Journal of the New Zealand Medical Association, 23-May-2008, Vol 121 No 1274
Psychotropic medications for elders in residential care
Concern about how psychotropic medicines are being prescribed for elders living in residential care is bubbling away in the New Zealand community, in international political and regulatory arenas, and in the scientific literature. This is mainly driven by a keener appreciation of various serious adverse drug reactions that may accrue to elders treated with such medications; the limited efficacy of some of these agents for several common problems such as “sundowning”; rising costs associated with using expensive medicines; and a sense that ‘there must be a better way’.
There is a group of people I come into contact with regularly whose management is often very challenging, as it will be for many readers. Following a sundowning pattern, agitation and even frank aggression become more common as the afternoon wears on. Intrusive care-eliciting behaviour increases at exactly the time that the carers need to absent themselves to deliver the evening meal and engage in staff handover.
It is very tempting to prescribe a touch of medication to ameliorate this syndrome as it is genuinely distressing to all concerned. Demented elderly in resthome care? No: my own children (whom I hasten to add have never been exposed to haloperidol). Why do we sanction medication for the former but recoil from using drugs for the latter?
Whether or not there is a ‘better way’, the residential care sector in which this prescribing is occurring faces very significant challenges over the next 30 years. Indeed, the current general practice, nursing, and allied health professional workforce engaged in caring for elders who live in care facilities is already stretched—with many shortfalls and marked inequity around the country. The same is true in relevant secondary care settings. This inevitably means that skill levels are not optimal and that staff turnover is high.
The workforce is itself ageing, especially in primary care medicine and nursing, with no compensatory peak in recruitment into these areas of practice. Across all professional groups, there is (on average) less glamour, lower remuneration, and poorer career advancement opportunities associated with this sector compared with others.
At the same time, the well-known twin impact of the ageing baby-boomers and marked increases in the longevity of current cohorts of elders mean that the population of people in the country who might benefit from or require residential care is growing rapidly. This immediate and dramatic increase in the number of New Zealanders over 85 years old is still largely ignored by the media and, one suspects, health planners whose attention is somewhat nervously focussed on the baby-boomers.
We also know that elders in care have a high prevalence of the common psychiatric disorders such as depression, anxiety, psychosis, delirium, and dementia. Despite the swing in emphasis in modern best-practice from medicalised and pharmacological management to more conservative psychosocial intervention plus medication as an adjunct, it is perhaps not surprising that a great deal of medicine is still prescribed given the context as I have described it. Indeed, it would not be surprising if there were a trend for prescribing to increase.
This issue’s study by Tucker and Hosford1 is an important contribution to thinking about the pharmacological aspects of the challenge of providing excellent residential care because there are no other published surveys of psychotropic utilisation in this setting in New Zealand.
A particular strength is that the survey has been repeated over a 15-year period. The main messages are a mixed bag of the potentially encouraging and the probably worrying. It may be a good thing that antidepressant prescribing has increased dramatically, although one worries about overcalling depression, a lack of more human, problem-focussed interventions for low mood, and the possibility that medications get started and never stopped.
It is good news that antipsychotic prescribing has remained stable and that doses are generally not large, but the mean doses of quetiapine and olanzapine in particular were still fairly high (which poor souls are getting much more than average?) and the marked shift from typicals to atyipcals cannot be supported by evidence in terms of efficacy, although the risk of extra-pyramidal side effects is generally lower.
The reduced regular usage of potent shorter-acting benzodiazepines is heartening, but on the other hand, do we really need to prescribe such a high proportion of long-acting agents instead? And what of psychotropic polypharmacy, its monitoring, and its reduction?
The main message from this paper that leaps out for me is that rates of psychotropic prescribing varied greatly between facilities offering more or less the same level of care. What can this mean from such a good regional sample other than that prescriber and environment factors are very potent influences upon prescribing patterns? Perhaps this means that educative and care-resource interventions can be selectively applied to reduce medication usage for outliers; perhaps it predicts a failure of applied logic to shift these variations in practice.
Of all these medicines, concern is highest for the antipsychotic drugs—necessary and demonstrably effective in the right setting at the right dose with the right support, but toxic in the wrong setting.
PHARMAC has recently commissioned the country’s old age psychiatrists to write guidelines for the prescription of these agents in residential care and a Primary Care group has been tasked with producing an educative and audit package. These endeavours must be applauded.
But they are not enough. The fundamental problem is not over-prescription of any particular class of drugs—it is an urgent need to improve our somewhat patchy and imperfect care for these most vulnerable citizens in the face of the great challenges that they present to carers, all at a time when the clinical need : clinical resources ratio is beginning to increase exponentially.
Disclaimer: The opinions expressed in this editorial are the author’s own and do not necessarily reflect the views of the any of the organisations with which he is associated, nor the NZMA.
Competing interests: No relevant financial interests. Convenor of FPOA(NZ) / PHARMAC Antipsychotic Prescribing Guidelines Project.
Author information: Matthew Croucher, Acting Chair, New Zealand Branch, Faculty of Psychiatry of Old Age of the Royal Australian and New Zealand College of Psychiatrists; Consultant Psychiatrist of Old Age, Canterbury District Health Board; Senior Clinical Lecturer, University of Otago, Christchurch
Correspondence: Dr Matthew Croucher, The Walshe Centre, PO Box 4345, Christchurch, New Zealand. Fax: +64 (0)3 3770267; email: firstname.lastname@example.org
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