New standard warns against over-medicating the elderly

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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