumer and carer expectations of aged care.

The provision of effective outreach services to RACFs by GPs, specialists and allied health professionals would involve private and state health care, and push–pull factors based on service models and funding. Thus the state–federal divide in funding and responsibility for health care is another complicating factor. Yet another issue is the research funding for design of innovative interventions for mental illness and BPSD in RACFs, which is largely dependent on federal government research funding.

The key to effective change may be sufficient organisational and political will to fund, study, design and implement interventions at a national level to improve mental health care for residents in RACFs. This will be a very complex challenge to which we do not foresee a clear set of solutions. Focusing predominantly on the use of psychotropic drugs in RACFs would be addressing only part of the systemic issues we have touched on in this article.