New standard warns against over-medicating the elderly

David Lam

9/05/2024 4:58:04 PM

Chemical restraint should only be used as a last resort when treating vulnerable patients, according to a new national standard.

Doctor giving patient medication.
Australian aged care residents have a 22% higher risk of death when on antipsychotic medication.

A new national standard has been launched to protect people living with cognitive impairment or intellectual disability from the potential harms of inappropriate psychotropic medication use.
The landmark ‘Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard‘ contains clear actions to ensure the responsible use of psychotropic medications, such as antipsychotics and benzodiazepines.
Launched by the Australian Commission on Safety and Quality in Health Care on Thursday, it aims to maintain the rights, dignity, health, and quality of life of vulnerable populations.
The long-awaited standard has been introduced in response to an alarming 60% increase in the use of psychotropic medications in Australia over the past 30 years.
The harm from inappropriate prescribing of antipsychotic medicine in residential aged care was initially flagged as a major problem by the Royal Commission into Aged Care Quality and Safety in 2021.
In addition to their traditional uses for bipolar disorder and psychotic illness, psychotropics have become a common treatment for behavioural disturbance in patients with cognitive impairment and intellectual disability.
At present, approximately one third of people with an intellectual disability are prescribed psychotropic medication.
However, with more use comes more danger, with older people being more at risk of worsening cognition, falls, stroke, and death when on these medicines.
These risks increase over longer periods of use, according to research by Dementia Australia.
In Australia, aged care residents have a 22% higher risk of death in the first 100 days after being commenced on antipsychotics.
Of equal concern, while there is clear evidence of harms associated with use of psychotropics in those with cognitive impairment, there is limited evidence of their effectiveness managing agitation, aggression and other behavioural disturbances in this population.
The Commission’s Chief Medical Officer and emergency physician, Associate Professor Carolyn Hullick describes the initiative as a long-overdue recognition of the rights of people with cognitive impairment to access safe and effective treatment options.
‘It’s essential for prescribers and clinicians to be mindful of the way they’re using psychotropic medicines because of their risks and limited benefits for people with behaviours of concern,’ she said.
‘Psychotropic medicines do have a place, but it is imperative that we use them judiciously and with a clear understanding of their purpose.’
Embedded into the standard is a clear message that, despite their commonness in the treatment of behaviour disturbance in people with cognitive impairment, psychotropic medication should be reserved as a last resort option.
This includes when other non-medication strategies have failed or there is significant risk of harm to the person or others.
The standard also emphasises the importance of clear communication of goals and plans among the GPs, other specialists and health workers caring for the patient, and for consultation with caregivers and family.
Neuropsychiatrist and National Centre of Excellence in Intellectual Disability Director, Professor Julian Trollor, said when prescribing these medicines, it is essential to have clear objectives and ways to measure their impact.
‘This includes collaborating with behaviour support practitioners to ensure that your prescribing has the intended response,’ he said.
Sydney-based GP and Chair of RACGP Specific Interests Aged Care, Dr Anthony Marinucci, also supports the standards from an aged care perspective.
He said that with a significant increase in psychotropic prescribing in Australia, doctors must be more mindful than ever that they are used in a safe manner.
‘We have been acutely aware of the risks associated with psychotropic medications, particularly those used in the context of chemical restraint with a relative scarcity of evidence,’ he told newsGP.
‘These standards highlight that psychotropics should be reserved as a last resort option when other non-medication interventions have not had an adequate response.’
As GPs are at the centre of multidisciplinary team care arrangements for the elderly, Dr Marinucci encourages all primary care providers to be familiar with the standard and its usefulness in helping to construct individualised non-medication strategies.
‘The standards have been created to better inform the whole team and to offer strategies to address the multidisciplinary support plan as a whole,’ he said.
‘It’s a natural corollary suggesting that non-medication interventions be the primary strategy in an overall comprehensive behavioural support plan.
‘The standard can be used to tailor an individualised support plan and offer the best chance to avoid inappropriate or excessive psychotropic prescribing in these vulnerable populations.’
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Dr Dhara Prathmesh Contractor   10/05/2024 6:27:21 AM

Glad to see and read this article after all.

We have been struggling to explain these facts to age care staff and their families sometimes. And struggle adjusting why ceasing certain medications will help patients safety over and over again.
Along with psychotropic medications, multiple other groups of medications ( for example: statins, antidepressants, opioids, Alzheimer’s medications in 95year olds etc..) need to be reviewed.
Pharmacological cocktails of medications along with strong psychotropic medications, no thought of drug interactions are administered on daily basis. A loaded trolley with medications 💊 different colours and size and shapes administered.
Stopped visiting age care.
As despite requesting changes sometimes some other doctors or specialist or after hours doctors or pharmacy etc… will request you to continue with these medications.
Which makes no sense sometimes.
If we follow our basic instincts of:
we will be able to overcome this easily.

Dr Ian   10/05/2024 7:20:34 AM

However we can not ignore the reality that pain may cause agitation and aggression and medication is needed .There are two articles of interest .
The older agitated patient in the Emergency Department by Maura Kennedy et al in JAMA open 2020 and an Australian study by Stephen McFarlane et al in frontiers in Psychiatry 2021 which emphasise the need to look for pain as a cause of agitation and the need to treat pain and review the degree of pain relief .
To asses a patient thoroughly one or two doses of psychotropics may be needed if verbal de -escalation which can be helpful but requires skill does not work .
It is weeks and months of psychotropic medication for the challenges of behaviour change in dementia and disability that are greatly overused .

Dr Sanjeevan Nagulendran   10/05/2024 10:00:55 AM

Individualised Patient centred evidence based healthcare is what we should be practising. Misuse of guidelines is completely inappropriate. Just taking people off medications that are efficacious just due to new guidelines without shared decision making is not acceptable. Everything in medicine is case by case and blindly saying all patients should not be on opiates or benzodiazepines which is what I have seen happen over the last few years is a national disgrace. We can see the effect of de prescribing in the massacre at bondi junction. This phenomenon seems unique to Australia - that medications are bad! Let’s hope all doctors apply some common sense in their clinical reasoning! There a risk benefit to everything we do - the idea that we can keep people living forever in perfect health when they smoke and take illicit drugs also needs urgent review - people get old and sick. We must all be realistic in our expectations.

A.Prof Christopher David Hogan   10/05/2024 3:39:39 PM

This is a counsel of perfection.
Like all guidelines, these are guidelines not tramlines.
Like most General Practice , residential aged care is full of complexity & uncertainty and there is always need for individual clinical decisions.
Often, aged care is equivalent to Palliative Care & when that occurs our primary aim is the comfort of the patient not their longevity!
I am appalled at the low level of community Health Literacy & when I did an introductory meeting with the person holding the patient's power of attorney , I was often asked if a person with dementia would improve.
I used set up meetings for friends & relatives about dementia but a lot still did not understand.

Dr Peter James Strickland   10/05/2024 7:42:46 PM

We cannot go too far the other way. I avoided giving anti-psychotics to a demented patient some years ago, and he killed another innocent resident in a state of paranoia by punching him, and the other person ending up on the floor with a fractured skull (fatal intracranial haemorrhage). Most GPs I have found are sensible with prescribing anti-pyschotics, but can get pressurised by nursing home staff to prescribe to help 'keep the peace'. My advice is use them sensibly, and review frequently for over-sedation and personality changes by asking family and friends of the patient, and watch for falls and such things as extrapyramidal effects.