Antipsychotics and other medications dispensed to people with dementia

What other medications were dispensed to people who were dispensed scripts for dementia-specific medications?

As people with dementia often have other co-existing conditions, they are likely to be prescribed a range of other medicines. Figure 8.6 shows the types of other medications dispensed to people who were dispensed dementia-specific medications in 2019–20, grouped at the highest level (Anatomical Therapeutic Chemical classification 1 (ATC1)). Refer to the Technical notes for further detail on the Anatomical Therapeutic Chemical classification and the grouping of medications by level.

The most common group of other medications dispensed was for cardiovascular system medications (dispensed at least once to 77% of both men and women who were dispensed dementia-specific medication). This was followed by nervous system medications (72% of men and 77% of women) and, alimentary tract and metabolism medications (64% of men and 63% of women).

Men were less likely than women to be dispensed medications for the nervous system (72% of men compared with 77% of women), and musculoskeletal system (29% of men and 38% of women), as well as systemic hormonal preparations (18% of men and 25% of women). However, men were more likely than women to be dispensed medications for blood and blood forming organs (41% of men and 34% of women) and medications for the genitourinary system and sex hormones (16% of men and 8.3% of women).

Figure 8.6: People who were dispensed scripts for dementia-specific medications in 2019–20: percentage who were dispensed scripts for other medications at least once, by sex and medications’ Anatomical Therapeutic Chemical group

Figure 8.6 is a bar graph showing the percentage of people dispensed dementia-specific medications who were also dispensed other medications in 2019–20, by medication type and sex. The medications are grouped at the highest Anatomical Therapeutic Chemical classification level. About three-quarters of men and women who were dispensed scripts for dementia-specific medications were also dispensed medications for the cardiovascular system, and nervous system. Men were less likely than women to be dispensed nervous system medications, musculoskeletal system medications, and systemic hormonal preparations. However, men were more likely than women to be dispensed medications for blood and blood forming organs and for the genitourinary system and sex hormones.

The most common subgroup of other medications was antibacterials for systemic use, dispensed at least once to 58% of people who were dispensed scripts for dementia-specific medications (Figure 8.7). These medications are used to treat a range of bacterial infections. The next most common subgroups were:

  • psychoanaleptics (50%; used to treat depression and other neurological and mental health conditions)
  • lipid modifying agents (48%; used to lower high levels of fats in the blood, such as cholesterol)
  • agents acting on the renin-angiotensin system (46%; used to treat high blood pressure and other cardiovascular diseases) 
  • analgesics (40%; used to alleviate pain). 

There were notable differences by sex and age in the most common medications dispensed at least once to people who were dispensed scripts for dementia-specific medication.

Overall, men were more likely than women to be dispensed scripts for lipid modifying agents (53% of men and 45% of women) and antithrombotic agents (34% of men and 26% of women). Whereas women were more likely than men to be dispensed scripts for psychoanaleptics (45% of men and 54% of women) and analgesics (37% of men and 43% of women). These differences were often greater in the older age groups. 

Psychoanaleptics were dispensed to a larger proportion of those with younger onset dementia (aged under 65) compared with people aged 85 and over (59% compared with 47%). However, most other medications were dispensed to a greater proportion of those aged 85 and over, with the greatest differences seen with antithrombotic agents (36% compared with 9.6% of people aged 30–64) and beta blocking agents (24% compared with 8.6%).

Figure 8.7: People who were dispensed scripts for dementia-specific medications in 2019–20: percentage who were dispensed scripts for other medications, by Anatomical Therapeutic Chemical (ATC) sub-group, age and sex

Figure 8.7 is a bar graph showing the percentage of people dispensed dementia-specific medications who were also dispensed other medications in 2019–20, by medication type, age and sex. The medications are grouped at the second highest Anatomical Therapeutic Chemical classification level. Over half (58%) of people were dispensed scripts for antibacterials for systemic use, which are used to treat a range of bacterial infections. Half were dispensed scripts for psychoanaleptics, which are used for depression and other neurological and mental disorders. Men were more likely than women to be dispensed scripts for lipid modifying agents and antithrombotic agents. However, women were more likely than men to be dispensed scripts for psychoanaleptics and analgesics. While the majority of medications were dispensed to greater proportions of older people who were dispensed dementia-specific medications, psychoanaleptics were dispensed to a larger proportion of those with younger onset dementia (aged under 65) compared with people aged 85 and over.

Dispensing of antipsychotics to people with dementia

People with dementia may experience changed behaviours, such as aggression, agitation and delusions, commonly known as behavioural and psychological symptoms of dementia (BPSD). To manage these symptoms, non-pharmacological interventions are recommended, but medical professionals may prescribe antipsychotic medicines to people with dementia with BPSD as a last resort. However, inappropriate prescribing of antipsychotic medicines is a major problem among people living in residential aged care and a key issue raised in the Royal Commission into Aged Care Quality and Safety (Royal Commission 2021) (see Box 8.2 for more information). Risperidone is the only antipsychotic that is currently listed on the PBS for BPSD.

In 2019–20, antipsychotic medications (which are part of the psycholeptics group) were dispensed to about one-fifth (21%) of the 64,600 people who had scripts dispensed for dementia-specific medication (Figure 8.8). This includes all antipsychotic medications and not just Risperidone.  

Around 56% or 7,700 of the people dispensed antipsychotic medications were women. The proportion of people within each age group who were prescribed scripts for antipsychotics decreased slightly with increasing age. The average age of people dispensed antipsychotic medications was 80 for men and 81 for women—the same age as men and women who were dispensed scripts for dementia-specific medication (age 80 for men and 81 for women).

In each age group, men were relatively more likely to be dispensed scripts for antipsychotics at least once than women (Figure 8.8a). However, as more women have dementia, overall more women were dispensed antipsychotic medication than men.

Antipsychotics were more likely to be dispensed to people who were also taking Memantine (35% of people on Memantine) compared with other dementia-specific medicines (27% of people on Rivastigmine, 20% of people on Galantamine and 19% of people on Donepezil) (Figure 8.8b). This probably reflects the fact that Memantine is prescribed for moderately severe to severe Alzheimer’s disease, whereas the other 3 dementia-specific medications are prescribed for mild Alzheimer’s disease. 

Although Risperidone is the only antipsychotic listed on the PBS for BPSD, scripts for other antipsychotic medications were dispensed to people with dementia. Around 39% of people with scripts dispensed for antipsychotic medication and dementia-specific medication were supplied Risperidone, followed by Quetiapine (29%) and Olanzapine (24%) (Table S8.11).

Figure 8.8: People who were dispensed dementia-specific medications in 2019–20: percentage who were dispensed antipsychotic medication (a) by age and sex and (b) by dementia-specific medication

Figure 8.8 shows two bar graphs depicting breakdowns of the percentage of people who were dispensed prescriptions for dementia-specific medications and also dispensed prescriptions for antipsychotic medications at least once in 2019–20. The first graph shows the percentage by age and sex and the second graph shows the percentage by the type of dementia-specific medication they were dispensed. Overall, around one-fifth of people who were dispensed prescriptions for dementia-specific medications were also dispensed antipsychotic medications. The proportion within each age group who were prescribed scripts for antipsychotics decreased slightly with age. Men were relatively more likely to be dispensed scripts for antipsychotics than women in each age group. Antipsychotics were more likely to be dispensed to people who were also taking Memantine, which is the only dementia-specific medication prescribed for moderately severe to severe Alzheimer’s disease.

Box 8.2: Antipsychotic medications for people with dementia and inappropriate prescribing of antipsychotics

Antipsychotic medicines should only be prescribed to people with dementia following the unsuccessful attempt of managing symptoms of dementia using non-pharmacological treatments, as the combined use of dementia-specific and antipsychotic medicine increases the risk of serious adverse effects, including death. This risk increases over longer periods of use (Dementia Australia 2016; Guideline Adaptation Committee 2016). Risperidone, which is a type of antipsychotic medicine, is the only antipsychotic currently listed on the PBS that may be prescribed to a person with dementia who displays persistent behavioural disturbances such as psychotic symptoms, restlessness and aggression (known as either ‘changed behaviours’ or ‘behavioural and psychological symptoms of dementia’ (BPSD)). However, inappropriate prescribing of antipsychotics to people living in residential aged care (where over half of people have dementia) is a major issue in Australia.

To reduce inappropriate prescribing of antipsychotic medicines to people with dementia, changes were made to the PBS for prescribing of Risperidone for managing changed behaviours. As of January 2020, prescribers will need to request authority approval from Services Australia to prescribe ‘continuing’ PBS-subsidised Risperidone treatment (beyond 12 weeks of initial use) to people with dementia (Department of Health 2021).

The Royal Commission into Aged Care Quality and Safety final report (Royal Commission 2021) recommends further revisions to the PBS to restrict prescribing of antipsychotics in residential aged care. Recommendation 65 states that ’By 1 November 2021, the Australian Government should amend the Pharmaceutical Benefits Scheme so that:

 a. only a psychiatrist or a geriatrician can initially prescribe antipsychotics as a pharmaceutical benefit for people receiving residential aged care, and

b. for those people who have received such an initial prescription from a psychiatrist or a geriatrician, general practitioners can issue repeat prescriptions of antipsychotics as a pharmaceutical‘ (Royal Commission 2021).