Last reviewed 25 August 2016

The improper use of psychotropic drugs as a “chemical restraint” is a serious concern in care and one which can have fatal consequences. In the following article, Vicky Powell examines some of the progress care homes have made in this regard and what more needs to be done to safeguard the health and quality of life of affected residents.

Over-medication of residents has long been a source of concern in the care sector, especially in the case of those whose behaviour is challenging.

In the worst cases, powerful psychotropic drugs have been used inappropriately, even for convenience, as a “chemical restraint” or “chemical cosh” to control challenging behaviour in place of other more suitable options.

Psychotropic drugs include:

  • antipsychotic drugs, which are prescribed to treat psychosis such as delusions or hallucinations

  • sedatives or hypnotics which are medically recommended as a short-term treatment for insomnia to help people sleep

  • anxiolytics, prescribed for anxiety and agitation.

One study by the Department of Health on the use of antipsychotic medication found that of 180,000 prescriptions for people with dementia, 140,000 were inappropriate.

Similarly, Alzheimer’s Society estimates that two out of three people with dementia who are prescribed antipsychotic medication have this medication prescribed unnecessarily.

Experts have warned that long-term use of these drugs are associated with significant weight gain, increased risk of strokes, organ failure and, in some cases, death.

Alarmingly, Alzheimer’s Society says that inappropriate prescription of antipsychotic drugs in people with dementia could contribute to as many as 1800 deaths a year and ironically even worsen certain dementia symptoms.

However, the problem of over-medication of psychotropics is not confined to care home residents with dementia.

It has been estimated that on an average day in England, some 35,000 people with a learning disability are being prescribed powerful drugs such as antipsychotics, antidepressants or both, without appropriate clinical justification such as an anxiety disorder or psychosis, and for too long.

With many proven alternatives to drugs available, reducing the unnecessary use of antipsychotic drugs for people in care homes has become a national priority.

Alternatives for residents with dementia

A great deal of campaigning and education has been undertaken by Alzheimer’s Society with regard to non-drug options for treatments and management of behavioural and psychological symptoms of people with dementia.

George McNamara, Head of Policy and Public Affairs at Alzheimer’s Society said: “Around 90% of people with dementia experience symptoms that affect their behaviour causing aggression, agitation, or even delusions and hallucinations. These symptoms can develop as part of the condition, but can also be caused by other issues — the person with dementia may be in pain or discomfort due to hunger, thirst or an infection that they cannot verbally communicate; they may not be receiving the right care, or their environment or social interactions may not be meeting their needs.”

George McNamara emphasises that it is “vitally important” to get to the root of the behaviour and resolve these issues quickly.

He says, “Often behavioural and psychological symptoms can be prevented through good person-centred care tailored to the person’s interests, abilities, history and personality to ensure they are comfortable and engaged. Simple approaches can be very effective and most symptoms improve within weeks without the need for medication.”

After years of awareness-raising by Alzheimer’s Society, most recently with its Fix Dementia Care campaign, some progress is being seen, but challenges remain.

George McNamara said: “The use of antipsychotic drugs is decreasing due to a better understanding of dementia and good care practices, but a recent investigation as part of Alzheimer’s Society Fix Dementia Care campaign found that 45% of care home managers do not think residents with dementia are getting good access to mental health services. This results in devastatingly long waiting times because of a lack of local services; in some cases people with dementia are being restrained under emergency Deprivation of Liberty Safeguards or placed on antipsychotic medication for months. The improper use of these drugs can have serious side effects, and can even be fatal. Better access to services, along with dementia specific training for carers, can head off these unnecessary and often distressing tactics.”

Learning disabilities and autism

Recently, attention has been focused on the issue of over-medication of people with learning disabilities and autism.

In June 2016, the Stopping Over-Medication of People with a Learning Disability (STOMPLD) pledge was signed by the Royal Colleges of Nursing, Psychiatrists and GPs, as well as the Royal Pharmaceutical Society, the British Psychological Society and NHS England at a summit in London.

At the summit, new guidance was launched to support healthcare professionals in reviewing inappropriate prescriptions for people under their care who have a learning disability and/or autism.

The guidance points out that doctors should consider prescribing antipsychotic medication to manage challenging behaviour only if:

  • psychological or other interventions alone do not produce change within an agreed time

  • treatment for any coexisting mental or physical health problem has worsened behaviour

  • the risk to the person or others is very severe, for example, because of violence, aggression or self-injury.

Even then, the guidance notes, antipsychotic medication should only be offered by doctors in combination with psychological or other interventions.

Success stories

The new STOMPLD guidance offers some extremely encouraging examples of psychotropic drug reduction under medical supervision.

One case study describes how a man with a learning disability was taking risperidone, based on his challenging behaviour, and mirtazapine for depression. However, over a period of time, the medications were gradually reduced, eventually being stopped altogether, with careful monitoring by doctors and care home staff and the man involved in all the decision-making.

Similar success stories have been observed in the case of care home residents with dementia.

In fact, Alzheimer’s Society says that it is often possible to avoid the use of drugs altogether by ensuring a person with dementia is physically healthy, comfortable and well cared for. Research indicates that recognising and treating pain can significantly reduce agitation and aggression in people with dementia.

The Society also emphasises the importance of helping residents to lead an active life, with interesting and stimulating daily activities.

Simple non-drug treatments, such as reminiscence therapy and social interaction, can prevent the need for drugs. Options could include aromatherapy, talking therapies, animal therapy, music and dance therapy and massage.

One piece of research has suggested that some dementia symptoms can be reduced by just 10 minutes of one-to-one time each day.

When such alternatives have been exhausted, and symptoms are severe or distressing, or the person poses a severe risk to the safety of themselves and others, medication may be necessary.

Nevertheless, best practice demands that doctors ensure psychotropic drugs are prescribed and continued only where absolutely necessary, and care homes can play a vital role in supporting the health and quality of life of residents in this regard.