What does best practice look like when managing psychotropic medication? 

Psychotropic medications are commonly used in residential aged care to treat a variety of symptoms and conditions, but they can be relied on too much and have not always been used appropriately.

Mismanagement of these medications has a huge impact on aged care clients, their quality of life and the staff who look after them. So what does best practice look like and how can you improve management of psychotropic medication in your organisation?

Guiding principles

Psychotropics are medications that can affect the way a person thinks, feels and behaves and experts in the sector hypothesis that a lack of knowledge about therapeutic alternatives to prescribing these drugs has lead to their over-prescription, especially when other treatments have been unsuccessful. 

Currently, these drugs are used to treat mental health conditions and disorders, epilepsy, to treat substance withdrawal, for pain management, in end of life care, and as a chemical restraint for changed behaviours in clients with dementia. But in some cases, medication is not always the best method of treatment. 

Data from the Registry of Senior Australians (ROSA) suggests that 21% of residents are dispensed antipsychotics, 30% benzodiazepines and 37% antidepressants within three months of being committed to an Australian residential aged care facility and are more commonly used among clients with dementia. 

To help providers properly manage the use of psychotropic medications, the Department of Health and Aged Care recently updated the Guiding principles for medication management in residential aged care facilities earlier this month and made 15 conditional recommendations and 49 good practice statements about the appropriate use of these drugs. 

Relying on an integrated knowledge translation process, the guiding principles are aimed to give providers practical ways to improve the management of psychotropic medication and ensure they are compliant with legislative requirements of the Aged Care Act.

A roadmap to compliant psychotropic drug management 

The new guiding principles relate to the safe and quality use of medicine and outlined some of the strategies that age care providers can use. 

One of the good practice statements says care staff should be trained to monitor for particular adverse reactions or events as a result of taking psychotropic medication and that all aged care residents using antipsychotics, benzodiazepines or antidepressants should have an adverse event monitoring protocol. 

The protocol should outline the specific roles and responsibilities that different health and care staff have in monitoring specific adverse events. 

Side effects

Common side effects of psychotropic medication care staff should be trained to look out for includes sedation and drowsiness, confusion, balance problems and falls, constipation, dry eyes and mouth, and appetite loss. 

These side effects can lead to weight loss, increasing frailty, loss of independent mobility and reduced ability to participate in activities and conversations that are meaningful to the person and enhance their quality of life.

Director at Monash University’s Centre for Medicine Use and Safety Faculty of Pharmacy and Pharmaceutical Sciences who specialises in dementia, Professor Simon Bell, said this aspect is particularly important for clients with who may not volunteer information about adverse events such as those with dementia. 

“People may not volunteer that information with things like sedation or orthostatic hypotension, which may increase the risk of falling, so it’s important for those that are involved in prescribing, dispensing and administering psychotropic medications to be trained to recognise those signs and symptoms.” he explained. 

A component of the principles includes the User Guide – Role of a Medication Advisory Committee (MAC), who plan an important role in the clinical governance of psychotropic medications by overseeing documentation and staff training. 

“Staff can be trained to identify and monitor the adverse events of psychotropic medications but the MACs can also monitor the administration of the medications and, if necessary, design local quality improvement activities to support staff to use those medications better,” Mr Bell said.

Prescribing psychotropic medications

Providers and care staff have a responsibility to be familiar with the best practice for managing psychotropic medication in their facility. 

Before a resident is prescribed and starts taking a psychotropic medication, a discussion needs to be had by the prescribing doctor, the resident and the person who may be their decision maker about the potential positive and negative effects of taking this medication.

Professor Bell said this is particularly important for residents with dementia as their decision-making capacity may be diminished which is where a comprehensive discussion between them, their families and their decision makers is vital to ensure they can give informed consent and their wishes are being respected.

“When those medications are prescribed, the date for review and/ or discontinuation should be documented in the medical record, the behaviour support plan and a nursing progress notes and should always be prescribed in conjunction with non-pharmacological strategies,” he said.

The Aged Care Quality and Safety Commission notes that the information given in this discussion allows the resident to give informed consent, which is a requirement when their treatment has significant risks, as is the case with psychotropic medication.

In a residential aged care facility, all care staff, pharmacists, residents and their relatives have a responsibility to work together to review psychotropic medications regularly.

Regular reviews of these medications ensures compliance with the management of psychotropic medication in line with legislative requirements. 

Discontinue of use

According to the Commission, all medication should be monitored and reviewed to establish or confirm:

• The reason for it being prescribed and whether that reason still exists
• Its effectiveness
• Its possible side effects
• The intended duration of use
• Possible interactions with other medications
• Whether the resident still wants to take it

The Commission’s Chief Clinical Advisor, Doctor Melanie Wroth, said that if it is no longer appropriate for a resident to continue taking psychotropic medication, it is vital that discontinuation advice comes from the prescribing doctor.

Some psychotropic medication may need to be weaned gradually and withdrawal symptoms may occur.

According to Doctor Wroth, the best practice for managing psychotropic medication in any setting is:

• To be clear about the resident’s condition or problem leading to a doctor’s consideration of prescribing a psychotropic medication and, if it is being considered to manage behaviour, to look at alternatives including non-pharmacological options
• For the prescribing doctor to articulate the anticipated benefits and potential harms or adverse effects with the resident and/ or the person who will be giving consent. 
• To establish a clear plan for monitoring and reviewing its use – how, by whom and when
• To discontinue the medication if it is identified as being ineffective, if the harms outweigh the benefits, if the resident’s circumstances have changed or if they no longer want to take the medication

Examples of mispractice

There is legislation covering the administration of some psychotropic medications which have clear oversight and documentation rules that must be complied with by providers to ensure correct dosage, correct storage and correct disposal of unused medication is being followed. 

Inappropriate psychotropic medication can refer to using these drugs when there are more harms than benefits for a resident, particularly if there is a safer alternative. 

Inappropriateness can also refer to not prescribing a psychotropic medication that would be beneficial to a resident and can include other factors such as what type of medication is prescribed, how much is prescribed and how long a resident is taking it without review. 

In the Australian Guidelines for the Appropriate Use of Psychotropic Medications, recommendations have been made about how long residents should take antipsychotic and benzodiazepine medications. 

Clinical behaviour by providers or care staff outside of the Commission’s recommended best practice can be considered inappropriate use of psychotropic medications, such as:

• Using psychotropic medication to sedate a resident without complying with all of the legislative requirements associated with use of medications to manage behaviour as outlined in the Quality of Care principles in the Aged Care Act
• Using psychotropic medication based on an opinion that a resident has a mental illness (such as schizophrenia or psychosis) without clinical justification for that diagnosis
• Long term use of psychotropics such as opioids and benzodiazepines for chronic pain, anxiety and sleep disturbance as they can be addictive and generally shouldn’t be used for a long period of time
• Continuing the use of these medications when they are not effective or when another medication added, rather than discontinuing the initial medication prior to trying an alternative
• Failing to recognise that a resident is experiencing adverse effects from a medication or medication combination

How providers can improve medication management

Outside of providers abiding by the legislative requirements around the management of psychotropic medication, there are some other ways you can work towards tightening that plan and making it as compliant as possible.

Doctor Wroth recommended that providers should ensure that their own policies and processes for monitoring and oversight of all medications are current, fit-for-purpose and enable them to understand where the risks lie to their residents. 

“They should have clear and transparent communications channels between prescribers, staff, residents and families, and an expectation that care staff and families will speak up where they feel a medication is no longer needed or where emerging risks become evident,” she explained. 

Similarly, providers with a Medication Advisory Committee are well placed to audit and carefully investigate medication related incidents, complaints, quality indicator and other data to support continuous improvement.

Available resources

To assist with this, the Commission has developed a number of resources to assist providers to understand psychotropic medications and their uses in aged care. 

Psychotropic medications used in Australia. Information for aged care gives providers a dictionary of terms and medication descriptions to further understand how psychotropic medication works and what the current medical guidelines are for using these drugs in residential aged care.

Restrictive practices scenarios assists providers in understanding restrictive practices, including chemical restraint, with a range of real-life scenarios.

The Psychotropic self-assessment tool can help assist providers to monitor psychotropic use and has proved useful in helping them to understand the extent of, and how, psychotropic medications are used in their facilities. This can often highlight areas which a provider may wish to review, audit or increase oversight of. The Frequently asked questions linked to the tool can help providers clarify some common areas of confusion or misunderstanding. 

The role psychotropic medication can play in improving the health and wellbeing of residential aged care clients is undeniable, but it is also clear that providers needed more guidance on how to properly administer and monitor this medication and the effects it may have. 

Working towards full compliance with legislation in the Aged Care Act and investing in psychotropic medication training for care staff is the way forward to ensuring these drugs are used properly and that the wellbeing of residents and staff remain at the forefront of the care provided.