Prescribing psychotropic medications in residential aged care facilities

Individualised care plans that take greater account of the behavioural and psychological needs of residents are needed

The prescribing of psychotropic medication for people living in residential aged care facilities (RACFs) is of concern to the community, as reflected in evidence presented to the Royal Commission into Aged Care Quality and Safety.1 Although there is a tendency to blame the prescribers, it is increasingly recognised that many RACFs are poorly equipped for managing cognitively impaired older people with challenging behaviours, particularly ambulant residents with dementia. Not all RACFs have adequate circulation space for reducing the likelihood of aggressive incidents, or accessible outside areas for regular physical exercise. Some RACFs have insufficient natural light for maintaining normal sleep/wake cycles, and many do not have enough staff trained in managing the behavioural and psychological symptoms of their residents. In some locations, public sector mental health services can assist with the assessment and management of RACF residents with mental illness or challenging behaviour, but these services are often under‐resourced and unable to respond quickly. In addition, Dementia Support Australia (https://dementia.com.au) offers multidisciplinary assessment and management advice.

Even in well designed RACFs with adequate numbers of trained staff, psychotropic medication still has a legitimate role in the management of the behavioural and psychological symptoms of dementia. Severe emotional distress and disruptive behaviour related to delusions or hallucinations may respond only to antipsychotic medication. In clinical trials, however, only about 20% of residents in aged care facilities who had dementia associated with aggression or psychosis and were treated with low dose antipsychotic medication responded meaningfully, and the risks of stroke and death were increased.2 Obtaining informed consent from proxy decision makers for treatment with antipsychotic medication and applying predefined stopping rules are both important.

Against this background, Harrison and her colleagues3 examined changes in psychotropic medication prescribing before and after people were admitted to RACFs in Australia, analysing a large national retrospective prescriptions dataset covering seven years to the end of June 2015. They found that prescribing of government‐subsidised psychotropic medications increased during the months preceding admission, but rose more steeply in the months after people entered RACFs. Admission to residential aged care is often precipitated by the inability of primary carers to sustain their caregiving role; a carer may have died, become ill, or may simply need to attend to other responsibilities. Alternatively, admission may be triggered by an escalation in the challenging behaviour of the older person, as suggested by the doubling of antipsychotic prescribing, from 6% to 12.3% of older people, in the year preceding RACF admission. Although the prevalence of schizophrenia and other psychoses was only 3.3%, Harrison and colleagues found that 21.3% of residents were prescribed antipsychotics within three months of admission, suggesting that most were prescribed for treating dementia‐related behaviour. Further, 30% of the residents prescribed antipsychotics during their first three months in RACFs were prescribed medications (olanzapine, quetiapine) with Pharmaceutical Benefits Scheme rules requiring the presentation of a serious mental illness other than dementia. A large proportion of residents (41.4%) were prescribed an antidepressant 9–12 months after admission; this level of prescribing should be further scrutinised, as evidence for the efficacy of antidepressants for treating depressive symptoms in RACF residents with dementia is scant.4

Harrison and colleagues acknowledge several limitations to their analysis. Most critically, medications prescribed may not be dispensed or administered, and people may also have taken medications dispensed by hospital pharmacies or on private prescriptions before their admission. Further, some dispensed medication may be taken pro re nata rather than regularly. As a consequence, the numbers of psychotropic prescriptions prior to admission may have been underestimated and the post‐admission rise in prescribing overestimated. Finally, dosage information was not available, so it was not clear whether guidelines for older people were being followed.

Admission to residential aged care is an important transition for an older person, one that should trigger a review of their care needs, including their prescribed medications. If Aged Care Assessment Team functions are to be outsourced, as has been proposed,5 such a review would be even more critical. Following a review of the care needs and symptoms of the individual resident, cautious psychotropic deprescribing may be appropriate. Clinical trials of antipsychotic deprescribing in people with dementia have found that it can often be successful,6 although neuropsychiatric symptoms may re‐emerge in more severely affected patients. Residents whose symptoms responded well to antipsychotic medication7 and those who have prominent hallucinations8 appear to be at greater risk of relapse on discontinuation.

Many aged care facilities need to devote more resources to developing and implementing individualised care plans that take greater account of the behavioural and psychological needs of their residents. National benchmarks need to be established against which facilities can measure their performance.