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Anti Psychotic Medications in Nursing Homes

By Megan Stoyles

Monday, 9th October, 2006

Nursing home residents- mostly women- with dementia are been inappropriately prescribed with the antipsychotic medication olanzapine- originally developed to treat schizophrenia - at levels which are causing professional concern and which are adding substantial amounts to the cost of the Pharmaceutical Benefits Scheme. There is also concern that use of this medication may be associated with cost cutting, as the resident may require less nursing care when it has been prescribed.

A recent Quality Use of Medicines symposium in Canberra held by the National Prescribing Service heard a paper by Queensland researchers, which analysed the use of atypical antipsychotic medications in older Australians.

Dr Samantha Hollingworth told the symposium that antipsychotic medications developed for schizophrenia, bipolar disorder and behavioural disturbances were being prescribed for elderly patients with dementia. Olanzapine, an atypical (newly developed) antipsychotic, cost the government $150 million in 2004-05 when it was publicly subsidised for schizophrenia. It requires special approval from Canberra for its use in any condition. Risperidone, also an atypical, was additionally subsidised for behavioural disturbances in dementia in February 2005.

“Our examination of the trends in the prescribing of subsidised atypical antipsychotics in the Australian population by gender and age, using Medicare prescription data, showed that atypical prescriptions as a proportion of all antipsychotics increased sharply from 40% in 2000 to 68% in September 2005,” she said.

Olanzapine’s share of all antipsychotics was 33% of DDD (defined daily dose /1000 population/day – a standardised measure of drug use) and 64% of costs since introduction. From 2002 in males there was a large peak in olanzapine use between 25–55 years (corresponding to schizophrenia), and in females between 75–100 years. There was substantial use of atypicals in people aged >65 years: 76% for females and 19% for males.

It is among the top 10 prescribed medications in terms of, prescriptions and cost on the PBS and is rising in usage.

“We conclude that atypical antipsychotics have been used outside of the indication for schizophrenia, despite an ‘Authority Required’ restriction, with significant financial implications for the Pharmaceutical Benefits Scheme. An insight into the reasons for their extensive use in the elderly may contribute to more rational prescribing and quality use of medicines, ” she said.

Patti Warn, a member of the NSW Government’s Minsterial Advisory Committee on Ageing , backed these statistics up with her experiences of a friend’s admission to a dementia ward in a Sydney nursing home. She had earlier detailed them in a submission to the House of Representatives enquiry on Ageing 3 years ago, which led to her invitation to speak at the symposium.

“Shortly after admission the 73 year old male - who had been diagnosed with frontal lobe dementia - was seen by a psychiatrist who had not treated him previously and who immediately prescribed olanzapine and melleril , another antipyschotic,” she said .

“A regular visiting GP - again unknown to the resident- was assigned to him by the home. The doctor had never prescribed olanzapine and was unfamiliar with its dosage and effects.”

“ My friend was reduced to a hunched, shuffling and drooling old man with glazed eyes and slurred speech, and his family could not recognise their father. Visits from friends were discouraged and though the dosage was reduced,the damage had been done.”

“This man had suffered identity theft by virtue of his medication rather than his condition.”

She gave other examples of female residents being prescribed these antipyschotics and while she did not make the point directly, others have suggested that the prevalence of scripts for elderly women may be due to a lesser tolerance by staff, family and medical practitioners of behaviours associated with dementia, being found in females - compared to male- residents.

Warn believes that “ along with other anti-psychotics, olanzapine is being used to control residents in nursing homes for the convenience and safety of the staff, prescribed by compliant doctors on staff reporting of so-called aggressive behaviours”.

“ A major review of medication used in British nursing homes a few years ago found an unacceptable degree of chemical constraint. We should be at least as concerned about that possibilty in Australian residential care as we now are about overuse of ritalin and anti depressants in our children.”