Researchers from the Dementia Centre for Research Collaboration (DCRC) and the Centre for Healthy Brain Ageing (CHeBA) at UNSW Sydney have highlighted a critical need to address non-consensual and overly lengthy use of antipsychotics in long term aged care residents.
The 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 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 2 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 New South Wales 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 (31/10/19) was 'to respond to the significant over-reliance on chemical restraint in aged care'."
Antipsychotic Usage and the Global Pandemic
Many residents of aged care facilities have been cut-off from visitors and many have become very anxious and depressed during their COVID-19 isolation. Also, visitor restrictions on nursing home entry have made it more difficult for a family member to give informed consent.
"We are particularly concerned that antipsychotic use may have been started without informed consent during lockdown of facilities due to the coronavirus pandemic", said Ms Harrison.
"Although family members may not be able to visit loved ones currently, we suggest they maintain communication with medical staff and nurses in relation to medications and other aspects of care. If a resident does not have capacity to give consent, the family member who is the person responsible, has a responsibility as well as the right to be asked for proxy consent before antipsychotic medications are prescribed and to advocate for changes to medications".
*The term 'Behaviours and psychological symptoms associated with dementia (BPSD)' is used respectfully for communication between professionals, people living with dementia and families (see Cunningham et al. 2019, IJGP). For more information about preferences on terminology, please consult the Dementia Language Guidelines produced by Dementia Australia.
For more information from the Royal Commission into Aged Care's Interim Report: https://agedcare.royalcommission.gov.au/publications/Pages/interim-report.aspx
Fleur Harrison 1 2 , Lynn Chenoweth 1 2 , Perminder Sachdev 2 3 , Brian Draper 1 5 , Henry Brodaty 1 2 5
