Defining psychotropic medicines in aged and disability care

The importance of ensuring the safe and appropriate use of psychotropic medicines in people with cognitive disability or impairment was stressed by two Royal Commissions, one on aged care and the other on disability care.^1,2 Both highlighted serious human rights and safety issues relating to the overuse of psychotropic medicines for the main purpose of influencing a person's behaviour (i.e. as chemical restraint), despite limited evidence of effectiveness and well-known risk of harms.They also highlighted that psychotropics are often prescribed for reasons outside their approved use for extended periods without review.³

So, what exactly is a psychotropic medicine? The term has various definitions and meanings and there is considerable debate about which medicines fall into this category. Psychotropics are often viewed as exclusively psychiatric medicines and, for some, synonymous with 'chemical restraint'. Frequently, the term 'psychotropic' is (incorrectly) used interchangeably with 'antipsychotic'.

The Royal Commission into Aged Care Quality and Safety stated that 'Psychotropic medications affect the mind, emotions and behaviours of a person.'³ This same definition was adopted by the Aged Care Quality and Safety Commission,⁴ and the Australian Commission for Safety and Quality in Health Care in their Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard (the Standard)⁵ (see article on the Standard in this issue).⁶ Similarly, the NDIS (National Disability Insurance Scheme) Quality and Safeguards Commission defined psychotropics as 'medicines that can affect the brain's function'.⁷ By using such broad definitions, one could argue that many medicines are 'psychotropics', including corticosteroids, certain antihypertensives and antiemetics.

The Aged Care Quality and Safety Commission published guidance to inform aged-care providers and clarify which medicines to include.^4,8 Antipsychotics, antidepressants and anxiolytic/hypnotics (e.g. benzodiazepines) were the main psychotropic classes, which is consistent with the Standard;^5,6 however, other classes such as anticonvulsants and opioids were also included because they are sometimes used off label to take advantage of their sedating qualities.

Another reason for increased vigilance regarding psychotropic medicines in aged care is that, aside from affecting the mind and behaviours, frail and older people are more vulnerable to their adverse effects, including sedation, delirium, metabolic changes, dysphagia and pneumonia.⁹ Taking multiple psychotropics amplifies the risk of falls, hospitalisations and death.¹⁰

Medicines for dementia (cholinesterase inhibitors and memantine) were also included in the Aged Care Quality and Safety Commission's guidance for providers⁴ because they were sometimes prescribed for behavioural and psychological symptoms of dementia (BPSD). With current evidence showing only modest benefit of these medicines for BPSD,¹¹ their inclusion in the Aged Care Quality and Safety Commission psychotropic guidance is under review.

In response to the Aged Care Royal Commission's findings, and to ensure older people's needs and rights are met, Australia's first legislation regulating restrictive practice in residential aged care (including chemical restraint) was passed in 2019, ensuring such practice is only used as a last resort to prevent harm, after best-practice behaviour supports have been considered, trialled and documented. Aged-care providers need to be satisfied that informed consent from the patient or a substitute decision-maker is gained by the prescriber before using chemical restraint, except in an emergency situation.¹² Similar NDIS restrictive practices and behaviour support legislation was passed in 2018.¹³

To help providers identify chemical restraint and ensure associated legislative requirements are met, and with the dual aim of implementing processes to identify, monitor and mitigate risks associated with psychotropics, the Aged Care Quality and Safety Commission promotes the use of a 'psychotropic self-assessment tool' in residential aged care, typically referred to as the 'psychotropic register'.⁸ Importantly, the register provides data for providers to enhance clinical governance by monitoring trends in use, and promotes regular review and continuous quality improvement strategies.

Prescribers and other clinicians often ask why certain medicines are included on an aged-care facility's psychotropic register. Antiemetics, medicines for Parkinson disease, and even nicotine are sometimes (incorrectly) included, despite no mention of these in the Aged Care Quality and Safety Commission's guidance. The likely explanation is that e-prescribing software programmers who incorporate registers into their software often code medicines using the World Health Organization (WHO) Anatomical Therapeutic Chemical (ATC) system which classifies them according to the system on which they act.¹⁴ A limitation of the ATC system is that medicines can only be coded into a single category. In practice, this means there can be a disconnect between the classification and the medicine's actual clinical use.¹⁵ For example, prochlorperazine is coded as an antipsychotic, but prescribed as an antiemetic in Australia. The ATC system also groups psychiatric, analgesic and neurological medicines together as 'CNS drugs'.¹⁴ Thus, when prescribers receive a pop-up message asking them if levodopa or an antiemetic is used as chemical restraint, software relying on an inflexible classification system may be to blame.

The WHO has defined a psychotropic as 'any medicine or substance whose primary or significant effects are on the central nervous system'.¹⁶ This definition, although also broad, goes further to state that psychotropic medicines are primarily used to treat mental health disorders (antidepressants, antipsychotics, anxiolytics, hypnotics and mood stabilisers), while psychotropic substances have a high potential for misuse due to their effects on mood, consciousness, or both (cannabis, opioids and stimulants).¹⁶ In view of the ambiguity over what medicines to include, consistent Australian adoption of the WHO definition of 'psychotropic' may help rationalise psychotropic registers.

Although sometimes administratively inconvenient, the enhanced oversight of psychotropic prescribing in aged care has had real impact, with antipsychotic and benzodiazepine use reducing substantially since the Aged Care Royal Commission.¹⁷ Ultimately, ensuring psychotropics are used judiciously in vulnerable older people and those with disability is fundamental to delivering safer, rights-based and genuinely person-centred care.

Conflicts of interest: Juanita Breen was a member of the advisory group for the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard 2024, and the expert group for Standard 5 (Clinical Care) of the Strengthened Aged Care Quality Standards. Juanita is a sitting member of the Tasmanian Civil and Administrative Tribunal, Protective Division (Guardianship Stream), and an Associate Investigator on an Australian Research Council grant titled 'Engaging residents and families about managing psychotropic medicines in aged care facilities' (The EngageMeds Project). Mandy Callary and Loren deVries declared no conflicts of interest.

 

References

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