Antipsychotic medicines dispensing, 65 years and over, from 2016–17 to 2020–21

Antipsychotic medicines are used to manage serious mental health conditions such as schizophrenia. Antipsychotic medicines may also be used to manage severe risk and distress and other acute behavioural disturbances related to dementia or delirium.

More than 90% of people with dementia experience some degree of behavioural and psychological symptoms of dementia (BPSD), such as agitation, aggression and psychosis (hallucinations and delusions).¹ Antipsychotic medicines offer only small benefits in managing BPSD, with the effect less than some non-pharmacological treatments.² They are associated with harms, including sedation, confusion, falls, pneumonia, hip fracture, reduced quality of life, stroke and death.³

Guidelines recommend that non-pharmacological strategies should be used to manage behavioural disturbances related to dementia or delirium before medicines are considered.⁴⁵ Non-pharmacological strategies include social contact, environmental changes, psychological interventions, providing meaningful activities and addressing unmet needs, such as loneliness, boredom, fear, hunger, thirst and toileting.⁴ Pain can also be a major contributor to BPSD,⁶ so it is important to manage possible causes of pain, as well as constipation or acute medical problems.

Antipsychotic medicines are an important management option for some people with severe BPSD.^7,4 However, these medicines are often prescribed outside guideline recommendations,³ and without proper consent, monitoring or dose adjustment.⁸

Most prescribing of antipsychotic medicines for BPSD occurs in residential aged care facilities (RACFs),^9,10 although use in the community is increasing.¹¹ Concerns have been raised that antipsychotics may be used as a form of restrictive practice to manage BPSD in people living in RACFs.¹²

Around one in five people living in RACFs are prescribed at least one antipsychotic medicine.^10,13 An Australian Department of Health expert clinical advisory panel estimated that psychotropic medicines, including antipsychotic medicines, are justified in only 10% of cases in residential aged care.¹⁴

The First Australian Atlas of Healthcare Variation¹⁵ found that almost 1 million (919,026) PBS prescriptions for antipsychotic medicines were dispensed for people aged 65 years and over in 2013–14.) The number of prescriptions dispensed was nearly eight times higher in the area with the highest rate compared to the area with the lowest rate.¹

The Third Atlas found that dispensing rates for people aged 65 years and over decreased by 6% between 2013–14 and 2016–17. However, the magnitude of variation increased: in 2016–17, the number of prescriptions dispensed was 15.7 times higher in the area with the highest rate compared to the area with the lowest rate.² This might indicate change in antipsychotic use in some areas of Australia but not in others.

Given the increase in the magnitude of variation between 2013–14 and 2016–17, a continued focus on reporting rates of antipsychotic medicines dispensing is warranted.

This report examines Pharmaceutical Benefits Scheme (PBS) prescriptions dispensing for people aged 65 years and over for antipsychotic medicines across five years, from 2016–17 to 2020–21.

The report presents national data, and data by state and territory, Primary Health Network (PHN) and local area (Statistical Area Level 3; SA3).

This report presents interactive data visualisations for:

• National, state and territory trends
• PHN trends
• Patient rate and defined daily dose rate 
• Remoteness and socioeconomic status
• Analysis by prescriber type.

Data are sourced from the PBS dataset. This dataset includes all prescriptions dispensed under the PBS or the Repatriation Pharmaceutical Benefits Scheme (RPBS). The dispensing of a medicine does not always mean the medicine is consumed. Some medicines may not be taken after dispensing or people may stop taking them.

Data used in this report exclude doctors’ bag items and any programs with alternative supply arrangements, such as direct supply to remote Aboriginal health services.

The PBS and RPBS do not cover medicines supplied to public hospital inpatients, over-the-counter medicines and private prescriptions. The data include prescriptions to patients on discharge from hospital and to outpatients in most states and territories, except in New South Wales and the Australian Capital Territory.

Data are reported according to where people live, not where the prescription was written or dispensed. 

The data are age- and sex-standardised to allow comparisons between geographic areas with different age and sex structures.

For more information about the data, see the Technical Note below.

Antipsychotic medicines dispensing rates for people aged 65 years and over fell nationally and in all states and territories between 2016–17 and 2020–21.

National trends

• There was an 11% decrease in the antipsychotic medicines dispensing rate – that is, the number of prescriptions dispensed per 100,000 people aged 65 years and over.
• There was a 13% decrease in the number of people aged 65 years and over per 100,000 people who had at least one PBS antipsychotic medicine dispensed.
• There was a 5% decrease in the overall volume of antipsychotic medicines supplied on any given day to people aged 65 years and over, as measured by the Australian rate of defined daily doses dispensed per 1,000 people per day. (Defined daily dose is the assumed average maintenance dose per day for a drug used for its main indication in adults.)
• There was a 22% reduction in the magnitude of variation: in 2020–21, the number of prescriptions dispensed was 12.3 times higher in the area with the highest rate compared to the area with the lowest rate. In 2016–17 the magnitude of variation was 15.7 times.

State trends

• Antipsychotic medicines dispensing rates fell in all states and territories. The largest decrease was in the Northern Territory (30%) and the smallest decrease was in the Australian Capital Territory (8%).
• Victoria had the highest rate of any state and territory in both 2016–17 (29,840 prescriptions dispensed per 100,000 people) and 2020–21 (26,250 prescriptions dispensed per 100,000 people).
• The Northern Territory had the lowest rate of any state and territory in both
  
  2016–17 (17,149 prescriptions dispensed per 100,000 people) and 2020–21 (11,931 per 100,000 people).

Prescriber type

• The proportion of geriatricians and psychiatrists prescribing antipsychotic medicines remained around the same, but the proportion of GPs prescribing antipsychotics decreased (89% to 84%).
• The proportion of ‘other professionals’ prescribing antipsychotic medicines increased (2% to 7%). Nurse practitioners were the largest group of ‘other professionals’.

Remoteness

• Dispensing rates were higher in major cities than in regional areas; rates were lowest in remote areas for each of the five years.

Socioeconomic disadvantage

• Dispensing rates increased with socioeconomic disadvantage for each of the five years.

PHN trends

• Dispensing rates decreased in all PHNs over the five-year period.
• North Western Melbourne PHN in Victoria had the highest PHN rate in both 2016–17 (33,517 prescriptions dispensed per 100,000 people) and 2020–21 (28,610 prescriptions per 100,000 people).
• The Northern Territory had the lowest PHN rate in both 2016–17
  
  (17,149 per 100, 000 people) and 2020–21 (11,899 per 100,000 people).

Consistently high and low local areas

Local areas (SA3s) with consistently high antipsychotic medicines use are those areas with dispensing rates in the top 10% for each of the five years:

• 20 of the 340 SA3s in Australia had consistently high rates.
• All 20 were in major cities (in New South Wales, Victoria, Queensland, South Australia and the Australian Capital Territory).
• Eight of the 20 were areas of socioeconomic disadvantage (lowest two SES quintiles).
• Leichhardt in New South Wales was the only consistently high local area that reduced dispensing rates each year for five years.

SA3s with consistently low antipsychotic medicines use are those areas with rates in the bottom 10% for each of the five years:

• 12 out of the 340 SA3s in Australia had consistently low rates.
• Four of the 12 were in remote areas; three were in outer regional areas; three were in inner regional areas and two were in major cities.
• Seven of the 12 were in areas of socioeconomic disadvantage (lowest two SES quintiles).

The 11% decrease nationally in the antipsychotic medicines dispensing rate for people aged 65 years and over between 2016–17 and 2020–21 continued the downward trend seen in the Third Atlas.

The data also show a small but consistent reduction in the overall volume of antipsychotic medicines used compared to third Atlas data. However, there was a 22% reduction in the magnitude of variation.

It is not known whether the fall in antipsychotic medicines dispensing for older people has been accompanied by an increase in the use of other psychotropic medicines such as sedating antidepressants and benzodiazepines.

It is also not known if there has been a switch to prescribing antipsychotic medicines on private prescriptions, which are not included in the PBS data.

The higher rate in Victoria was also noted in the First Atlas. The reasons for this higher rate are uncertain. Victoria has a higher proportion of public sector RACFs than other states¹⁶ and there is evidence of high rates of PRN (as needed) prescribing in Victorian public RACFs.¹⁷ However, it is not known if these characteristics or others contribute to the higher rates.

The lower rates of antipsychotic medicines dispensing in the Northern Territory may be because PBS data do not capture medicines that are supplied through remote Aboriginal health services.

Efforts to reduce the inappropriate use of antipsychotic medicines in older people in Australia have included legislative changes, guidelines, safety warnings, education and policy changes.¹⁸

The Australian Commission on Safety and Quality in Health Care (the Commission) has had a sustained focus on antipsychotic medicines dispensing, including reporting rates in the Atlas series and recommending and implementing actions to improve the appropriateness of antipsychotic medicines use.¹⁸

The COVID-19 pandemic, which heavily impacted aged care facilities, may have affected prescribing rates, but this impact is not yet known.

Initiatives and reforms aimed at reducing the inappropriate use of antipsychotic medicines in older people over the past five years are discussed below.

Government review and reform

The Royal Commission into Aged Care Quality and Safety (the Royal Commission) was established in 2018 and released its final report in March 2021, near the end of data period of this report.¹⁹ Media reporting of the background papers, hearings and the Commission’s Interim Report may have contributed to the reduction in antipsychotic use seen in the time series data.²⁰

There is evidence that legislation appears to have the greatest impact on the inappropriate prescribing of antipsychotics medicines for people with BPSD.^21,22

The Royal Commission Interim Report identified widespread use of “chemical restraints” in RACFs.¹⁴ In response, the Australian Government moved to protect people living in RACFs from the inappropriate use of physical and chemical restrictive practices through amending the Quality of Care Principles in 2019. For the first time, providers had to satisfy requirements before using any form of restrictive practice, including that alternatives had been tried, that the least restrictive form was used, and that informed consent from the person or their substitute decision-maker had been obtained. Changes to the Aged Care Act 1997 in July 2021 built on these changes,²³ including requiring residential aged care providers to have a behaviour support plan for each consumer who requires the use of restrictive practices as part of their care.²⁴

Standards and guidelines

There has been a range of work in standards and guidelines that emphasise the use of

non-pharmacological strategies as first-line management of BPSD.

In 2016, the Australian and New Zealand Society for Geriatric Medicine recommended against the use of antipsychotic medicines as the first choice to manage BPSD.²⁵

Also in 2016, the Commission released the Delirium Clinical Care Standard to improve the prevention of delirium in people at risk and the management of people with delirium.⁵ Updated in 2021, it recommends that non-pharmacological strategies should be used to manage a person with BPSD.⁵

Prescribing changes

Changes to prescribing rules may have contributed to the reduction in the use of antipsychotic medicines. Risperidone is the only antipsychotic medicine subsidised on the PBS for the management of BPSD. In 2015, the Therapeutic Goods Administration (TGA) limited the recommended duration of treatment with risperidone to 12 weeks for people with Alzheimer’s type only (moderate to severe) and only after non-pharmacological interventions had failed.²⁶ The PBS authority listing for risperidone was changed to align with this indication. The changes were followed by a 22% decrease in the use of risperidone subsidised for dementia in people aged 65 years and over.³ A PBS change in January 2020 allowed risperidone to be prescribed on authority for longer than 12 weeks for people with Alzheimer’s disease who have BPSD.²⁷

There may have been an increase in off-label private prescriptions for antipsychotic medicines in response to the increased prescribing restrictions. Two antipsychotic medicines, olanzapine and quetiapine, have gone off-patent²⁸ in recent years, reducing the cost of private prescriptions.

Quality improvement and education programs

Multidisciplinary quality improvement programs in RACFs are effective in reducing the inappropriate use of antipsychotic medicines in older people,¹³ and may have contributed to the decrease observed in the data.

A prominent example in Australia is the RedUSe (Reducing Use of Sedatives in residential aged care facilities) program, which aims to reduce prescribing of antipsychotic medicines and benzodiazepines in RACFs.¹³ The program includes medication audit and feedback, staff education and interdisciplinary case review.

Implemented in 150 RACFs around Australia, RedUSe achieved significant reductions in antipsychotic and benzodiazepine prescribing without substitution by other psychotropic medicines. After six months, the medicines were stopped, or doses reduced, in almost 40% of people living in RACFs who were prescribed these medicines.¹³

National programs in education and quality improvement that may have reduced the inappropriate use of antipsychotic medicines include the following:

• NPS MedicineWise implemented a national program between December 2020 and December 2021 that highlighted the importance of non-pharmacological options for people with dementia experiencing changed behaviours. The program trained GPs, nurse champions and pharmacists in 1,000 RACFs on best practice, person-centred care for people with dementia and provided a range of resources and tools for health professionals, consumers and carers.²⁹
• The Commission implemented medication safety programs for antipsychotic medicines, and resources and programs for health services, clinicians and consumers to address the inappropriate use of antipsychotics. These include the Better Way to Care series and consumer factsheets summarising issues and strategies. The Commission also developed guidance on the best practice use of antipsychotic medicines and other psychoactive medicines in managing cognitive impairment.
• The Aged Care Quality and Safety Commission implemented a range of initiatives for residential aged care providers, health professionals and consumers to increase awareness of best practice in the management of BPSD. These include setting up a Behaviour Support and Restrictive Practices Unit, pharmacist educational visits in remote and rural areas, and a tool for residential aged care providers to oversee the use of psychotropic medications in residents. The Aged Care Quality and Safety Commission is also collaborating with the Older Persons Advocacy Network to educate consumers and their families about restraint, behaviour support and informed consent.

Although these findings are encouraging, a continued focus on reducing the inappropriate prescribing of antipsychotic medicines is warranted. All Government-subsidised RACFs have had to report on antipsychotic medicines use since July 2021 as part of the National Aged Care Mandatory Quality Indicator Program.³⁰ The first data from this program showed that 22% (or around 36,000) people living in residential aged care received antipsychotics in July to September 2021, but around half of these people did not have a diagnosis of psychosis.³⁰

The Commission is working with the Aged Care Quality and Safety Commission and the National Disability Insurance Scheme Quality and Safeguards Commission to reduce the inappropriate use of antipsychotic medicines.³¹ The Commission is also developing a clinical care standard on the use of psychotropic medicines for managing behaviour that will support continued improvement across the disability, aged care and healthcare sectors.

Initiatives that have come from Royal Commission recommendations may help to reduce inappropriate prescribing of antipsychotic medications in older people. These include the following.

Standards

The Commission is developing the clinical care components of the Aged Care Quality Standards that will cover medication safety, including the appropriate prescribing of antipsychotic medicines.

Quality indicators

Although it is too soon to know the impact of the National Aged Care Mandatory Quality Indicator Program, which included reporting of antipsychotic use since July 2021,^30,32 evidence from Canada indicates public reporting of antipsychotic medicines use may reduce inappropriate prescribing.²¹

Education

The Royal Commission found “overwhelming evidence” of a lack of knowledge among personal care workers, nurses and GPs about the impact of restraints and the safe and appropriate management of BPSD.¹⁴

Further work to upskill the aged care workforce, including GPs, registered and enrolled nurses and assistants in nursing, in both dementia care and non-drug management techniques for BPSD, is needed to further reduce the inappropriate use of antipsychotic medicines. This is in line with the Royal Commission’s recommendation that aged care workers should do regular training in dementia care.³³

Two Dementia Support Australia programs focus on education and support for behavioural interventions. The Dementia Behaviour Management Advisory Service and the Severe Behaviour Response Team, which provide information, clinical advice, assessment and short-term case management interventions, have been found to improve BPSD and caregivers’ distress.³⁴ A state example is Primary Health Tasmania’s work to develop a suite of resources for clinicians and consumers about de-prescribing medicines, including antipsychotic medicines.

Models of GP care

Initiatives that facilitate continuity of care, time for review, patient-centred care and opportunities for a team approach in RACFs may reduce inappropriate prescribing of antipsychotic medicines. An Australian study found rates of dispensing of psychotropic medicines were higher for people with dementia who changed GP when they entered an RACF.³⁵ The authors concluded that facilitating continuity of GP care for new residents and more structured transfer of GP care may prevent potentially inappropriate initiation of psychotropic medicines.³⁵

The Royal Commission recommended that the Australian Government should trial and implement a new model of primary care in which general practices may choose to apply to become accredited aged care general practices.³⁶

Medication Advisory Committees

The Australian Government recommends that each RACF should establish or have access to a Medication Advisory Committee, which can improve the quality use of medicines in RACFs.³⁷ Following recommendations from the Fourth Australian Atlas of Healthcare Variation, the Commission is involved in developing a user guide on the role of Medication Advisory Committees in RACFs.

Appropriate management of BPSD in the community

Changes to improve the use of antipsychotic medicines in aged care facilities do not cover the use of these medicines for people with BPSD living in their own home. Work is needed to support appropriate use of antipsychotic medicines in this group.¹⁴

As well as the actions above, members of the expert advisory group for this report have proposed a variety of options to support the appropriate use of antipsychotic medicines in RACFs.

Workforce:

• Ensure adequate staff levels in aged care facilities to allow staff enough time to use non-pharmacological strategies for BPSD
• Increase involvement of specialist geriatricians, such as through funded positions on Medication Advisory Committees, more visits and telehealth consultations
• Create new funding models for diversional therapists, psychologists and social workers to work in RACFs
• Establish new GP incentive payments that are not linked to practices (GPs who are not part of a practice do not receive Practice Incentive Payments for visits to RACFs)
• Increase engagement with PHNs in education and best practice.

Medication monitoring and reviews:

• Improve the role of pharmacists in education, monitoring and de-prescribing
• Increase frequency of pharmacist-conducted medication reviews
• Allow nurse practitioners to conduct medication reviews and nurses to attend 12-week reviews
• Monitor therapeutic substitution for antipsychotic medicines
• Improve communication between prescribers, GPs and consumers to clarify who is responsible for medication review and de-prescribing.

Environment:

• Enhance environments in RACFs, such as creating wandering areas and reducing excess noise, people and clutter.

Consumers:

• Empower residents and families to ask nurses and doctors about minimising use of antipsychotics and other sedatives
• Strengthen avenues for complaint where best practice is not occurring.

Aged Care Quality and Safety Commission

• Medication – it’s your choice
• Restrictive practices provider resources
• Restrictive practices consumer resources

Further resources

• Professional practice guideline: Antipsychotic medications as a treatment of behavioural and psychological symptoms of dementia,² The Royal Australian and New Zealand College of Psychiatrists,
• Role of pharmacological management for acute behavioural disturbance in older people 2021,⁴ Therapeutic Guidelines
• Reducing inappropriate use of antipsychotics in people with behavioural and psychological symptoms of dementia (BPSD) - Infographic, Australian Commission on Safety and Quality in Health Care
• Dementia and psychotropic medicines, NPS MedicineWise
• Six steps for safe prescribing antipsychotics and benzodiazepines in residential aged care, Australian Government Department of Health and Aged Care Quality and Safety Commission
• A guide for family carers dealing with behaviours in people with dementia, Dementia Support Australia

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