Reducing the 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.

The Australian Commission on Safety and Quality in Health Care (the Commission) is concerned for people with cognitive impairment in all settings where antipsychotic medicines are being prescribed inappropriately as a form of chemical restraint 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:

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.

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.

Delirium Clinical Care Standard

Minimising the use of antipsychotics is included as Quality Statement 6 in the 2016 Delirium Clinical Care Standard. The quality statement reflects guidelines, stating that treatment with an antipsychotic medicine is only considered if a person with delirium is distressed and the cause of their distress cannot be addressed and non-drug strategies have failed to ease their symptoms. It also advises clinicians to avoid the use of physical 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.

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.