Nov 27, 2019

Devil is in detail in government response to psychotropic misuse


Restricting the use of one type of psychotropic is likely to mean other, less well studied drugs will be prescribed in their place, says a leading dementia medication expert.

On Monday, the government announced a $537m funding package to address concerns raised in the Royal Commission into Aged Care Quality and Safety’s interim report.

Most of the funding was directed to an additional 10,000 home care places, but more than $35m was allocated to reducing the use of medication as a chemical restraint in aged care.

“I think the government is to be commended on addressing the issues,” Juanita Breen, senior lecturer Wicking Dementia Research and Education Centre, told HelloCare.

“But I think more detail is needed,” she said, noting that the government was probably “under pressure” to respond to the report.

Dr Breen said the absence of a commitment to increase staffing in aged care was “the elephant in the room”.

“We always hear that more staff are needed, and there isn’t any announcement there for increased funding of staff,” she observed.

Crackdown on psychotropics may lead to other drugs being prescribed

A key plank of the government’s changes is that doctors will have to seek special approval if they want to prescribe the antipsychotic medication risperidone beyond 12 weeks.

Dr Breen said past experience has shown this usually results in other, less well-known medications being used instead.

“What happened in the US is other medications with sedating properties were used instead,” she said.

“In the US, when they had a big crackdown on antipsychotics… benzodiazepine use went up, but also other agents that weren’t audited, including anticonvulsants, which are used for epilepsy, (went up). 

“That’s what happens. People use work-arounds,” Dr Breen explained.

“People turn to other medications which have less evidence for effect and come with their own problems,” she said.

Similar trends have also been observed in the UK and are well documented in research literature, according to Dr Breen.

Doctors under pressure to prescribe psychotropics

Dr Breen also questioned the targeting of doctors for improved training, but said it was encouraging to see $10m put towards more training for aged care staff to better equip them for managing residents living with dementia. 

“Targeting doctors as a sole remedy doesn’t really look at the underlying causes of problems when caring for people living with dementia,” she said.

“Other initiatives that have been targeted at prescribers haven’t proven very successful because it’s complex,” she said.

“Most of the GPs I’ve spoken to have said they know the risks associated with these drugs, but they are under a lot of pressure to use them.”

She said residents sometimes would not be able to remain in residential aged care unless they are given medication.  

“If we don’t give them a bit of something we’re going to have to put them in hospital or put them in an older person’s mental health unit. That’s the sort of pressure,” she explained.

“I think GPs largely know about the adverse effects associated with these medications or the guidelines for use because they have been heavily promoted for a long time,” Dr Breen said.

Staff training to apply non-pharmacological strategies

Dr Breen told HelloCare the key to managing complex and challenging situations with people living with dementia is staff training, reviewing medications with a team of nurses, doctors, and pharmacists, and support for staff to be able to apply non-pharmacological strategies, such as activities, improving the environment, and proper assessments.

The government’s response to the interim report does seem “overly focused on GP prescribing”, Dr Breen said. “What evidence have they got that those strategies will be highly effective?” she asked.

“Targeting the GPs ignores all the other contributing factors that I thought were very well described in the ‘Neglect’ report.”

More detail needed for $25.5m on medication management

The government has also promised $25.5 million for medication management programs, “including support for pharmacists to ensure more frequent medication reviews can occur”.

“If the medication management programs that are currently in use can be more adapted to reduce the use of psychotropic medication, that’s a really good thing,” Dr Breen said.

“I hope it’s not just throwing more money at pharmacists to do more medication reviews, because they’ve been in existence for 20 years and they really haven’t shown a lot of effect to reduce psychotropic medication. 

“There’s no point pharmacists coming in and recommending changes (to medications), because a lot of the time that’s not supported by the staff who have to deal with the issues,” Dr Breen explained.

“More clarification” about how the $25.5m was going to be used would be helpful, she said.

Some residents will always need to use psychotropic medication

Rather than focusing on the issue of chemical restraint, Dr Breen said she believes it’s more useful to ensure psychotropic medication is being used appropriately. 

Despite the obvious problems with antipsychotic medications, she said they are helpful at times for some residents.

She said most aged care residents – 86 per cent – have a mental health condition. 

“There are times when someone is acutely distressed, you can talk to most aged care staff and they’ll tell you about it, and they may need some medication, whether it be a little bit of antipsychotic or benzodiazepine, just to handle that particular situation so you can work out what’s going on,” she said.

In the US and the UK, people don’t focus on restraint-free practice, they focus on minimising the use of psychotropics and making sure that when they are used, there’s appropriate consent, sufficient monitoring, and they are only used for short periods, Dr Breen said. 

In the US, psychotropic use is down to around 15 per cent of residents, compared with 22-25 per cent in Australia.

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  1. Well said Dr Breen. The frenzy to forbid sedation is based on ignorance unfortunately. Where and how could we possibly manage residents with violent tendency, severe depression, delusions etc… and where would they go.
    The recent funding doesn’t touch the sensational footage shown on TV about nursing home staffing, food, etc. It’s a distraction our government hasn’t done one thing to alleviate one single problem in facilities.
    Clearly the surplus is more important to Mr Morrison than seniors.

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