In Australian aged care facilities, the reliance on prescription medications, particularly opioid painkillers, is a growing concern.
A recent study from Monash University and Japan’s Institute for Health Economics and Policy revealed that opioid use in Australian residential aged care facilities is 30 times higher than in Japan, with 74% of Australian residents prescribed regular painkillers compared to just 10% in Japan.
This stark contrast highlights a cultural and systemic issue in Australia’s approach to pain management, with potential consequences for residents, including dependency and withdrawal symptoms that can mimic or exacerbate cognitive decline, such as dementia.
The scale of painkiller use in Australian aged care
Approximately 178,000 Australians aged 65 and older reside in permanent aged care, with women nearly doubling men in number.
The high prevalence of opioid prescriptions, up to one-third of residents according to prior studies, reflects a therapeutic goal of alleviating pain, often prioritised over non-pharmacological alternatives.
Professor Dimity Pond, a general practitioner with extensive experience in aged care, notes that Australia’s approach is heavily medication-focused. “We don’t like to see [older people] in pain, and that’s kind of our cultural approach, to use a medication for that,” she explains. In contrast, countries like Japan employ physical therapies, socialisation, and distraction techniques to manage pain, reducing reliance on opioids.
This heavy dependence on painkillers, such as oxycodone, can lead to long-term use, particularly in scenarios where residents experience chronic pain from conditions like arthritis or acute pain from injuries, such as falls requiring extended opioid treatment.
Professor Pond highlights that even stable, long-term use of these medications can cause cognitive side effects, including confusion, agitation, and memory loss, which may be mistaken for dementia progression.
Withdrawal symptoms mimicking dementia
The abrupt cessation or rapid reduction of opioids in aged care residents can trigger withdrawal symptoms that closely resemble or exacerbate cognitive decline.
Professor Pond confirms that sudden opioid withdrawal can cause confusion, disorientation, agitation, and even memory loss, particularly in residents with pre-existing dementia. “The ageing brain is very sensitive to medication and changes in medication,” she says.
These symptoms can be mistaken for worsening dementia, complicating diagnosis and care.
Delirium, a state of acute confusion, is another potential consequence of rapid opioid withdrawal. “It certainly can [trigger delirium],” Professor Pond notes, describing symptoms such as confusion, agitation, and calling out, which overlap with dementia presentations.
This overlap poses a significant challenge in aged care settings, where residents with advanced dementia may struggle to communicate their pain or distress, leading to misattribution of symptoms to cognitive decline rather than medication effects.
Challenges in distinguishing withdrawal from cognitive decline
Distinguishing between withdrawal symptoms and true cognitive deterioration is complex, particularly when residents cannot articulate their experiences.
Professor Pond emphasises the importance of clinical tools, such as cognitive function assessments and medication charts, to monitor changes during deprescribing. “If we start to withdraw someone slowly from a medication, we’ll keep a note of any side effects from withdrawal,” she explains.
These records track increased agitation, pain, or cognitive changes, allowing staff to adjust deprescribing schedules gradually, reducing doses incrementally over weeks to minimise distress.
However, the lack of resources in aged care facilities hinders effective management. Professor Pond points out that non-pharmacological interventions, such as physiotherapy, massage, or social activities, require significant staff time and funding, which are often in short supply.
“It would be much better if there were more staff, if there was more funding,” she says. Comments from medical professionals on the Monash study echo this sentiment, with Dr Peter James Maguire noting that prescribing long-acting opioids is often a practical response to understaffed facilities where immediate-release medications may not be administered consistently.
The risk of painkillers for behavioural management
Another concerning trend is the use of painkillers for behavioural management rather than solely for pain relief. Professor Pond acknowledges that pain and agitation are intertwined: “If a person’s in pain, they’re likely to be agitated, walking around, calling out, maybe crying.”
In residents with severe dementia who cannot verbalise pain, staff may trial painkillers like paracetamol or opioids to address suspected discomfort, inadvertently leading to prolonged use.
Dr Maureen Anne Fitzsimon recounts a case where a resident’s family opposed painkillers despite evident suffering, highlighting the ethical dilemmas in balancing pain relief and medication risks (newsGP, 2024).
Systemic barriers and solutions
The systemic issues in Australian aged care, underfunding, staff shortages, and high staff turnover, exacerbate the problem. Professor Pond compares staff training to painting the Sydney Harbour Bridge: “When they’ve painted the whole bridge, they have to start at the beginning again.”
Dementia Training Australia offers programs for aged care staff and GPs, but the constant influx of new staff means training must be ongoing and structured, potentially integrated into TAFE or university curricula.
The EMBRACE trial, a helix-counterbalanced randomised controlled trial, is exploring innovative solutions by evaluating knowledge brokers, on-site pharmacist. This trial aims to reduce inappropriate medication use and improve concordance with clinical guidelines, potentially offering a model for managing painkiller dependency.
Moving forward: A holistic approach
Australia’s aged care sector stands at a crossroads – between a system designed for efficiency and one built for dignity.
The over-reliance on opioids, often used as a workaround for deeper systemic problems like understaffing and limited funding, has unintended consequences. When withdrawal symptoms mirror dementia, it’s not just a clinical issue – it’s a human one. Misdiagnosis can lead to inappropriate care, distress, and a diminished quality of life for those already vulnerable.
Professor Pond’s insights make one thing clear: the ageing brain is fragile, and our response to its care must be both thoughtful and deliberate. True reform means moving beyond quick fixes. It means prioritising non-drug interventions, redesigning training systems to keep pace with staff turnover, and reshaping the cultural lens through which we view ageing, pain, and personhood.
Because in the end, the question isn’t just whether we’re managing pain – but whether we’re paying enough attention to what pain is trying to tell us.
