How Prolific is Psychotropic Medicines Use in People with Dementia in Australia Within the Community Setting? A Retrospective Analysis
Drugs - Real World Outcomes
How Prolific is Psychotropic Medicines Use in People with Dementia in Australia Within the Community Setting? A Retrospective Analysis
Dianne Goeman 0 1 2 3
Kira Harvey 0 1 2 3
Cik Yin Lee 0 1 2 3
Neil Petrie 0 1 2 3
Chris Beanland 0 1 2 3
Christine Culhane 0 1 2 3
Susan Koch 0 1 2 3
Key Points 0 1 2 3
0 Suite 5 No 10 Station Rd , Cheltenham, VIC 3192 , Australia
1 RDNS Institute , 31 Alma Rd, St Kilda, VIC 3182 , Australia
2 & Dianne Goeman
3 Psychotropic Drug Advisory Service, The Florey Institute of Neuroscience and Mental Health , Parkville, VIC , Australia
Background When used for a therapeutic purpose such as for psychiatric illness, psychotropic drugs may enhance quality of life; however, when used to treat behaviours associated with dementia, they may have only a modest effect but lead to negative outcomes. Objective We undertook an analysis of communitydwelling people with dementia or cognitive impairment to ascertain how prolific psychotropic medicine use is within the Australian community setting, which psychotropic medicines are being prescribed and to whom, and whether the use of such medicines is in accordance with therapeutic guidelines. Methods We undertook a retrospective review of medication records, including medication charts, for 412 people with cognitive impairment, discharged from a home nursing service in Victoria, Australia, during the 6-month period between 1 January and 30 June 2013. Results Cholinesterase inhibitor use exceeded the number of individuals with a recorded diagnosis of Alzheimer's disease; in some cases, the dosage exceeded recommendations. Antidepressants were used by more than double the number of people documented with a history of depression. Antipsychotic medicines were prescribed for undocumented purposes, in some cases above maximum response levels, and multiple benzodiazepines were prescribed.
1 Background
Psychotropic drugs are medicines that impact on mental
functioning and may alter cognition, emotions and
behaviour. The word psychotropic originates from the Greek
term ‘psycho’, referring to ‘the mind’, and ‘tropic’,
referring to ‘turning’. Psychotropic drugs may be used in either
a positive or a negative manner. When used for a
therapeutic purpose such as for the treatment of psychiatric
illness, these drugs may enhance quality of life; however,
when used to treat behaviours associated with dementia,
they have been shown to have only a modest effect and
may lead to many negative outcomes [
1
].
Psychotropic medicines include the following:
antipsychotics—medicines used to treat psychotic disorders;
antidepressants—medicines used to treat depression and
anxiety disorders; anxiolytics—medicines used to treat
anxiety disorders; hypnotics—used to treat insomnia; mood
stabilisers—used to treat bipolar disorders; and
cholinesterase inhibitors—used as cognition-enhancing agents in
Alzhiemer’s disease [
2
]. More specifically, antipsychotic
medicines, benzodiazepines and antidepressants became
available in the 1950s as a treatment for schizophrenia,
psychosis, paranoid delusions, abnormal thoughts or
behavioural disorders and depression. However, since the
late 1980 s, there has been a steady stream of new agents
introduced to treat depression, anxiety, insomnia and
neuropsychiatric and behavioural disturbances [
2
].
Behavioural and psychological symptoms of dementia
(BPSD), including agitation and aggression, are
increasingly recognised as a major risk factor for caregiver stress
and institutionalisation of people with dementia [
3–5
]. The
use of psychotropic drugs to control BPSD in older people
with dementia is widespread, both in Australia [
6
] and
internationally [
7, 8
]. Treatment of BPSD using
psychopharmacological approaches, especially antipsychotics,
is problematic, as exposure to anticholinergic and sedative
medications is associated with functional impairment in
older people; additionally, the use of antipsychotic
medicines in older people frequently leads to adverse
effects, including the risk of cerebrovascular events
(increased risk of stroke), extrapyramidal side effects, tardive
dyskinesia (movement disorders) and mortality [9].
Consequently, the use of antipsychotic medicine to control
BPSD in older people with dementia has become
controversial [
5, 10–13
].
A recent study of Scottish nursing homes reported that
three-quarters of all residents received at least one
antipsychotic medicine to manage behavioural symptoms,
and over 70 % of 1715 people admitted to aged care homes
during this study commenced the medication prior to their
admission [
14
]. Rattinger et al. [
15
] similarly reported a
high use of psychotropic medicines in older people with
dementia, both in residential care facilities and in those
living in the community in the USA. Currently, in Australia
there is also evidence of an increase in the prescribing of
psychotropic medicines for older people living in aged care
homes (...truncated)