Issue 36 / 26 September 2011

THERE is clear evidence that older people are prescribed psychotropic drugs at a rate that is much higher than for young or middle-aged people.

A recent article in the Australian and New Zealand Journal of Psychiatry, of which I was a coauthor, found that this was particularly true for women aged 85-95 years.

Antipsychotics, antidepressants and sedatives are all prescribed at higher rates in older people. At first glance, this is curious because findings from the 2007 National Survey of Mental Health and Wellbeing show clearly that rates of anxiety and depression are much lower in community-residing older people than in young or middle-aged people.

However, the national survey did not include people living in residential aged care settings and so might have missed considerable morbidity among older people. Perhaps the high rate of psychotropic prescribing to older people reflects high rates of psychiatric disorder in nursing homes?

We know that most people living in nursing homes have dementia and that dementia is usually associated with behavioural and psychological symptoms (BPSD).

People with dementia are prone to anxiety, depression and psychotic episodes, and also experience frequent episodes of delirium. They sometimes exhibit challenging behaviours, including physical aggression, particularly when personal care is being provided.

While psychosocial interventions are useful in the management of many nursing home residents with BPSD, most nursing homes do not have the trained staff needed to implement individualised psychosocial treatments or to modify care routines to minimise the impact of challenging behaviours.

The Productivity Commission recently handed down its report on options for reform of the aged care system. Unfortunately, the report did not really come to grips with the economics of providing appropriate psychosocial care to older people with dementia. Nor did it deal conclusively with the key workforce issues that compound the problem for nursing home residents.

It appears that there  is simply insufficient well trained medical, nursing and other staff in Australian nursing homes. Related to this are poor salaries for nurses working in nursing homes and inadequate Medicare rebates for GP visits.

The federal government funds the Dementia Behaviour Management Advisory Service in each state and territory, which provides assessment and advice to professional and family carers of people with dementia complicated by BPSD. By all accounts, it seems to be doing a great job in many areas.

However, the service is a limited resource and cannot deal with the sheer magnitude of the problem. In some places there are dedicated inpatient units for the management of severe behavioural disturbance, but these are quite limited in their geographical coverage.

Despite the best intentions of those dedicated individuals involved in providing care to nursing home residents, most responses to BPSD still seem to involve the prescription of psychotropic drugs, even though they do not work very well in people with dementia. Of nursing home residents treated with antipsychotic medication for agitation, only about 20% derive any benefit.

These drugs are also associated with an increased risk of transient ischemic attack, stroke and death in this population. Fortunately, it is possible to withdraw antipsychotic medication from most people with dementia without deleterious effects.

There is also recent evidence that antidepressants are no better than placebo for the treatment of depression arising in the context of dementia. While I am not suggesting that we cease all antidepressants in people with dementia, this finding should certainly should give us reason to pause before starting antidepressants in this group.

So what is the way forward?

We should think twice before initiating psychotropic medication in very old people. We should also have a low threshold for ceasing medications, particularly antipsychotic drugs that are ineffective or no longer needed in older people.

In people with dementia we should apply psychosocial interventions first, and only resort to trials of psychotropic drugs for severe BPSD.

We should lobby for a properly funded aged care system where health care workers, including nurses and doctors, are properly remunerated.

We should ensure that residential aged care facilities have appropriate access to clinical psychologists and other health workers with specific training in the management of challenging behaviours in the context of dementia.

Associate Professor Gerard Byrne is head of psychiatry at the University of Queensland.

Posted 26 September 2011

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