The data has been gathered as part of the National Aged Care Mandatory Quality Indicator program, which has included medication management since 1 July 2021.
The latest data reflects the period 1 July 2021 to 30 September 2021. For the survey, nearly 170,000 residents were assessed at more than 2,400 aged care homes. More than one in five – 21.6% – of residents received antipsychotic medication, while only about one in 10 – 11.6% – received antipsychotics with a psychosis diagnosis.
Juantia Breen, Affiliate Associate Professor with the University of Tasmania, who also provides training to aged care homes on medication use on behalf of the Aged Care Quality and Safety Commission, told HelloCare research she did seven years ago found 22% of residents in their sample of 150 homes were taking antipsychotics.
The more recent data indicates an identical rate of antipsychotic use today in over 2,000 homes.
“I would have expected the rate of use to be lower given new legislation, prescribing restrictions, focussed attention on this issue and this new quality indicator,” Breen said.
Breen said the reasons rates remain high are “complex”.
“It’s a combination of low rates of staff, not enough training and support given to staff to manage behaviours of dementia by using other strategies, but also issues with the organisational culture in many homes where GPs and staff reach for sedating medicines as the first resort rather than the last resort.
“I also see many homes not referring people to old age mental health services and dementia support,” instead preferring to manage complex behaviours in-house.
Breen said another reason rates remain high is that a lot of older people come into residential aged care on the medication and stay on it for “much longer periods than the guidelines and the legislation recommends”.
It’s chemical restraint
The fact that high numbers are still being given antipsychotics without a psychosis diagnosis tells Breen the medications are being used “for reasons other than what they are intended for – often to manage behaviour of people with dementia, but also of people with intellectual disability and of people who may have no diagnosis but may be agitated or distressed”.
Aged care homes can benchmark against the data
Breen said the quality indicators are a “good start” in helping to reduce the use of antipsychotics in aged care, but aged care homes need to be more proactive about their approach to the drugs.
“Hopefully homes will now gauge and benchmark their use.”
She added, “If antipsychotics are used at rates at 22% or more, the home needs to ask why?
“What other behavioural support mechanisms do they employ? The most important questions are how long has this resident been taking this medication? Is it working? Does it have side effects and can we reduce the dose with a view to ceasing?
“Involving relatives and decision makers in these decisions is not only good practice but now legally and ethically required,” she pointed out.
Royal commission prompted reforms around chemical restraint
The Royal Commission into Aged Care Quality and Safety heard of “excessive use … of physical or chemical restraints, which rob our elders of their dignity and autonomy, and which can result in serious physical and psychological harm, increased health complications and … death.”
They noted that deficiencies in the regulation of chemical and physical restraint in aged care are a “significant human rights issue” in Australia.
The regulation of chemical restraint was tightened from 1 July 2021. From that date, when medication was used as chemical restraint, the prescriber had to obtain consent. In the common situation where the older person is not able to give consent, consent will need to come from the “restrictive practices substitute decision maker”.
The new legislation also requires chemical restraint only to be used where there is clear documentation of behaviour that may cause harm or distress to the older person, that there is a risk of harm to the person or to another person, and that there has been an assessment of this behaviour by a medical or nurse practitioner who has day-to-day knowledge of the older person or by a behaviour support specialist.
There also needs to be documentation of alternative strategies that have been tried, and that what is being proposed is the least restrictive alternative.
However, the latest QI data shows the rates of psychotropic use remain high.
Providers should be held accountable
Human Rights Watch has issued a statement suggesting the high rate of antipsychotic medication in aged care is related to inadequate staffing and training, factors that have been exacerbated by the pandemic.
Elaine Pearson, Australia Director with Human Rights Watch, said, “The Australian government should ensure that policies for older people respect their dignity and human rights.”
They said providers should be dealt tougher penalties when they misuse the medications.
“The Australian government should ensure aged care providers that wrongly administer medication to restrain older people are held accountable for their actions.”