Introduction by Croakey: Recently released figures showing as many as one in five aged care residents are still receiving antipsychotics in 2022 should be a call to action for the new Government, Charles Maskell-Knight writes.
Anika Wells, the newly elected Minister for Aged Care, has previously called for urgent implementation of Royal Commission recommendations preventing the use of chemical restraints by restricting their use to only the most extreme cases and only as a last resort.
Last week Wells described the crisis in the aged care sector as “worse than we thought,” telling the Guardian the Government’s most immediate priorities were short-term risks including those related to COVID-19 with funding reforms to follow.
Charles Maskell-Knight writes:
In its interim report the Aged Care Royal Commission observed that “restrictive practices [in aged care] have been identified as a problem in Australia for more than 20 years… Many recommendations for reform have been made, but not fully implemented”.
The Royal Commission went on to summarise the evidence relating to the use of pharmaceuticals as a form of restraint, noting that “research dating back to the 1990s has shown that the rate of prescription of psychotropic medication in residential aged care substantially exceeds the reasonable expected clinical needs of the people receiving care”.
It cited research by Dr Joanna Breen showing that 21.8 percent of residents were administered antipsychotics, and a study by the Registry of Older South Australians Research Team showing that the utilisation rate of antipsychotics among people entering aged care increased from well under 10 percent in the year before admission to over 20 percent following admission. It also referred to the Department of Health’s Aged Care Clinical Advisory Panel estimate that only 10 percent of antipsychotics and benzodiazepines used in residential aged care were clearly justified in the treatment of residents.
The Royal Commission also set out the side-effects from use of antipsychotics, including possible falls, fractures, increased confusion, and Parkinson-like effects. The Royal Australian and New Zealand College of Psychiatrists told the Commission that antipsychotics are associated with increased risk of respiratory complications, stroke, and heart rhythm abnormalities.
It is completely implausible that one in five aged care residents are suffering from a psychotic illness – psychosis does not confer a survival benefit. They are much more likely to be suffering from behavioural and psychological symptoms of dementia, and are being prescribed antipsychotics in the mistaken belief that these drugs will alleviate their symptoms.
Regulatory regime
Only one of the antipsychotics registered for use in Australia by the Therapeutic Goods Administration – risperidone – has registered indications that include “the treatment (up to 12 weeks) of psychotic symptoms, or persistent agitation or aggression unresponsive to non-pharmacological approaches in patients with moderate to severe dementia of the Alzheimer type”. Use of other antipsychotics to address behavioural and psychological symptoms of dementia is so-called “off-label” use.
The conditions for the supply of antipsychotics under the Pharmaceutical Benefits Scheme reflect the TGA indications. Most antipsychotics are restricted to use in patients with schizophrenia or bipolar disease under so-called “authority” requirements. Only risperidone is available for use in addressing behavioural and psychological symptoms of dementia, and then subject to a range of conditions, including that the patient has failed to respond to non-pharmacological methods of treatment.
However, as then Chief Medical Officer Professor Brendan Murphy told the Royal Commission, the Department of Health does not monitor compliance with PBS authority requirements, and does not audit prescribers to check that they hold supporting evidence. There can be no assurance that residents receiving risperidone have been offered non-pharmacological alternatives, nor that residents receiving antipsychotics limited to people suffering schizophrenia or bipolar disease have undergone a robust diagnostic process.
Carnell-Paterson review
It is important to note that the Royal Commission was not breaking new ground in examining the use of antipsychotics as chemical restraint. Two years earlier the Carnell-Paterson Review of National Aged Care Quality Regulatory Processes observed:
The use of antipsychotic drugs as a restrictive practice to control behaviour in residents with dementia may be inappropriate for several reasons.
First, there is evidence of their limited effectiveness in treating certain symptoms of dementia.
Second, there is at times an over-reliance on using antipsychotics as a first line of response, missing other needs of the resident.
Overuse of antipsychotic drugs may be the result of a ‘quick-fix’ mentality, reflecting an organisational culture that is not centred on the resident, or lack of training, qualified staff or other resources.”
It also drew attention to the significant adverse side effects of the medications.
The Review recommended that the “Chief Clinical Advisor [in the proposed Aged Care Commission] must approve the use of antipsychotic medications for aged care residents” (recommendation 7(iv)).
The Government did not accept this recommendation. It responded that:
“The recommendation that the Chief Clinical Advisor must approve the use of anti psychotic medications for aged care residents is not supported as prescribing and managing antipsychotic medication is best undertaken by an individual’s health professional team in consultation with the resident and their representatives.
“Conducting desktop assessments of the appropriateness of prescribing antipsychotic medication without direct engagement with residents to assess their care needs presents risks.”
In other words, despite all the evidence that residents’ “health professional teams” were overprescribing ineffective and harmful medications, they should be left to get on with it.
Royal Commission recommendation
In its final report the Royal Commission returned to the issue of overprescription of antipsychotics. It noted that under the Pharmaceutical Benefits Scheme the antipsychotic risperidone could only be dispensed for the treatment of autism in children if the child’s treatment was under the supervision of a paediatrician or psychiatrist.
It recommended that the Government should amend the PBS by November 2021 so that “only a psychiatrist or a geriatrician can initially prescribe antipsychotics as a pharmaceutical benefit for people receiving residential aged care”, with GPs able to issue repeat prescriptions for up to a year (recommendation 65).
The Government responded that it “accepted in principle” this recommendation – the kiss of death for any hope of prompt or effective action. It went on to say:
The Government supports better regulation of the use of prescribed antipsychotics in residential aged care settings. In accordance with legislation, the Government relies on the advice of the independent, expert Pharmaceutical Benefits Advisory Committee (PBAC) regarding new Pharmaceutical Benefits Scheme (PBS) listings and changes to PBS listings. The Government will refer this recommendation to the PBAC for consideration.”
At its November 2021 meeting the PBAC determined that it would not implement the recommendation because of the ‘substantial risk’ of unintended consequences. In making this determination it had before it several submissions from medical groups strongly opposed to the recommendation.
In other words, despite all the evidence that large numbers of aged care residents are being prescribed ineffective medications with a substantial risk of adverse health consequences, nothing should change.
What do the latest data show?
Since June 2021 the previously very limited suite of residential aged care performance indicators has been expanded to include the number of residents receiving antipsychotic medications. Data is reported quarterly by the Australian Institute of Health and Welfare, with the most recent data released last week on the day before Australia’s Health 2022 was published.
The March 2022 quarter data shows that, in those providers who supplied data on time, 35,619 or 20.5 percent of residents received an antipsychotic. While this is a decline from the 36,310 or 21.6 percent reported in the September 2021 quarter, it is far too early to call this a trend. It may simply reflect differences in the composition of the group of responding providers.
In any event, the headline estimate of about a fifth of residents receiving antipsychotics is broadly the same as that found in the research from the period up to 2015 reported by the Carnell-Paterson Review and the Royal Commission.
Nothing has changed.
Ministerial action
The previous Government seemed prepared to go along with a situation where – as its own Advisory Panel concluded – 90 percent of the 36,000 or so people receiving antipsychotics are doing so without a clear justification and at a risk to their health.
Under the PBS children are not prescribed antipsychotic drugs without the involvement of a specialist – why should vulnerable older people be able to receive these drugs without a similar level of professional scrutiny?
Ministers Mark Butler and Anika Wells should revisit this issue if they are serious about improving the quality of life for people in residential aged care.
Charles Maskell-Knight, a former senior public servant in the Commonwealth Department of Health for over 25 years, contributes regularly to Croakey.
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