Supporting the appropriate use of psychotropic medicines in aged and disability care

SUMMARY

Royal Commissions into the aged-care and disability sectors revealed significant concerns about the inappropriate use of psychotropic medicines as chemical restraint in people with cognitive disability or impairment.

In response, the Australian Commission on Safety and Quality in Health Care developed the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard (the Standard), aiming to guide psychotropic use and ensure best practice in supporting people with cognitive disability or impairment. This article provides an overview of the Standard and its application in the aged-care and disability sectors.

The Standard promotes person-centred care and prioritises thorough assessment, non-medication strategies, and the development of individual behaviour support plans before considering psychotropic medicines. It encourages healthcare services to have clear policies around psychotropic use, including the need for documentation of non-medication strategies trialled before such use, and for monitoring the effectiveness of any psychotropic medicine prescribed.

Informed consent is a regulatory requirement before using psychotropic medicines as a form of restrictive practice. Clear treatment goals, clinical handover during transitions of care, and regular psychotropic review and deprescribing are emphasised in the Standard to minimise harm, particularly in cases of long-term use and psychotropic polypharmacy.

 

Introduction

Psychotropic medicines are broadly defined as any medicine that can influence the mind, emotions or behaviour.¹ They have important roles in the management of a range of medical and mental health conditions. In limited situations they may be an appropriate part of managing behaviours of concern in people with cognitive disability, dementia or delirium (e.g. emergency use and where imminent physical risks arise). However, the Royal Commission into Aged Care Quality and Safety, and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability, highlighted the extent to which inappropriate prescribing of psychotropic medicines was occurring in the aged-care and disability sectors in Australia, especially antipsychotic medicines (e.g. risperidone, quetiapine) and anxiolytic or hypnotic medicines (mostly benzodiazepines such as diazepam, oxazepam).^2,3

In aged care, the issue primarily related to the overuse of psychotropic medicines for people with behavioural and psychological symptoms of dementia (BPSD), whereas in the disability sector it related to psychotropic management of behaviours of concern largely in the context of non-progressive cognitive disability.

While these Royal Commissions brought the extent and human impact of inappropriate psychotropic medicine use into the public spotlight, concerns had existed for many years, with high rates and considerable variation in prescribing reported.^4-9

As part of a national effort to address these concerns and establish the standard of care for clinicians and health service providers, the Australian Commission on Safety and Quality in Health Care developed the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard (the Standard) in consultation with the NDIS (National Disability Insurance Scheme) Quality and Safeguards Commission and the Aged Care Quality and Safety Commission.^10,11

This article provides an overview of the best-practice use of psychotropic medicines in people with cognitive disability or impairment based on the Standard.¹¹

 

Psychotropic medicines as chemical restraint

In this article, the use of psychotropic medicines refers specifically to the context of use for behaviours of concern, also called changed behaviours, among other terms (Box 1). Use of psychotropic medicines in this context is regarded by legislation as chemical restraint, which is a type of restrictive practice defined as the use of a medicine or chemical substance for the primary purpose of influencing a person's (or care recipient's) behaviour (Box 1).^12-15

This definition specifically excludes the use of medicines prescribed for the treatment of a mental or physical illness or condition, including end-of-life care. It also excludes medicines used to support access to necessary medical appointments or investigations, such as when a benzodiazepine is administered before a blood test or imaging procedure. These are important exclusions, as psychotropic medicines are used for a broad range of therapeutic purposes, and clearly not all psychotropic use equates to chemical restraint.

The Standard focuses predominantly on 3 psychotropic medicine groups: antidepressants, antipsychotics, and anxiolytics/hypnotics.¹¹ However use of other medicines (e.g. anticonvulsants) for the primary purpose of influencing a person's behaviour would also be considered chemical restraint.

 

Best-practice management of behaviours of concern

The Standard comprises 8 quality statements addressing priority areas where improvements in clinical practice are expected to translate to better health outcomes for people with cognitive disability or impairment (Box 2). Each quality statement is accompanied by one or more indicators that may be used by clinicians and health service providers to assess and monitor their care practices and to improve them where action is required.

Best-practice management of behaviours of concern in both aged and disability care is broadly agreed to comprise an initial thorough assessment to enable identification and management of any underlying causes of behaviour change. This is followed by discussion with the patient, their family and caregivers about the issues, and providing them with non-medication management (e.g. behavioural strategies) and problem-solving approaches. Environmental approaches and adaptations, in conjunction with a tailored activity program, are also important. Last in the process, if the above approaches are not adequate, is a stepped trial of medicines.

Behaviour support plans

It is good practice, and a regulatory requirement for both the aged-care and disability sectors, to develop and implement an individual behaviour support plan (Box 1) for a person with behaviours of concern.^16,17 Psychotropic medicines and other types of restrictive practice for behaviours of concern must be a last resort following consideration and use of alternative strategies which must be detailed in the behaviour support plan.

Informed consent for psychotropic medicines

Medical practitioners need to independently obtain informed consent from either their patient or their patient's legally appointed medical decision-maker prior to the use of restricted practice, including the prescription of a medicine. Where there is no person who is authorised under relevant jurisdictional legislation to provide consent, escalation through the relevant state- or territory-specific authorising body is required.

Aged-care and disability providers have additional requirements under their regulatory frameworks for authorisation of restrictive practice (including ensuring informed consent has been obtained by the prescriber), and for monitoring and reporting the use of chemical restraint to the Aged Care Quality and Safety Commission and the NDIS Quality and Safeguards Commission respectively.

While regulatory frameworks are legally binding on aged-care and disability service providers, they are not binding upon individual prescribers who provide medical services either within service providers' facilities (such as general practitioners and nurse practitioners) or in general practice, other specialist clinics and hospitals. Service providers and prescribers may therefore approach behaviour management from different perspectives, leading to challenges in coordinating inputs into approval processes.¹⁸ In practice, this places prescribers in a situation of needing to support service providers with authorisation and document the reason for chemical restraint.

Appropriate reasons for prescribing

The Standard emphasises that clinicians should only consider prescribing psychotropic medicines to influence behaviour if the behaviours either pose a substantial risk to the person or to others, or are significantly reducing the person's quality of life. Emergency use is also justified if such use can facilitate necessary clinical assessments or interventions.

It is important to be aware that not all behaviours of concern respond to psychotropic medicines (e.g. antipsychotic drugs are usually not effective for reducing calling out, disinhibition, wandering and exit-seeking, but they may reduce agitation and aggression).^19,20

The Standard encourages service providers to have clear policies in place around psychotropic use, including the need for documentation of non-medication strategies trialled before such use, and for monitoring of the effectiveness of any psychotropic prescribed.

Appropriate prescribing in aged care

An Australian clinical practice guideline for the appropriate use of psychotropic medicines in people living with dementia and in residential aged care (including people with both dementia and intellectual disability) was published in 2023. This guideline provides recommendations and good practice statements about antipsychotics, benzodiazepines and antidepressants, specifically with respect to their benefits and harms, discontinuation and pro re nata (PRN) use.¹⁹

Appropriate prescribing in disability care

Guidance on prescribing psychotropic medicines is more limited for people with intellectual and developmental disabilities due to a paucity of high-quality evidence in this population. Some evidence supports the use of risperidone and aripiprazole in reducing behaviours of concern in children with intellectual disability, and the use of atypical antipsychotics and attention deficit hyperactivity disorder medicines in reducing irritability in autism, although side effects are problematic.^21-23 Key considerations for prescribing psychotropic medicines for people with intellectual disability are discussed elsewhere.²⁴

Importance of regular psychotropic review

The Standard emphasises the importance of regular monitoring and review of psychotropics to ensure that potential benefits outweigh harms and remain in line with the individual's treatment goals and needs. Common harms associated with most psychotropic medicines include, but are not limited to, cognitive impairment, sedation and increased risk of falls. Adverse effects associated with antipsychotic medicines include extrapyramidal side effects, weight gain, increased cardiovascular risk, and, in people with dementia, increased risk of cerebrovascular events and death.^25-27

Review of psychotropic medicines in aged care

Agitation and irritability are the behaviours most commonly leading to referral to Dementia Support Australia (Dementia Support Australia, unpublished data) and account for much of the inappropriate prescribing that occurs in people with dementia. Despite fears that behaviours of concern may re-emerge if psychotropics are stopped, many behaviours such as agitation and irritability are relatively transient and self-limiting.²⁸ It is common for psychotropic medicines to be continued long term (e.g. one Australian study reported usage for an average of 2.2 years),²⁹ despite the risks from longer term use being well known.^25,26 Many older people who have had antipsychotics initiated in hospital for short-term management of behaviours of concern have them continued upon discharge.³⁰

Review of psychotropic medicines in disability care

For people with cognitive disabilities, including those with intellectual and developmental disabilities, psychotropic medicines are frequently prescribed to manage behaviours of concern in the absence of a diagnosed mental illness, and their ongoing use may no longer be appropriate as circumstances evolve, or once behavioural and environmental strategies have taken effect. Psychotropic polypharmacy is common in this population and should be rationalised and minimised wherever possible.^31,32 People with intellectual and developmental disabilities have varying abilities to recognise and communicate adverse effects, necessitating proactive and vigilant monitoring.

Review frequency and process

The frequency of review should be guided by the context of use, the medicine, and clinical need – typically more frequently during initiation and dose changes, and whenever there are new behaviours, emerging adverse effects, or changes in health or circumstances.

The Standard highlights the need to consider the potential for dose reduction or stopping psychotropic medicines (deprescribing) at each review, taking into account whether behaviours have stabilised and adverse effects have emerged. If behaviours have been settled for 3 months or more at review, the need for ongoing use should be assessed.

Involving the person's family or support network in the review process facilitates shared decision-making; and clear documentation of review outcomes – including the rationale for continuing, changing or stopping medication – is important for continuity of care.

Stopping a psychotropic medicine should usually be undertaken slowly using an individualised tapering plan to reduce the risk of discontinuation symptoms.¹⁹ The Australian Deprescribing Network provides a gateway to local and international resources to support and guide deprescribing for a range of medications, including psychotropic medicines.³³ Ideally, a plan for deprescribing should be made when the medicine is started; as a minimum, the expected duration of therapy should be communicated to the patient and those involved in their care.^11,20

Information sharing at transitions of care

Transitions of care are associated with risk of medication errors and adverse events.³⁴ Shared accountability and collaboration across care settings is essential to deliver safe, person-centred care for people with cognitive disability or impairment, and to meet the expectations of the Standard. Aged-care and disability providers must ensure that up-to-date behavioural data, medication lists, medical histories and contact details of key people in the person's support network are available at clinical appointments and transfers to hospital. Clinicians, in turn, must clearly communicate their clinical findings and recommendations to all those involved in the person's care and support, subject to appropriate consent.

To reduce the risks at transitions of care, whenever psychotropic medicines are prescribed, clinical communications should include the rationale for medication initiation, target symptoms, evidence of effectiveness, potential and observed adverse effects, reasons for any medication changes, and recommendations for duration of therapy and ongoing monitoring.

Among people discharged from hospital with a psychotropic medicine for behaviours associated with dementia or other cognitive disturbance, very few are provided with a psychotropic management plan.³⁰ Providing a plan for reviewing and stopping the psychotropic medicine is an important step to prevent long-term inappropriate use.

 

Conclusion

Royal Commissions highlighted concerns around psychotropic prescribing and use for people in the aged-care and disability sectors. Implementing the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard¹¹ provides a way forward to address these significant quality issues regardless of where clinical care is provided.

This article was finalised on 4 December 2025.

Conflicts of interest: Stephen Macfarlane was on the working group for the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard. He is on medical advisory boards for Eli Lilly and Eisai, and gave a paid presentation on the use of monoclonal antibodies in Alzheimer disease to Eisai employees in 2024. Current and past research clinical trial sponsors include Eli Lilly, Novo Nordisk, Bristol Myers-Squibb, Janssen and Anavex Life Sciences Corporation.

Julian Trollor was on the working group for the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard. He is a member of various Commonwealth and state government advisory groups and committees related to intellectual and developmental disability. He has received funding from the Australian Government for research via the Medical Research Future Fund (MRFF), the National Health and Medical Research Council, the National Centre of Excellence in Intellectual Disability Health and the Australian Government National Disability Insurance Agency.

Rebecca Koncz is currently co-authoring a NSW Health Intellectual Disability Mental Health Strategy. Her appointment at UNSW Sydney is funded by the NSW Ministry of Health, Mental Health Branch and the Australian Government Department of Health, Disability and Ageing. She has received honoraria from HETI and the University of Sydney for lectures related to intellectual disability.

Maria Sukkar was involved in writing the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard.

Carolyn Hullick chaired the work on the development of the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard. She has received an MRFF grant for the IMPROVE study (implementation science for management of spontaneous pneumothorax in emergency departments) and a Hunter Medical Research Institute grant for biostatistics support for care of older people in emergency departments. Carolyn received support from a Harkness Fellowship to attend the 100th anniversary meeting in Barcelona in 2025.

This article is peer reviewed.

 

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