The findings expressed in the interim report of the Australian Royal Commission into Aged Care Quality and Safety have challenged practices that are widespread in the aged care setting. In particular, there has been a great deal of attention in relation to the use of chemical restraint in aged care. The findings have included assertions of widespread overuse of psychotropic drugs in nursing homes and related settings. Let it be absolutely clear: there can be no doubt that the indiscriminate use of psychotropic drugs (or indeed any medications) in aged care is not consistent with best practice and must be challenged.
Influential individuals have testified to the Royal Commission, expressing their opinions that it is their belief that psychotropic drugs are vastly overused for older people in residential care. Notwithstanding this, not everything that has been asserted in hearings of the Royal Commission is indisputable. It is worth pointing out that there are situations in which the use of medications may be necessary to protect a specific resident from physical harm and psychological distress, and moreover there are instances whereby this is necessary not only in the interests of an individual, but in the interest of other residents who may be affected by the actions of a person whose behaviour creates potential danger for others. It is also the case that behavioral and psychological symptoms associated with disorders affecting cognition (including primary psychiatric illnesses) can create danger for the staff involved in caring for these people. In essence, at times it is absolutely appropriate to prescribe and administer psychotropic drugs for people who live in aged care facilities.
In response to the findings of the Royal Commission, it is laudable that Australia’s Federal Government has announced intentions to implement significant systems reforms , and nested within these reforms are measures proposed as a mechanism to address over use of chemical restraint in the aged care system. The advantages of this approach are self-evident, and no one would argue that efforts to improve the quality of psychotropic drug use in Australia’s aged care facilities would not be welcome. Even so, to implement sweeping changes without careful consideration of the potential downstream consequences of these actions is unwise. Before seeking to effect very significant modifications to the way in which psychotropic drugs are prescribed and administered in aged care, it is important that the range of potential downstream consequences must be carefully considered. Some of these are summarised below:
- As is the case for all Australians, there are many people living with significant mental illness amongst the residents of aged care facilities. It is critically important that the treatment provided for these people should not be altered or withdrawn without appropriate input from qualified the mental health specialists involved in their care. To indiscriminately withdraw psychotropic drugs used in the treatment of serious psychiatric conditions will result in significant morbidity and also potentially loss of life, in addition to exerting significant duress upon public health systems and incurring a large associated cost.
- The use of non-drug interventions should really be regarded as the first line approach for the management of behavioral and psychological symptoms secondary to the effects of cognitive disorders. However, the configuration of the current aged care system in Australia is not currently compatible with ready access to staff that would need to be available to deliver these interventions. Unless the fundamental structures for the staffing of aged care in Australia are comprehensibly overhauled, to circumvent access to pharmacological measures (particularly those that would be used in cases where behavioral and psychological disturbance is most severe) before facilitating staffing structures that would underpin the use of non- pharmacological strategies, would be potentially damaging.
- An indiscriminately applied strategy that seeks to curtail the use of specific psychotropic drugs in Aged Care may simply have the effect of channeling treatment towards the use of alternative medications that have other serious adverse effects, and which may be less effective than the pharmacological strategies that are currently used. There is evidence to suggest that this kind of phenomenon has already occurred in other areas: for example steep rise in prescribing of gabapentinoids that has occurred in the context of the opioid crisis.
- An investment in the deployment of staff to support high quality prescribing in the aged care sector is welcome, but it is not the case that the work force required to provide specialist oversight of psychotropic drug prescribing in this setting is necessarily available to immediately deploy. This being the case, it is potentially unhelpful to suggest that this specialized oversight can be provided by people without extensive training and experience, and to provide in a highly specialized area of medication use from generalist practitioners (pharmacists, doctors and nurses) may even prove to be counterproductive to the best interests of the elderly people who stand to be affected.
- There also needs to be some consideration of the effects of interventions upon the human resource dynamics of servicing the needs of elderly people living in aged care settings. If the changes that are mooted create downstream effects that discourage general practitioners from choosing to provide services in nursing homes, the effects will quickly be manifested in a generalized crisis of medical care. Likewise, if proposed changes to workplace practices present difficulties in attracting and retaining experienced nursing staff to the aged care sector, the effects of this would be potentially catastrophic.
Much of this discussion cuts to the very heart of the nature of aged care services in Australia and around the world. As the population ages and the proportion of people requiring care in residential settings increases, the issues will rapidly magnify. The average age of residents living in aged care facilities has increased dramatically over the last 25 years and this is a trend that can be expected to continue. There needs to be some consideration of some broader philosophical questions relating to the extent of public sector environment in the management of aged care, the effective governance and oversight the aged care sector, and the extent to which Australians are comfortable with a model of practice that involves care for profit. If the care of the elderly in aged care facilities is to become largely or exclusively managed in the public sector, it will be necessary to fund this through taxation or levies. If the current model that includes privately run facilities which operate for profit is envisaged to continue as a future option, there needs to be one of two outcomes: either there will need to be greater regulation (impacting upon the principles of private trade and profitability), or the costs of providing care for the people living in these settings will need to be properly reflected in the charges that are levied. It would appear that each of these options alluded here are relatively unpalatable to at least the Australian public, but nevertheless it is clear but the status quo cannot continue.
Change to the way in which psychotropic medications are used in the aged care sector is inevitable and is welcome: it would be best if this change is carefully considered, implemented and monitored for impact.