Reducing the inappropriate use of antipsychotics

The Commission is concerned for older people and people with disability in all settings where antipsychotic medicines are being prescribed inappropriately as a form of restrictive practice to control behaviour, off-label and for extended periods without review.

The Commission has undertaken a number of initiatives to reduce inappropriate use of antipsychotics.

Antipsychotic medicines are used to help manage psychosis for people with mental health conditions such as schizophrenia or bipolar disorder.  They can be effective in controlling symptoms and are an important part of treatment.

Antipsychotics are also prescribed for people with cognitive impairment such as people with dementia, intellectual disability or autism who may also have mental health conditions.


Joint Statement on the Inappropriate Use of Psychotropic Medicines

The Royal Commission into Aged Care Quality and Safety and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability identified that psychotropic medicines are being misused and overused, particularly with older people and people with disability. Inappropriate use of psychotropic medicines has been recognised as a safety and quality issue in health care.

On 21 March 2022, the Commission, the Aged Care Quality and Safety Commission and the NDIS Quality and Safeguards Commission launched the Joint Statement on the Inappropriate Use of Psychotropic Medicines to Manage the Behaviours of People with Disability and Older People as a form of restrictive practice, and committed to collaborative action to reduce it.


Literature Review

The Commission engaged Professor Sarah Hilmer (Head of Department of Clinical Pharmacology, Royal North Shore Hospital and Conjoint Professor of Geriatric Pharmacology, Northern Clinical School, Faculty of Medicine and Health, the University of Sydney) to conduct a literature review to better understand the current clinical environment for the use of antipsychotic medicines for people aged 65 years and over.

Australian Atlas of Healthcare Variation

Atlas 2015

The Commission's first Australian Atlas of Healthcare Variation in 2015 found high and variable antipsychotic use in people aged 65 and over.

Atlas 2018

The repeat analysis published in the 2018 Atlas showed, there had been little change in the overall amount of use during the four years. Given the lack of progress, ACSQHC proposed a series of regulatory responses.

Atlas 2015

The Commission's first Australian Atlas of Healthcare Variation in 2015 found high and variable antipsychotic use in people aged 65 and over.

Atlas 2018

The repeat analysis published in the 2018 Atlas showed, there had been little change in the overall amount of use during the four years. Given the lack of progress, ACSQHC proposed a series of regulatory responses.

Delirium Clinical Care Standard

Avoiding the use of antipsychotic medicines is included as Quality Statement 7 in the 2021 Delirium Clinical Care Standard.

Small pic of head with puzzle piece, cover of Delirium Clinical Care Standards page.
2021
Publication, report or update

The quality statement reflects guidelines, stating antipsychotic medicines are not recommended to treat delirium. Behavioural and psychological symptoms in a patient with delirium are managed using non-drug strategies. Clinicians are advised to investigate possible causes of the behaviour. However short-term antipsychotic use may be considered in limited circumstances - for instance, when non-drug strategies are unsuccessful and there is imminent risk of the patient harming themselves or others. in such cases, the clinician is advised to assess the potential harms and benefits of prescribing an antipsychotic and, whenever possible, discuss the use of the medicine with the patient and family and obtain informed consent. It also advises clinicians to avoid the use of physical or mechanical restraints if possible, as they can increase agitation, prolong delirium and increase the risk of injury.

Specific Cognitive Impairment Actions under the National Safety and Quality Health Service (NSQHS) Standards

Action 5.29b

Action 5.29b requires management of the use of antipsychotics and other psychoactive medicines, in accordance with best practice and legislation.  In responding to behavioural changes, the essential first steps are to investigate and address the possible causes and use targeted non-pharmacological strategies through a person-centred approach to care. Antipsychotics are only indicated if a person is severely distressed, or there is an immediate risk of harm to themselves or others.

Action 5.30

Action 5.30 requires clinicians, patients, carers and families work together to minimise anxiety or distress experienced by the person with cognitive impairment.

Action 5.29b

Action 5.29b requires management of the use of antipsychotics and other psychoactive medicines, in accordance with best practice and legislation.  In responding to behavioural changes, the essential first steps are to investigate and address the possible causes and use targeted non-pharmacological strategies through a person-centred approach to care. Antipsychotics are only indicated if a person is severely distressed, or there is an immediate risk of harm to themselves or others.

Action 5.30

Action 5.30 requires clinicians, patients, carers and families work together to minimise anxiety or distress experienced by the person with cognitive impairment.

Medication Safety

WHO Global Patient Safety Challenge

The Commission developed a national response to the third WHO Global Patient Safety Challenge to reduce severe, avoidable medication-related harm by 50% in the next five years. The three flagship areas of the Challenge are inappropriate polypharmacy, medication safety at transition of care and misuse of high-risk medicines, including antipsychotics.

Quality use of Medicines and Medicine Safety

As part of Quality Use of Medicines and Medicines Safety as the 10th National Health Priority Area ACSQHC was engaged to develop a national baseline report on the Quality Use of Medicines and Medicines Safety, with an initial focus on polypharmacy, use of antipsychotic medicines and transitions of care in aged care.

WHO Global Patient Safety Challenge

The Commission developed a national response to the third WHO Global Patient Safety Challenge to reduce severe, avoidable medication-related harm by 50% in the next five years. The three flagship areas of the Challenge are inappropriate polypharmacy, medication safety at transition of care and misuse of high-risk medicines, including antipsychotics.

Quality use of Medicines and Medicine Safety

As part of Quality Use of Medicines and Medicines Safety as the 10th National Health Priority Area ACSQHC was engaged to develop a national baseline report on the Quality Use of Medicines and Medicines Safety, with an initial focus on polypharmacy, use of antipsychotic medicines and transitions of care in aged care.

Expert Roundtables

In 2016 and 2017, the Commission consulted with experts to obtain advice on potential strategies to reduce the inappropriate use of antipsychotics, focusing on older people with behavioural and psychological symptoms of dementia (BPSD).

The roundtable participants agreed that strategies should aim to create a more person-centred, non-pharmacological approach to care to reduce inappropriate use. Due to the complexity of the problem, participants agreed that there was a need for a coordinated system response which included regulatory levers to drive change and multi-component strategies to change practice. It was also agreed that interventions should also target the issues driving prescribing, with a focus on the knowledge and skills of the prescriber, nursing staff, family members and carers.

The Commission produced an infographic that shows how individuals and organisations can reduce the inappropriate use of antipsychotics across multiple healthcare settings.