National standard to tackle psychotropic medicines harm

Prescriptions for psychotropic medicines for all Australians have increased by a staggering 60% over the past three decades¹.

Older people are particularly susceptible to adverse effects from psychotropic medicines, including worsening cognition and an increased risk of falls, stroke and death.

While an increased awareness of the risks associated with using these medicines has led to a slight decline in antipsychotic prescriptions among older Australians², significant challenges persist.

To tackle these challenges, the Australian Commission on Safety and Quality in Health Care (the Commission) has introduced a national standard to improve the care of people with cognitive disability or impairment.

The Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard outlines clear actions to ensure the responsible and appropriate use of psychotropic medicines, representing a significant step towards ensuring safer, more effective treatment practices.

In Australia, aged care residents have a 22% higher risk of death in the first 100 days when antipsychotics³, a commonly used type of psychotropic medicine, are prescribed. Around a third of people with intellectual disability are prescribed psychotropic medicines and are exposed to potential short- and long-term adverse effects.

While psychotropic medicines play an important role in treating mental health conditions, they are also commonly used to manage behaviours of concern experienced by people with cognitive disability or impairment. This is despite the known harms of these medicines and the lack of evidence that they are effective for managing behaviours, which may include aggression, agitation and sometimes self-harm.

Non-medication interventions

The standard aims to curb the inappropriate use of psychotropic medicines and promote patient safety. It highlights the importance of non-medication interventions as the primary method for addressing behaviours of concern, with psychotropic medicines reserved as a last resort option when other strategies have failed, or there is a high risk of harm to the person or others.

Importantly, non-medication strategies should be designed around the person’s individual needs and expressed wishes, and in consultation with family and others the person has agreed should be involved in their care.

The Royal Commission into Aged Care Quality and Safety and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability revealed concerning trends in psychotropic medicines misuse and overuse in the aged care and disability sectors.

Risks and benefits

Conjoint Associate Professor Carolyn Hullick, Chief Medical Officer at the Commission and Emergency Physician in Hunter New England Health NSW, emphasised the significance of this standard, which is a long-overdue recognition of the rights of people with cognitive impairment to safe and effective treatment options.

“From my perspective, I think it’s essential for prescribers and clinicians to be mindful of the way they’re using psychotropic medicines because of their risks and limited benefits for people with behaviours of concern. Psychotropic medicines do have a place, but it is imperative that we use them judiciously and with a clear understanding of their purpose,” she said.

Professor Julian Trollor, Director of the National Centre of Excellence in Intellectual Disability at the University of New South Wales Sydney, advocates for greater support for prescribing practices for people with intellectual disability.

“When prescribing these medicines, it’s essential to have clear objectives and ways to measure their impact, including by collaborating with behaviour support practitioners to ensure that your prescribing has the intended response,” he said.

Regular reviews

Juanita Breen, an Affiliate Associate Professor and a credentialed pharmacist specialising in dementia research at the University of Tasmania, explained the importance of monitoring and evaluating prescribing practices. “Clinicians and doctors should regularly review medicines to ensure their effectiveness and be mindful of potential side effects. We should always be asking: Could this medicine dose be reduced? Can we improve these symptoms through non-medicine approaches?” Breen said.

When people with intellectual disability or impairment receive care in different settings, this can result in a disjointed and inconsistent experience, which can be very difficult to navigate. Effective communication during transitions of care and support for decision-making processes is essential to upholding patient autonomy and safety so that medicines and other strategies are used consistently wherever the person is treated.

The standard applies to all healthcare services provided to people of all ages with cognitive disability or impairment and is relevant in any setting where they receive care, including hospitals, aged care facilities and the community.

Information sharing

Professor Eddy Strivens, Geriatrician and Clinical Director, Cairns and Hinterland Hospital and Health Service, emphasised the need for coordinated efforts. “This is a supportive standard for prescribers and clinicians. It provides practical information, encourages sharing information across care settings and will help ensure that these agents are used least and last, rather than first and foremost.”

In March 2022, the Commission joined with the Aged Care Quality and Safety Commission and the NDIS Quality and Safeguards Commission to release a joint statement on the inappropriate use of psychotropics to manage the behaviours of people with disability and older people.

The joint statement highlighted the detrimental impact of the inappropriate use of psychotropic medicines for older people and people with disability. The release of this standard joins other efforts to improve the safety and quality of health care, aged care and disability support for all Australians.

The Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard and resources are available at safetyandquality.gov.au/psychotropics-ccs.

^{1 AIHW
2 ACSQHC
3 Harrison et al. Aging Clin Exp Res 2021}

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