Antipsychotics overused in residential aged care: Study

Amanda Lyons

25/07/2019 3:24:32 PM

Research reveals concerning rates of antipsychotics use in aged care, showing many doctors and facilities are not following best-practice guidelines.

Antipsychotic medication in aged care.
A recently published study has provided further evidence of overuse of antipsychotic medication in residential aged care.

A new study has confirmed significant over-prescribing of antipsychotic drugs in residential aged care facilities (RACFs).
‘Our research shows that people with dementia are on antipsychotic medication for roughly twice as long as the recommended maximum time to treat behavioural and psychological symptoms of dementia,’ Dr Kimberly Lind, the study’s lead author and research fellow at the Australian Institute of Health Innovation at Macquarie University, said.
The longitudinal study, published earlier this week in Alzheimer disease and associated disorders, tracked 5825 people with dementia aged 65 years or older in 68 RACFs between 2014–17. Their medication administration records were used to identify the use of antipsychotic medication, and then its prevalence, duration and time to initiation.
Guidelines recommend not to extend the use of antipsychotic medications in patients 65 years and older with dementia for longer than 12 weeks, or 84 days.
Despite this, Macquarie University study found that an overall 65% of study participants who used antipsychotics did so for far longer – with mean durations of use at 212 days for women and 216 days for men, or around 30 weeks. 
This has led the study’s authors to warn that doctors and RACFs are not following current guidelines and restrictions governing the use of antipsychotics in aged care, and that these may be insufficient to prevent overuse of such medication.
New regulation applying to all RACFs around monitoring the excessive use of physical and chemical restraints has been in effect since 1 July this year, and the Department of Health has provided a number of resources to help compliance with the requirements.
The Australian Commission on Safety and Quality in Health Care recommends use of antipsychotic medicines be considered a last resort option in aged care, because they provide only modest benefit and are associated with harms such as falls, stroke and confusion.
‘There is sometimes a role for them, but if we treated 1000 people for a few months with antipsychotic medications we would get some improvements in some of those target symptoms in around 10%, maybe 12% of those people,’ President of the Australian and New Zealand Society for Geriatric Medicine, Associate Professor Edward Strivens told the Royal Commission into Aged Care Quality and Safety.
However, other expert testimony to the aged care royal commission has indicated that a fall in the numbers of medically-trained staff at RACFs combined with a rise in the complexity of patient needs has contributed to an overreliance on the use of antipsychotics.
Professor Deborah Parker, Professor of Nursing and Director of the Centre for Applied Nursing Research at Western Sydney University, testified about the impact of a decline in trained nursing staff within RACFs, which has fallen from 21% in 2003 to a current level of 14.9%.
‘There has been an increase in what’s called the assistant in nursing, or personal care worker, the unregulated worker,’ she told the royal commission.
‘The enrolled nurses operate under the supervision of the registered nurse, but the unregulated worker with a very short certificate training, with approximately 120 hours in care – is not prepared and does not have the level of 10 assessment and planning skills required to meet the needs of the current aged care clients.’
Associate Professor Joel Rhee, a GP with a special interest in aged care, has observed a similar fall in numbers of GPs attending patients in RACFs, a phenomenon that he believes has been largely driven by insufficient funding.
‘The current remuneration structure is discouraging, it’s a barrier for GPs,’ Associate Professor Rhee told newsGP last year.
‘It makes no sense. I think the Government would have recognised that there is a huge issue with the funding, and yet they haven’t done anything about it.’
Professor Dimity Pond, a GP with a special interest in dementia care, believes a tightening of processes around the administration of antipsychotics in RACFs, as well as the employment of properly trained healthcare professionals, is necessary to address the problem.
‘GPs should be able to work with registered or enrolled nurses who have enough background to understand what the GPs are trying to do,’ she told newsGP earlier this year.
‘Ideally, the nurse should be available to come around with the GP, or at least discuss the patients they have seen. The nurse should also know why the GP has been called to see a particular patient and, if not, notes should be thoroughly documented.’
Dr Lind thinks solutions to the problem of overuse of antipsychotics need to include measures beyond increased regulation, such as providing RACFs with greater support and more effective systems for medication management.
One tool she feels could be particularly helpful in these efforts is the use of electronic health records.
‘Maximising the use of information in electronic health records would assist aged care providers to monitor medication use patterns to ensure patients are not on medication longer than recommended and put at risk of stroke,’ she said.
The aged care royal commission has identified six main barriers to use of non-pharmacological interventions to negate or mitigate the need for restraint in aged care, including:

  • perceptions about safety, fear of resident injury and legal concerns
  • residential facility characteristics such as staff and resource constraints and organisational culture
  • lack of knowledge about effects of restraints and alternative practices
  • beliefs and expectations of staff, family and residents, including a paternalistic attitude towards older people
  • inadequate review
  • communication barriers.

Aged Care antipsychotics Chemical restraints RACFs Residential Aged Care Facilities Royal commission Royal Commission on Aged Care Quality and Safety

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Dr Peter J Strickland   26/07/2019 1:18:08 PM

The use of anti-psychotics in dementia, and especially nursing homes is a vexed question. I have had a demented patient NOT on anti-psychotics, and who virtually murdered another patient by knocking them down and causing serious head injuries, and death within hours. Other previous gentle patients (male and female) becoming seriously abusive and threatening to staff or partners etc. When one has a demented patient who was previously mobile and communicative, and now sleeping, dribbling, not eating etc. it is time for review of dose and all medications, and that can be done by good liaison by staff to GP.

Bill Thompson   22/08/2019 7:59:35 PM

this research is all very well from an academic point of view ,done by researchers who probably haven't any clinical responsibilities themselves to actually care for residents in aged care facilities
The current Royal Commission would love this as evidence that Nurses and Doctors who actually do the work must be pretty hopeless is this area .
This is scapegoating the glaring issue with nursing homes which is that there are insufficient staff on duty .
To qualify for high level care in a nursing home, the patient is already at a fairly late stage of dementia or significant physical and psychological distress ,needing 24 hour professional supervision and care with an emphasis on palliative measures to adequately treat pain ,nausea ,vomiting etc and other distressing symptoms which quite often include psychotic agitation caused by the terror they feel especially with paranoid delusions .Increase the trained nurse numbers and we can throw away Rx.