Mary’s 85-year-old husband had been in an aged care home for just over a week. He had been getting frailer but was still sharp mentally. However, Mary* became extremely worried when her husband started sleeping all day.
After much ado, Mary obtained access to the medication chart for her husband. The aged care home’s GP had prescribed risperidone (an anti-psychotic medication), oxazepan (a benzodiazepine that is highly addictive and causes sedation), mirtazapine (an anti-depressant) and a norspan patch (an opiate for pain relief). Mary’s husband had never taken any of these drugs before being admitted to an aged care home.
When Mary complained about these drugs being prescribed, and asked for them to be discontinued, she met resistance from the GP. Mary fought to have her husband reviewed by a specialist geriatrician. The geriatrician agreed the medication was inappropriate.
Mary’s husband spent the last month of his life being weaned off psychotropic medication. After he died, Mary felt angry. The sedating effect of these drugs had robbed her of spending precious time with her husband.
The first national audit of psychiatric medication prevalence in aged care homes earlier this year found nearly two-thirds of all residents are prescribed psychotropic agents regularly, with more than 41% prescribed antidepressants, 22% antipsychotics and 22% of residents taking benzodiazepines.
The overuse of sedative medication as “chemical restraints” in aged care homes is not a new problem. In the past 20 years, there have been several government inquiries into an over-reliance on medication to manage the behaviour of residents. These inquiries recommended educating staff working in aged care homes about alternative ways to manage behavioural problems. The elephant in the room, however, is doctors who prescribe the medication.
There is strong evidence that many psychiatric drugs are not only often ineffective but may also cause older people substantial harm, including falls, pneumonia and sometimes premature death. So why are doctors prescribing these drugs?
Royal Australian College of General Practicioners president, Bastian Seidel, said: “Medical sedation is a foul compromise for inadequate nursing care”. University of NSW conjoint professor of psychiatry Carmelle Peisah went a step further by describing the administration of psychotropic medication without consent as “elder abuse”.
Who is committing the elder abuse – the doctor who prescribes the medication or the nurse who administers it?
Many attribute blame for the administration of psychotropic medication on providers of aged care homes. My research found these medications are sometimes being inappropriately used to sedate residents due to inadequate staffing levels and levels of training.
Doctors often prescribe psychotropic medications to be taken “pro re nata” (as circumstances require, as needed). This may encourage the use of sedation rather than taking the time to assess why someone is agitated or why they might be having sleeping problems. Is the resident in pain or does she have an infection?
Without enough trained staff on duty to make clinical assessments or provide diversional activities, circumstances may require residents to be given medication rather than care. This is often the case in the late afternoon when residents with dementia are more likely to experience confusion and agitation.
There is no doubt that caring for older people in an aged care home is a demanding job that requires specific expertise. With the increasing number of residents diagnosed with dementia, staff also require specific training to ensure residents with dementia are treated respectfully.
Good activity programs in an aged care home minimise the need for chemical restraint. For example, looking through a photo album and talking about who is in the pictures is an effective technique. However, this technique requires a staff member to have the time to initiate such individualised care.
A Human Rights Watch report describes the misuse of administering antipsychotic medication to people with dementia. This investigation raised the issue of consent, given that people with dementia are unable to give informed consent.
A recent study demonstrated that targeted interventions reduced the over-reliance on psychotropic medication. This intervention was implemented in 150 aged care homes in Australia. My mother was a participant in this research (without her consent). It was recommended that she decrease her daily dose of oxaxepam (a benzodiazepine).
Luckily, I stumbled upon my mother’s sedative review plan before it was implemented. I explained to the clinical nurse manager that Mum began taking benzodiazepines in the early 1960s when these drugs (along with a gin and tonic every evening) were considered a “housewife’s little helper”. Mum had been taking benzodiazepines for more than 50 years, long enough to develop a dependency.
The time to withdraw benzodiazepines was when Mum was 60 years old, not 90. In her twilight years, a daily dose of oxazepam was doing her no harm, whereas withdrawing oxazepam could have done a lot of harm (there is a very long list of potential withdrawal symptoms).
It was certainly not elder abuse to prescribe benzodiazepines for my mother.
According to Ken Wyatt, aged care minister: “A top priority for the chief clinical adviser within the new and independent Aged Care Safety and Quality Commission will be to monitor and advise on the use of psychotropic agents, while also seeking out and working to eliminate any inappropriate use of these drugs.”
The first step is to question the practice of doctors prescribing these drugs to be given “as circumstances require”. The second is to ensure enough trained staff are on duty to encourage engagement rather than sedation for all residents living in an aged care home.
* Names have been changed
First published in The Guardian on 14 September 2018