Medication use

As people age, they may develop a number of chronic conditions. [1] When they take multiple medications to manage each of these conditions, this is called ‘polypharmacy’. [2] Older people are already more vulnerable to the harm of medicines due to increased frailty or age-related changes to the way their bodies process medications. [3] However, when medications known to interact with each other are combined, it can place older people at risk of medication-related problems such as delirium, falls, hospitalisations, and death. [2]

Around 74% of people in residential aged care are prescribed 10 or more medications. [4] Some of these will be potentially inappropriate medications (‘PIMs’). [5] PIM use is defined as the use of ‘medications or medication classes that should generally be avoided in persons 65 years and older because they are either ineffective or they pose an unnecessarily high risk for older persons and a safer alternative is available.’ [6] The rate of PIMs prescribed in the residential aged care setting is much higher than in the community setting. [7]

Medications are commonly relied upon to manage mental health conditions in older people. However, benzodiazepines (often taken for anxiety and/or insomnia) and antidepressants are known to be especially risky medications for older people and are considered best avoided. [8] Benzodiazepines can affect cognition and delirium while some forms of antidepressants can cause dizziness and fainting on standing up. [3] Both types of drugs are associated with confusion, falls and increased healthcare costs. [9] People with dementia may also be prescribed antipsychotic medications to help residential aged care staff manage responsive behaviours. [10] These drugs, designed for treating schizophrenia and bipolar disorders, can lead to a range of harms including stroke or sudden death. [10] They are also not supported by strong evidence of effectiveness. [11] Despite the potential health risks, older Australians are likely to be prescribed at least one of these medications soon after being admitted to a residential aged care facility. [12, 13]

In Australia, medical practitioners (usually general practitioners) can order a Domiciliary Medication Management Review for people living in the community or a Residential Medication Management Review for permanent residents of a residential aged care facility. These reviews are conducted by an accredited pharmacist to identify potentially inappropriate medications (PIMs). [3] They take a holistic view of the person’s medications, accounting for personal preferences and the reasons why practitioners may have prescribed any potentially inappropriate medications. However, it has been found that few people entering residential aged care are currently being offered this service. [14]

This evidence theme on medication use is a summary of one of the key topics identified by a scoping review of research on the mental health and wellbeing of older people receiving aged care. If you need more information on this topic, try using the PubMed search below.

We found four reviews relevant to medication use for mental health concerns in older people living in the community or residential aged care. [10, 15-17] One review found that mental health diagnoses increase the risk of being prescribed a potentially inappropriate medication more consistently than having physical conditions, apart from diabetes. [15] Furthermore, benzodiazepines and antipsychotics are common PIM combinations in this setting. [15] Other risk factors for being prescribed a PIM for a mental health condition in this setting include:

• Being female (for benzodiazepine prescribing) [15]
• High staff turnover in the facility [15]
• Lack of a weekly visit by a medical practitioner [15]
• A low ratio of registered nurse to residents [10]

The size of the facility does not appear to have any influence on PIM prescribing rates in the residential setting. [15]

One review found that antidepressant medications are the most commonly prescribed approach to treat depressed nursing home residents. [16] Here they are far more commonly recommended than nonpharmacological approaches, despite studies showing non-drug treatments can be effective and carry less risk of harm. [18]

Two reviews looked at the effectiveness of antidepressant medications, including second-generation antidepressants such as selective serotonin reuptake inhibitors (SSRIs) that selectively target neurotransmitters. [15, 16] Both reviews included studies where one group of residents received the antidepressant medication while a second group received a treatment that, unknown to them, would likely have no effect (i.e., a placebo). These comparisons showed that there was little difference in depression levels between the two groups after taking either treatment. [15, 16]

When antidepressants were tested without a comparison group, there was a modest improvement in people’s levels of depression. [15] However, this finding may not be reliable as we cannot know if this was a genuine effect of the medication or if improvement was due to people’s belief in the product and their expectation of improvement (i.e., the ‘placebo effect’). The most that can be said about antidepressants is that they may have limited benefits for older adults in aged care. We also need more studies about their safety in this age group. [19]

These two reviews highlighted concerns about the methods used by some of the studies. This may reduce any certainty we have about the benefits of antidepressants among aged care populations. For example:

• Some studies only had a small number of participants. [16]
• Studies used different scales to measure response to treatment. These scales may differ in how they measure change (e.g., self-report versus observation), the amount of detail they go into, and what they measure. [16] The high variety in approaches to measurement mean that it is difficult to reach strong conclusions about medication effectiveness.
• Participants varied in depression severity and duration. Some may have never been depressed before and others will have experienced reoccurrences of depression. This can make comparing results across studies challenging. [17]
• Some studies included both people with dementia and people without dementia and did not report results separately for each group. This makes it difficult to know whether people respond differently depending on dementia diagnosis. [17]

Care workers and nurses

• Those who are providing direct care might make themselves familiar with some of the more common side effects of the main medications for treating mental health conditions. These include antidepressants and benzodiazepines. Care workers and nurses working closely with older people are in a good position to detect medication-related issues early on.
• Care workers and nurses might also reflect on the number of medications a person in their care takes regularly. If the number seems excessive, or if there are clear signs that the person is experiencing side effects, consider discussing this with the person, the wider care team, and/or the person’s family. It may be time for a medication review.
• Escalate concerns about medications to your manager.

Prescribers

• Consider the limited effectiveness of antidepressants in older people and the high placebo response rate. Account for individual differences in response to these medications when prescribing, especially where people who are frail or have mental-physical multimorbidity are concerned.
• Monitor the individual’s response to these medications on an ongoing basis.
• Carefully consider the practice of prescribing antipsychotics for the responsive behaviours of dementia after discussion with the person with dementia, their carers and family. Discuss the possible benefits in tandem with risk factors such as an increased risk of stroke or sudden cardiac death.
• Before prescribing antipsychotics, look for underlying causes of responsive behaviours including pain, a urinary tract infection, or sensory problems such as hearing or vision difficulties.
• Consider recommending non-pharmacological interventions such as psychotherapies as frontline approaches to managing depression, anxiety, and responsive behaviours.

• Encourage staff to raise concerns around medication use.
• Provide all staff with training about the side effects associated with commonly prescribed psychotropic drugs to support them to be vigilant to medication-related risks such as dizziness, falls, and delirium.
• Ensure clinical staff are aware of and have access to current clinical practice guidelines for the care of the older person with mental health conditions and/or dementia.
• Work with general practitioners to ensure older people taking multiple medications are routinely considered for a medication review.

1. Fabbri E, Zoli M, Gonzalez-Freire M, Salive ME, Studenski SA, Ferrucci L. Aging and multimorbidity: New tasks, priorities, and frontiers for integrated gerontological and clinical research. J Am Med Dir Assoc. 2015 Aug 1;16(8):640-7.  
2. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017 Oct 10;17(1):230. 
3. Australian Commission on Safety and Quality in Health Care. The fourth atlas of healthcare variation 2021 [Internet]. Sydney: ACSQHC; 2021 [cited 2023 Jun 27]. Available from: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/fourth-atlas-2021-62-medication-management-reviews-75-years-and-over
4. Jokanovic N, Tan EC, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and factors associated with polypharmacy in long-term care facilities: A systematic review. J Am Med Dir Assoc. 2015 Jun 1;16(6):535.e1-12.
5. Eshetie TC, Roberts G, Nguyen TA, Gillam MH, Maher D, Kalisch Ellett LM. Potentially inappropriate medication use and related hospital admissions in aged care residents: The impact of dementia. Br J Clin Pharmacol. 2020 Dec;86(12):2414-2423. 
6. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991 Sep 1;151(9):1825-32. 
7. Bony H, Lloyd RA, Hotham ED, Corre LJ, Corlis ME, Loffler HA, et al. Differences in the prescribing of potentially inappropriate medicines in older Australians: Comparison of community dwelling and residential aged care residents. Sci Rep. 2020 Jun 23;10(1):10170.  
8. 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694.
9. Thiruchelvam K, Byles J, Hasan SS, Egan N, Kairuz T. Impact of medication reviews on potentially inappropriate medications and associated costs among older women in aged care. Res Social Adm Pharm. 2022 May 10:S1551-7411(22)00153-X. 
10. Cioltan H, Alshehri S, Howe C, Lee J, Fain M, Eng H, et al. Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review. BMC Geriatr. 2017 Jan 26;17(1):32. 
11. Yunusa I, Rashid N, Demos GN, Mahadik BS, Abler VC, Rajagopalan K. Comparative outcomes of commonly used off-label atypical antipsychotics in the treatment of dementia-related psychosis: A network meta-analysis. Adv Ther. 2022 May;39(5):1993-2008. 
12. Harrison SL, Sluggett JK, Lang C, Whitehead C, Crotty M, Corlis M, et al. The dispensing of psychotropic medicines to older people before and after they enter residential aged care. Med J Aust. 2020 Apr;212(7):309-313.
13. Harrison SL, Sluggett JK, Lang C, Whitehead C, Crotty M, Corlis M, et al. Initiation of antipsychotics after moving to residential aged care facilities and mortality: A national cohort study. Aging Clin Exp Res. 2021 Jan;33(1):95-104. 
14. Sluggett JK, Bell JS, Lang C, Corlis M, Whitehead C, Wesselingh SL, et al. Variation in provision of collaborative medication reviews on entry to long-term care facilities. J Am Med Dir Assoc. 2021 Jan;22(1):148-155.e1.
15. Nothelle SK, Sharma R, Oakes AH, Jackson M, Segal JB. Determinants of potentially inappropriate medication use in long-term and acute care settings: A systematic review. J Am Med Dir Assoc. 2017 Sep 1;18(9):806.e1-806.e17.
16. Boyce RD, Hanlon JT, Karp JF, Kloke J, Saleh A, Handler SM. A review of the effectiveness of antidepressant medications for depressed nursing home residents. J Am Med Dir Assoc. 2012 May;13(4):326-31.
17. Mallery L, MacLeod T, Allen M, McLean-Veysey P, Rodney-Cail N, Bezanson E, et al. Systematic review and meta-analysis of second-generation antidepressants for the treatment of older adults with depression: Questionable benefit and considerations for frailty. BMC Geriatr. 2019 Nov 12;19(1):306. 
18. Chen YJ, Li XX, Pan B, Wang B, Jing GZ, Liu QQ, et al. Non-pharmacological interventions for older adults with depressive symptoms: A network meta-analysis of 35 randomized controlled trials. Aging Ment Health. 2021 May;25(5):773-786. 
19. Sobieraj DM, Martinez BK, Hernandez AV, Coleman CI, Ross JS, Berg KM, Steffens DC, Baker WL. Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults. J Am Geriatr Soc. 2019 Aug;67(8):1571-1581.