Jan 15, 2019

Sixty per cent of residents on psychotropic medications, says Royal Commission submission

Psychotropic medications are being taken by more than 60 per cent of aged care residents, says dementia researcher Dr Juanita Westbury in her submission to the Royal Commission.

Dr Westbury told HelloCare that most staff who administer the medications believe the drugs are more beneficial than evidence actually suggests, and they are not aware of the potential side effects or professional guidelines about their use.

In her submission, which she has sent to the Royal Commission and was provided to HelloCare, Dr Westbury noted that doctors generally prescribe the medications at the request of nursing staff, assuming that “non-drug strategies” had already been tried.

Use of psychotropic medication often wasn’t reviewed, despite guidelines requiring that they are, she said.

Dr Westbury is calling on the government to fund her RedUSE program, which has already been successfully trialled, and is aimed at reducing reliance on antipsychotics benzodiazepines in nursing homes.

RedUSE educates staff about the “modest benefits” of the drugs and their side effects, and challenges some of the positive beliefs about the drugs’ effectiveness. The program also provides guidance for “deprescribing” the drugs.

What are psychotropic medications?

Psychotropics are powerful medications that are generally only used to treat mental illnesses, such a schizophrenia and bipolar disorder.

Examples of psychotropics include antidepressants, antipsychotics and the sedative, benzodiazepine.

More than half (53%) of all aged care residents will have dementia, and most of them will experience some type of “changed behaviour” at some stage, including anxiety, agitation, depression and insomnia, Dr Westbury writes.

Though using psychotropics can have some benefits in treating these conditions, the benefits don’t outweigh the risks, Dr Westbury says.

“Although there is some evidence to support using psychotropics to treat these conditions [mild depression, anxiety, insomnia and “changed behaviour”], for most older people their effect size is small and they can cause severe adverse effects such as falls, pneumonia and stroke.

“They also cause excessive sedation, movement and language disturbances, heart rhythm changes, metabolic disturbances and worsen confusion,” she writes in her submission.

Chief Executive of the Council of the Ageing, Ian Yates AM, told HelloCare the Carnell-Paterson review found drugs are being administered without a prescription. He also said anecdotally we know that “in many cases these medications are being prescribed without consent”.

“Repeat dosage without any attempt at behavioural and environmental solutions reportedly occurs in plus or minus half of all facilities,” he noted.

Over-medication robs residents of their dignity

Mr Yates said over-prescribing of medication is “widespread” in aged care, and is stripping residents of their “health, dignity and personality”.

“In many cases, nursing home residents ‘act badly’ because they are in undiagnosed and untreated pain, or a subject to disruptive and frightening behaviours and environments. Instead of those issues being addressed, residents are dosed with sedatives and their underlying health problems are untreated.

“It is a lazy, ignorant and disturbing practice,” he said.

Mr Yates said over-prescribing of medication should be “urgently addressed” by the Chief Clinical Adviser at the new Aged Care Quality and Safety Commission, and the Royal Commission should “most definitely” be addressing the issue and making recommendations.

Mr Yates would like to see a number of changes in relation to the prescribing of psychotropic medications.

“We need to have tougher standards”

“We need to have tougher standards in nursing homes which spell out in very clear terms in what cases, in what circumstances, and for what periods the prescription of psychotropic medications is deemed appropriate.

“The issue of consent needs to be thoroughly examined by the Royal Commission and clearer processes need to be put in place for engaging family members before a resident is being prescribed psychotropic medication.”

Mr Yates also called for more funding to train the aged care workforce in dealing with people with dementia, and he said the AMA and the RACGP need to be involved in addressing over-prescribing of psychotropics as a “high priority”.

Focussing on unmet needs reduces reliance on medication

Colin McDonnell, dementia excellence practice lead with Scalabrini, told HelloCare that Scalabrini has been able to significantly reduce its use of antipsychotics by focussing on residents’ unmet needs.

He said by shifting their focus away from BPSD (the Behavioural and Psychological Symptoms of Dementia) and instead identifying and addressing the unmet needs of residents when they became distressed or agitated, they were more effectively able to calm situations.

Medications can be a “quick fix”, he said, but it has been shown they aren’t effective and can actually cause other problems, such as falls.

Mr McDonnell said Scalabrini trialled programs with Dementia Training Australia and Curtain University that were based on the work of Professor Henry Brodaty, who advocates for a psychosocial approach.

Scalabrini’s trials are now complete, and the learnings from those programs have been incorporated into the facility’s daily practices with high rates of success.

Please note: The image used to illustrate this article does not reflect actual people or events. Image: iStock.

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  1. From my personal experiences, I would most definitely say the percentage of elderly dementia patients chemically restrained as the first option in HOSPITALS is HIGHER than the 60% of residents reportedly chemically restrained in residential aged care. Yet mandatory staffing ratios already exist in hospitals!!!. We are talking supposedly “qualified and skilled” acute nurses and physicians. Why does this not cause outrage in peak representative bodies, such as Dementia Australia and COTA, who say they advocate on behalf of the elderly and people living with dementia? Why is this not being reported on? Why is NOTHING being done to stop this after years on inaction? Why is the focus solely on residential aged care and NOT HOSPITALS, which are critical pathways to residential aged care. Clearly staffing ratios are NOT the root cause of chemical restraint. People living with dementia need action NOW – they have waited too long for others to advocate on their behalf and achieve little. Vulnerable people are dying or being harmed from unlawful chemical restraint and that is not OK with me.

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