Education on Best-Practice Standards

The release of new regulatory standards or best-practice guidelines often sparks a need for training and education. This is because a pressing need arises for the updated advice on a topic to be effectively transferred from document to reality. While there are many ways to meet new regulations, guidelines and standards, education and staff training often proves to be one of the most effective. Education closes existing or new gaps in knowledge or skills. This kind of initiative does more than just tick a compliance box; it helps staff feel more confident and competent in their roles, which can make a real difference in people's lives.

By being well-informed about these changes, L&D teams can effectively facilitate appropriate education and training updates and engage staff in meaningful learning experiences that directly transfer the new changes into practice.

What Are the Changes?

The Royal Commission into Aged Care Quality and Safety (Aged Care Royal Commission) and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (Disability Royal Commission) found that psychotropic medicines are being misused and overused, particularly in older people with cognitive disability or impairment.

In May 2024, The Australian Commission on Quality and Safety in Healthcare launched The Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard .

Why Develop a New Standard?

This standard aims to ensure the safe and appropriate use of psychotropic medicines in people with cognitive disability or impairment and to uphold their rights, dignity, health, and quality of life. It guides clinicians, healthcare services and consumers. The Aged Care Royal Commission and Disability Royal Commission highlighted the safety concerns of these medicines.

Some of these concerns were:

• Discrepancies between the rates of prescribing psychotropic medicine and the prevalence of dementia or mental health conditions,
• High rates of psychotropic polypharmacy (use of two or more psychotropic medicines), and
• Long-term use of psychotropic medicines as chemical restraints.

What is a Psychotropic Medicine?

To understand this standard a bit better, let’s look at what a psychotropic medicine is and why we are worried about its overuse in dementia and disability care.

Types of Psychotropics

There are several different types of psychotropics, but the ones that this standard refers to are antipsychotic, antidepressant, and anxiolytic/hypnotic medicines. Most often, psychotropic medicines are used as important treatments for mental health conditions such as depression, anxiety, and schizophrenia. However, sometimes, they are used to control the way a person is behaving, not to treat a mental health condition as such.

Let us look at what behaviours are of concern.

Behaviours of Concern

Behaviours of concern indicate a risk to the safety or well-being of the person who exhibits them or those around them. These behaviours may be challenging to the person and caregivers. Sometimes, a person with cognitive impairment may be trying to communicate an unmet need that they cannot communicate otherwise. Behaviours that can cause concern to others may not be concerning to the person who exhibits them. Many other terms are used to describe behaviours of concern, such as ‘changed behaviours,’ ‘challenging behaviours,’ ‘distressed behaviours,’ ‘behaviours that cause distress,’ ‘complex behaviours of concern,’ ‘responsive behaviour, ‘non‑cognitive symptoms,’ ‘neuropsychiatric symptoms’ or ‘expression of unmet need.’

So, do psychotropics have any place in management at all?

The Role of Psychotropics

Guidelines recommend that psychotropic medicines should only be used when non-medication strategies have been tried and failed, except in behavioural emergencies. Careful assessment and monitoring are required to minimise the potential for harm and to deliver the benefits of psychotropic medicines.

However, studies over the years have shown that psychotropics have a limited role in influencing behaviour using their sedative effects, specifically for behaviours that put the person or others at risk. They lack efficacy and are associated with high rates of adverse effects such as weight gain and obesity, extrapyramidal symptoms and other metabolic effects and premature mortality. The use of psychotropic medicines for behaviours of concern in the absence of a mental health condition is questionable because of the lack of high‑quality evidence. Compared with the general population, people with intellectual disability may be more vulnerable to adverse effects associated with psychotropic medicines.

Concerns Surrounding Use

Despite these recommendations, there is ongoing concern about the increased use of psychotropic medicines in people with a cognitive disability or impairment in the absence of a mental health condition. It is found that in the majority of cases, they are used at excessive doses, for prolonged periods, often off-label, and with no clear clinical justification, adequate monitoring or review and consent.

Quality Statements

This standard is based on eight quality statements. A summary of those statements is as follows:

Quality Statement 1

Emphasise person-centred care and guide clinicians in effective communication. This includes tailoring and providing information to match the person’s health literacy, medicine literacy, and communication needs and allowing sufficient time for discussions.

Quality Statement 2

Informed consent for psychotropic medicines. It emphasises the importance of consent from the person and their family, support people or nominated decision-maker before the use of psychotropic medicines. Information should include the reason, intended duration, and potential benefits and harms of treatment. Documentation is necessary before use. In an emergency, or if the person cannot decide even with support, processes are followed in accordance with relevant legislation.

Quality Statement 3

Emphasises comprehensive assessment of behaviours by a suitably trained individual. Comprehensive assessments are necessary to identify clinical, psychosocial, and environmental causes of behaviours and understand the context in which they occur. This is required to provide person-centred care and management according to the person’s needs.

Quality Statement 4

Non-medication strategies are the first line in managing behaviours of concern. A combination of individualised non-medication strategies may be used and is usually most effective. Documentation and communication of strategies are important for continuity of care.

Quality Statement 5

Behaviour support plans are written plans prepared with the person and their family to support their behaviour. This plan informs those involved in the person’s daily life and care to reduce or prevent behaviours of concern and potentially eliminate the need for restrictive practices.

Quality Statement 6

Appropriate reasons for prescribing psychotropic medicines. Psychotropic medicines are considered only when there is a significant risk of harm to the person or others, or when the behaviours have a major impact on the person’s quality of life and a trial of non-medication strategies have been ineffective. Psychotropic medicines are also considered when a mental health condition has been diagnosed or is suspected following a documented clinical assessment. Again, it emphasises documentation of the reason for prescribing these medications.

Quality Statement 7

Monitoring, reviewing, and ceasing psychotropic medicines. These medicines require ongoing careful monitoring to review the benefits and harm from the treatment. The outcome needs to be documented and communicated, along with the timing of the next review.

Quality Statement 8

Information sharing and communication at transitions of care (TOC). TOC is a crucial point in care when medication misadventures can happen. This statement guides sharing information to the relevant care providers about behaviour support plans, the reason for the use of psychotropics, their intended duration, the timing of the last administration, and plans for monitoring and review.

The standard also provides indicators for local monitoring.

Conclusion

Ensuring the appropriate use of psychotropics in persons with a cognitive disability or impairment is everyone’s responsibility.

The launch of Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standards emphasises the critical role of L&D teams in healthcare to translate new evidence into the knowledge, skills and practices of staff. This standard, developed in response to significant safety concerns, necessitates updated training and education for staff. It's crucial for L&D professionals to understand and integrate these guidelines to ensure that training aligns with the best practices and regulatory requirements, enhancing patient care and safety.

Additional Resources

This standard is a great guide to help us achieve that! Several resources have been identified that are relevant to Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standards. These can be found here.

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