The first national study to rigorously evaluate psychotropic medication in aged care following landmark reforms has found the use of antipsychotics is twice as high in residents with dementia.
Macquarie University research, done in the wake of measures to reduce overprescribing in aged care facilities, also revealed a rising trend in antidepressant use in those with dementia.
Almost half of residents with the condition were taking an antidepressant in 2022, according to the team led by Associate Professor Magda Raban, of the university’s Australian Institute of Health Innovation.
“We wanted to understand whether recent aged care reforms, particularly those following the 2018 Royal Commission, had influenced the use of psychotropic medications in residential aged care,” Associate Professor Magda Raban says.
The measures included greater regulatory scrutiny, dementia support service availability, implementation of quality indicators and medication reviews in aged care settings.
Overall researchers observed a decline in the use of antipsychotics, sedatives and antiseizure medications in people with and without dementia in residential aged care.
“Our findings suggest that the government reforms may be contributing to positive changes,” Associate Professor Raban says.
“This was encouraging and reflects the commitment among many aged care providers to delivering quality care.
“However, there is a plateau in the decline suggesting further improvements are possible.
“A persistent two-fold higher use of antipsychotics in residents with dementia and a rising trend in antidepressant use among people with dementia, highlight areas needing urgent attention.”
What are psychotropic medications and why do they matter?
These are medicines which have an effect on the mind, emotions and behaviour and include several classes of drugs such as antipsychotics, antidepressants, sedatives and anti-seizure medications.
They should only be used as a last resort — and for the shortest possible time — when other approaches have not been successful.
They are prescribed to older people to treat conditions such as anxiety, difficulty in sleeping and depression.
In those with dementia, antipsychotic medications are sometimes used to manage behavioural and psychological symptoms such as agitation, anxiety and sleep disturbances.
“However, they carry significant risks, including increased risk of stroke and death, and there is also limited evidence to show they make a difference to the symptoms,” Associate Professor Raban says.
“Thus, they should only be used as a last resort - and for the shortest possible time - when other approaches have not been successful.”
Upwards trend in antidepressant use in those with dementia
Their study analysed data from 2018 to 2022, using figures on medications administered to residents at least once a month.
It covered almost 38,000 residents with and without dementia across 428 aged care residential facilities all over Australia.
Among those with dementia, there were significant reductions in the use of antipsychotics in the study period, (which fell from 33 per cent to 23 per cent of residents in 2022), sedatives (from 24 per cent to 15 per cent) and antiseizure medications (from 19 per cent to 14 per cent.)
Similar downward trends were seen among residents without dementia.
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Despite the improvements, antipsychotic use remained twice as high in residents with dementia (23 per cent) compared to those without (11 per cent.)
“This is concerning because it suggests that people with dementia are still being disproportionately exposed to medications that carry serious risks,” Associate Professor Raban says.
“This highlights the need for continued efforts to promote safer, more appropriate care strategies for this group.”
The research also noted an upwards trend in antidepressant use among those with dementia, rising from 42 per cent to 48 per cent between 2018 and 2022.
Associate Professor Raban says that may suggest a shift away from antipsychotics towards antidepressants which are possibly perceived as a safer alternative.
“However, antidepressants also have side effects and limited evidence of benefit for behavioural symptoms, including depression, in dementia,” she says.
“So this warrants careful monitoring, to make sure antidepressants don’t replace antipsychotics, and that the positive trends continue.”
The way forward
Aged care providers, clinicians and families all have a role to play in the future in reducing unnecessary psychotropic use, Associate Professor Raban says.
“Ongoing investment in workforce training, dementia support programs, medication reviews and leveraging the technology available in aged care is essential,” she says.
“Continued monitoring of trends, by dementia status, will be critical to evaluate ongoing efforts to improve the quality of care of older adults living in aged care.”
Magda Raban is an Associate Professor at the Australian Institute of Health Innovation and the Centre for Health Systems and Safety Research.
