Without need or consent: antipsychotic findings


elderly couple silhouette made from pills

Residents in an aged care study had been on antipsychotics equivalent to more than 80% of the time they had been living in care… and medicines reviews weren’t helping

Researchers from the Dementia Centre for Research Collaboration (DCRC) and the Centre for Healthy Brain Ageing (CHeBA) at UNSW Sydney have highlighted what they call a critical need to address non-consensual and overly lengthy use of antipsychotics in long term aged care residents.

These medicines in residential aged care came to the attention of media and legislators in September 2018 after a Four Corners program, Who Cares? aired on the ABC critiquing the way in which they are used. This was followed by a Royal Commission into the issue.

The new research, which was formed by a collaboration between consumers, aged care providers, staff, GPs, Medicare Locals and researchers and published in International Psychogeriatrics, provides a snapshot of prolonged use of antipsychotic medications among these residents, the researchers say.

The research assessed 146 older people living in 24 long-term care facilities across Sydney, Australia as part of the Halting Antipsychotic use in Long Term Care (HALT) project. 

Lead author and PhD Candidate at CHeBA, Fleur Harrison, said that it is known that antipsychotics are given to many residents of aged care homes who have changed behaviours. 

This occurs despite the serious side-effects of these medications in older people, such as higher risk of death, stroke and falls. 

“It also occurs in the face of evidence that other non-drug interventions are equally or more effective for behaviours and psychological symptoms of dementia, as well as cost-effective,” said Ms Harrison.

According to Professor Henry Brodaty, Co-Director of CHeBA and leader of the HALT study, little is known about  for how long these medications are administered to residents. Anecdotal reports and recent evidence presented at the Royal Commission into Aged Care Safety and Quality suggest it may be much longer than recommended.

Government guidelines limit the use of these medications to 12 weeks—only for people with severe behaviours of a certain type—and require they be stopped as soon as the symptoms for which they were prescribed have improved.

“Our findings show that this had not happened for participants in the HALT project,” said Ms Harrison.

At the first research visit to each HALT participant, previous medical records were located and scrutinised to determine exactly how long each person had been prescribed antipsychotics. 

“What we found was troubling,” said Ms Harrison.

According to the research, participants had been prescribed antipsychotics for longer than two years on average. This was equivalent to more than 80% of the time they had been living in care and without a single adjustment to the dose in over a year.

It was an under-estimation of the actual duration of the prescription, given that full medical records could sometimes not be located despite researchers’ determined efforts. Only prescriptions which were fully documented were included in HALT calculations.

In addition, it appeared that most participants no longer had severe behavioural symptoms.

Written consent for the use of antipsychotics was found for only one of the 146 participants.

This was despite it being a legal requirement in NSW to obtain informed consent before any psychotropic medication is prescribed.

In addition, the standard practice of regular medication reviews appeared to have failed to help address long-term use of antipsychotics for these participants.

In more than two-thirds of cases a health professional, such as a pharmacist, had reviewed the person’s medications and documented that the antipsychotic was no longer necessary.

However, these recommendations had not been followed through.

Professor Brodaty said that, overall, it appeared antipsychotics were being given without need, without consent, and without close monitoring to see whether they were still needed.

The findings highlight insufficient monitoring of prescriptions for these medications for residents of aged care homes. Systems are being introduced to prevent unnecessary prescriptions for antipsychotics and to limit their continuation despite the risk of severe side-effects.

“These results align with the evidence presented at the ongoing Royal Commission into Aged Care, showing that vast improvements are needed in the aged care system,” said Professor Brodaty.  

“One of the three key recommendations in the Commission’s interim report was ‘to respond to the significant over-reliance on chemical restraint in aged care’.”

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1 Comment

  1. Debbie Rigby
    08/06/2020

    These are pretty damning results – on prescribers and pharmacists
    conducting RMMRs and QUM services. The editorial says “we must do
    better”. Two-thirds of residents had documented recommendations from
    pharmacists to review or cease antipsychotics, but these recommendations
    were not implemented. I know we can’t **make** prescribers act on our
    RMMR recommendations; and I know it can be very frustrating. The
    recently revised program rules for RMMRs which fund one or 2 follow-up
    consultation plus the doubling of funds for QUM services will hopefully
    impact on this inappropriate use of antipsychotics in people with BPSD.
    As shown in the HALT and RedUSE studies multifaceted interventions are
    needed to reduce inappropriate use of antipsychotics and benzos in aged
    care – not just an RMMR once every 2 years; not just a half-hour lecture
    to staff at the end of their shift; interventions need to include audit
    and feedback, education to staff, academic detailing to prescribers,
    medication reviews, and discussion at MACs as part of a QUM plan. The
    PBS changes (limiting risperidone PBS supply to max of 12 weeks) from
    January this year are likely to have a positive impact on the
    inappropriate long duration of risperidone use. But these regulatory
    changes may not affect the off-label use of quetiapine and may drive
    private scripts for continued antipsychotic use. So it’s time for
    accredited pharmacists conducting RMMRs and QUM services to reflect on
    their practice, upskill their knowledge and skills if necessary, develop
    and implement a QUM plan with a focus on psychotropic stewardship, and
    improve communication and trust with prescribers. “We need to do
    better”.

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