Psychotropic medication use in adults with intellectual disability in Queensland, Australia, from 1999 to 2015: a cohort study

Psychotropic medicines' prevalence, patterns and effects on cognitive and physical function in older adults with intellectual disability in Ireland: longitudinal cohort study, 2009-2020

BACKGROUND

The frequent prescribing of psychotropics and high prevalence of polypharmacy among older adults with intellectual disabilities require close monitoring.

AIMS

To describe change in prevalence, predictors and health outcomes of psychotropic use during the four waves (2009/2010, 2013/2014, 2016/2017, 2019/2020) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA).

METHOD

Eligible participants were adults (≥40 years) with intellectual disabilities who participated in all four waves of IDS-TILDA and who reported medication use for the entire period. Differences between groups were tested using Cochran's Q test for binary variables and the McNemar-Bowker test for variables with more than two categories. Generalised estimating equation models were used to assess associations between psychotropic use, participants' characteristics and health outcomes.

RESULTS

Across waves (433 participants) there were no significant differences in prevalence of psychotropic use (61.2-64.2%) and psychotropic polypharmacy (42.7-38.3%). Antipsychotics were the most used subgroup, without significant change in prevalence between waves (47.6-44.6%). A significant decrease was observed for anxiolytics (26.8-17.6%; P < 0.001) and hypnotics/sedatives (14.1-9.0%; P < 0.05). A significant increase was recorded for antidepressants (28.6-35.8%; P < 0.001) and mood-stabilising agents (11.5-14.6%; P < 0.05). Psychotropic polypharmacy (≥2 psychotropics) was significantly associated with moderate to total dependence in performing activities of daily living over the 10-year period (OR = 1.80, 95% CI 1.21-2.69; P < 0.05).

CONCLUSIONS

The study indicates an increase in usage of some classes of psychotropic, a reduction in others and no change in the relatively high rate of antipsychotic use over 10 years in a cohort of older adults with intellectual disabilities and consequent risk of psychotropic polypharmacy and medication-related harm.

Pharmacological treatment for challenging behavior in adults with intellectual disability: Systematic review and meta-analysis

INTRODUCTION

Few evidence on the use of antipsychotics in people with intellectual disabilities and challenging behaviors, generates the need to develop studies that contribute to collect, compare and synthesize the available information. The present systematic review and meta-analysis aims to determine the clinical efficacy of antipsychotic medication in reducing critical episodes in this population.

METHODS

We searched Web of Science, Scopus, EBSCO, Embase, and PubMed for randomized controlled trials of antipsychotic medication versus placebo. Preliminarily yielded 1354 abstracts and citations; six studies with 274 subjects met the inclusion criteria of studies with experimental design, longitudinal type, with pre- and post-intervention measurements.

RESULTS

There is evidence for the use of psychotropic drugs in the acute management of challenging behaviors in patients with intellectual disability (SMD=-0.85; 95% CI=-1.69 to -0.01; p=0.05).

CONCLUSIONS

Our results coincide with the recommendations on the efficacy of the use of antipsychotics. Although our study provides evidence, the limited number of studies included in this research does not allow us to obtain totally conclusive results, although it can be considered as a guide for future studies.

Use of psychotropic medications in adults with intellectual disability: A systematic review and meta-analysis

OBJECTIVE

This study presents the proportion of adults with intellectual disability using psychotropic medications including antipsychotics, antidepressants, anxiolytics, hypnotics and sedatives, and psychostimulants.

METHODS

A search was performed in PubMed, Embase, PsycINFO, Web of Science, and Scopus up to 31 December 2021. Articles were included if they reported the proportion of adults with intellectual disability using psychotropic medications. Frequency of use was estimated using a random effects meta-analysis. Meta-regression analysis was used to assess the association between study-level characteristics and variability in estimates, when heterogeneity was considerable.

RESULTS

Twenty-four articles were included in pooled analysis. The pooled prevalence of psychotropic medications was 41% (95% confidence interval: 35-46%). Pooled prevalences of subclasses were as follows: antipsychotics 31% (27-35%), antidepressants 14% (9-19%), anxiolytics 9% (4-15%), hypnotics/sedatives 5% (2-8%), and psychostimulants 1% (1-2%). Heterogeneity was considerable between studies, except for psychostimulants. There was no significant association between assessed characteristics and variability in prevalence estimates.

CONCLUSION

Two-fifths of adults with intellectual disability were prescribed psychotropic medications. Antipsychotics and antidepressants were used by one-third and one-seventh of adults, respectively. There was considerable variability between studies, and further investigation is required to determine the source of variability. More studies are needed to better characterise prescribed psychotropic medications, including effectiveness and adverse effects, to ensure appropriate use of these drugs.

Staff perceptions following a training programme about reducing psychotropic medication use in adults with intellectual disability: The need for a realistic professional practice framework

BACKGROUND

Adults with intellectual disability are at higher risk of being administered psychotropic medications. The UK-developed SPECTROM (Short-term PsychoEducation for Carers To Reduce Over Medication of people with intellectual disabilities) training programme educates disability support workers on psychotropic medications and alternatives to these medications.

METHOD

Interviews were conducted with 10 participants who took part in the pilot SPECTROM training programme to elicit their views on the programme and its appropriateness in an Australian context.

RESULTS

The key theme was 'Need for a psychotropic medication practice framework'. Four sub-themes were Broad satisfaction with the SPECTROM training programme; Disability support workers acknowledging the limitations of their scope of practice; Empowering training through prescriptive and reflective methods and; Need for future mentoring from Multi-Disciplinary Team members in the application of new knowledge.

CONCLUSIONS

Participants felt that whilst they could improve their knowledge and attitudes surrounding psychotropic medication administration for behaviours of concern through SPECTROM training, a national practice framework is needed to execute its goals at scale.

Management of psychotropic medications in adults with intellectual disability: a scoping review

BACKGROUND/OBJECTIVE(S)

Psychotropic medications are commonly prescribed among adults with intellectual disability, often in the absence of a psychiatric diagnosis. The aim of this scoping review is to provide an overview of the extent, range, and nature of the available research on medication use and practices and medication management in people with intellectual disability taking psychotropic medications for behaviours that challenge.

MATERIALS AND METHODS

A scoping review of research studies (qualitative, quantitative, and mixed design) and Grey Literature (English) was carried out. Databases included: Ovid MEDLINE, Embase, CINAHL, JBI Evidence Synthesis, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Scopus. A three-step search strategy was followed, with results screened by two independent reviewers. Data was extracted independently by two reviewers using a data extraction tool with results mapped and presented using a narrative form supported by tables and diagrams to the research questions.

RESULTS

Following the removal of duplicates, records were screened, full texts assessed, and 49 studies were included. Medication outcomes included reduced repetitive, stereotypic, and/or aggressive behaviours. High dosing/prescribing in the setting of an absent/unclear clinical indication was associated with worsening of symptoms for which psychotropics were prescribed. While psychotropics had a role in managing behaviours that challenge, reducing or discontinuing psychotropics is sometimes warranted. Study designs were frequently pragmatic resulting in small sample sizes and heterogeneous cohorts receiving different doses and combinations of medications. Access to multidisciplinary teams, guidelines, medication reviews, staff training, and enhanced roles for carers in decision-making were warranted to optimize psychotropic use.

CONCLUSIONS

These findings can inform prescribing interventions and highlight the need for timely and comprehensive patient outcome data, especially on long-term use of high doses of psychotropics and what happens when reduce or stop prescribing these doses.KEY MESSAGESPsychotropic medications are frequently prescribed for people with intellectual disabilities, often at high doses and these medications are associated with both positive and negative patient outcomes.Work to rationalize psychotropic use has been reported with interventions aiming to reduce polypharmacy or deprescribe a single psychotropic medicine. These interventions had mixed success and risk of relapse was documented in some studies.Limitations in sample size and heterogenous patient cohorts make it challenging to understand the risks and benefits associated with reducing or stopping psychotropic medicines.Patient, carer, and clinician partnerships are critical to advance medication management.

Psychotropic drugs intake in people aging with intellectual disability: Prevalence and predictors

Background

Psychotropic medication is frequently administered to people with intellectual disability with mental health and/or behavioural problems, instead of other non‐pharmacological interventions. This study describes the mental health and behavioural problems of people aging with intellectual disability, their psychotropic medication intake, and the factors contributing to a greater medication intake.

Method

The sample consisted of 991 people with intellectual disability over 45 years. Descriptive statistics and multinominal logistic regression were carried out.

Results

Antipsychotics were the most used psychotropic drug. Older people with mild intellectual disability living in institutions and affected by mental health and behavioural problems were more likely to take larger amounts of psychotropic medication.

Conclusions

Antipsychotics continue to be widely used by people with intellectual disability and mental and behavioural health problems, especially those in institutionalised settings. Future research should consider if medication intake could be reduced providing better supports in the community and non‐pharmacological interventions.

Psychiatric Presentations and Medication Use in Older Adults With Intellectual and Developmental Disabilities

OBJECTIVE

Adults with intellectual and developmental disabilities (IDD) are living longer, yet research about the medical and psychiatric needs of older adults still lags behind that of younger individuals with IDD. The aim of this study was to assess age-related differences in the mental health presentations of adults with IDD.

METHODS

Fully deidentified data for adults 30 years and older were extracted from the START (Systemic, Therapeutic, Assessment, Resources, and Treatment) Information Reporting System, a deidentified database housed at the Center for START Services. Caregivers and START team documents reported psychiatric diagnoses, service use, recent stressors, and challenging behaviors. t Tests, Mann Whitney U tests, χ² tests, and multinominal logistic regression models were used to compare the two age groups, 30-49 years (n = 1,188) versus 50 years and older (n = 464).

RESULTS

Older adults had more medical conditions, fewer reported psychiatric conditions, and were more likely to be taking more psychiatric medications compared to younger adults, after adjusting for demographic variables, disability level, and number of recent stressors.

CONCLUSION

Although older individuals reported fewer psychiatric diagnoses, they were more likely to take higher numbers of psychiatric medications and have more medical conditions. Clinicians and researchers ought to devote more attention to the healthcare needs of older adults with IDD, a vulnerable group exposed to polypharmacy and at risk of adverse events.

Changes over a decade in psychotropic prescribing for people with intellectual disabilities: prospective cohort study

OBJECTIVES

To investigate psychotropic prescribing in the intellectual disabilities population over 10 years, and associated mental ill health diagnoses.

DESIGN

Comparison of cross-sectional data in 2002-2004 (T1) and 2014 (T2). Longitudinal cohort study with detailed health assessments at T1 and record linkage to T2 prescribing data.

SETTING

General community.

PARTICIPANTS

1190 adults with intellectual disabilities in T1 compared with 3906 adults with intellectual disabilities in T2. 545/1190 adults with intellectual disabilities in T1 were alive and their records linked to T2 prescribing data.

MAIN OUTCOME MEASURES

Encashed regular and as-required psychotropic prescriptions.

RESULTS

50.7% (603/1190) of adults in T1 and 48.2% (1881/3906) in T2 were prescribed at least one psychotropic; antipsychotics: 24.5% (292/1190) in T1 and 16.7% (653/3906) in T2; antidepressants: 11.2% (133/1190) in T1 and 19.1% (746/3906) in T2. 21.2% (62/292) prescribed antipsychotics in T1 had psychosis or bipolar disorder, 33.2% (97/292) had no mental ill health or problem behaviours, 20.6% (60/292) had problem behaviours but no psychosis or bipolar disorder. Psychotropics increased from 47.0% (256/545) in T1 to 57.8% (315/545) in T2 (p<0.001): antipsychotics did not change (OR 1.18; 95% CI 0.87 to 1.60; p=0.280), there was an increase for antidepressants (OR 2.80; 95% CI 1.96 to 4.00; p<0.001), hypnotics/anxiolytics (OR 2.19; 95% CI 1.34 to 3.61; p=0.002), and antiepileptics (OR 1.40; 95% CI 1.06 to 1.84; p=0.017). Antipsychotic prescribing increased for people with problem behaviours in T1 (OR 6.45; 95% CI 4.41 to 9.45; p<0.001), more so than for people with other mental ill health in T1 (OR 4.11; 95% CI 2.76 to 6.11; p<0.001).

CONCLUSIONS

Despite concerns about antipsychotic prescribing and guidelines recommending their withdrawal, it appears that while fewer antipsychotic prescriptions were initiated by T2 than in T1, people were not withdrawn from them once commenced. People with problem behaviours had increased prescribing. There was also a striking increase in antidepressant prescriptions. Adults with intellectual disabilities need frequent and careful medication reviews.