Optimising Psychotropic Medication Use in Older Adults and People with Dementia

Abstract

With global population ageing, dementia has become a leading cause of disease burden in older adults. Psychotropic medications are widely used to manage mental health conditions in this group but carry significant risks, including cerebrovascular events and mortality, with antipsychotics being of highest concern. This thesis examines prescribing patterns and determinants of psychotropic use in older Australians—particularly those with dementia—and explores strategies to optimise safe, appropriate use.

Chapter 1 outlines the clinical challenges, pharmacological classes, age-related pharmacological changes, and heightened risks of drug-related problems, focusing on antipsychotic use for behavioural and psychological symptoms of dementia (BPSD). Two objectives guide the work: (1) assess psychotropic use and associated factors, and (2) investigate treatment modifiers and predictors of risperidone response in dementia.

Chapter 2 uses linked 2021 Census–PBS data for 3.85 million Australians aged ≥65, finding one-third received at least one psychotropic, with antidepressants, opioids, and benzodiazepines most common; 8.4% had psychotropic polypharmacy. Use varied significantly across dementia status, Aboriginal and Torres Strait Islander peoples, CALD groups, and non-private dwellings, highlighting inequities.

Chapter 3 analyses six clinical trials, finding risperidone effective for psychosis, aggression, and anxiety/phobias, but not for affective, activity, or sleep disturbances. Modifiers included sex, BMI, endocrine disease, and race. Early response at week 2 strongly predicted later outcomes.

Chapter 4 synthesises findings, proposing a framework for personalised antipsychotic prescribing. The thesis underscores high psychotropic use and disparities, calling for targeted, evidence-based, and culturally informed strategies to ensure safe, equitable use in aged care