Theresa Flavin, a 57-year-old mother of five, was diagnosed with dementia at just 46. She says older Australians and those with cognitive dysfunction need a pharmacist ‘on the team’ to promote the quality use of medicines and prevent medicine-related harm.
Speaking at the ‘Medicines nightmare in aged care’ session at PSA21 Virtual on Friday, Ms Flavin said her first experience of medicine-related harm was when her mother-in-law, who had Alzheimer’s Disease, kept having falls in her residential aged care facility (RACF).
Her mother-in-law was ‘on an absolute boatload of very strong pain medication’, to manage osteoarthritis, but ‘when we looked at the progression of her time in aged care, it almost felt like the pain medication was being used as a sedative,’ Ms Flavin said.
While she knew her mother-in-law needed medicine to treat her pain, Ms Flavin said she wished the family had ready access to a pharmacist who could have reviewed her medicines.
‘We need to help people to feel comfortable in their later years, that’s really important, but the risks aren’t always communicated well to the [RACF] staff, they’re not always communicated well to families,’ she said.
‘What I’ve seen from my personal experience is that these medications [antipsychotics] result in falls. This means we give our lives so that somebody can have a quieter day’s work. It’s wrong.’
In her own experience as a person with dementia, Ms Flavin said she has seen medicines used to control unsociable behaviours.
Reducing the use of chemical restraint in RACFs has been a key focus of the Royal Commission into Aged Care Quality and Safety, with the commissioners calling on the government to introduce stricter requirements for prescribing antipsychotic medicines.
‘When you are diagnosed with dementia, you have a grieving process … We’re angry with ourselves for our loss, we’re angry with the disease, but that can sound like we’re angry with you,’ Ms Flavin said.
‘But violence aside, which is a different matter, older people, people with dementia and other cognitive dysfunction, have a right to express ourselves, just like everyone else.
‘What I’ve seen from my personal experience is that these medications result in falls. This means we give our lives so that somebody can have a quieter day’s work. That offends me. It’s wrong.
‘Anything that shuts down our cognition is just making life worse for us. It’s like giving a drunk person a spiked drink. It’s just cruel.’
New approaches needed in RACFs
For pharmacist and Member for Dobell Emma McBride MPS, who lost her father to younger onset Alzheimer’s and her grandmother to dementia, promoting the quality use of medicines in aged care is ‘as much personal as it is professional’.
It is estimated 30% of all hospital admissions of older people are medicine-related and approximately half are preventable. And more than 50% of all people living in RACFs are prescribed medicines that are considered potentially inappropriate for older people.
‘These figures are stark, they’re quite concerning, but they’re also an opportunity for pharmacists to make a genuine and transformative contribution to aged care and the wellbeing of older Australians,’ Ms McBride told PSA21 Virtual attendees.
‘How do we, individually and professionally, respond to this crisis?’
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She pointed to a pilot program in the ACT, where an accredited pharmacist spent 15 hours in an RACF per week. The result was ‘a significant drop in the potentially inappropriate use of medications, particularly around inappropriate use of psychotropics, antipsychotics and benzodiazepine,’ Ms McBride said.
Other outcomes included a decrease in emergency department presentations and an increase in immunisation rates.
‘This is a really exciting opportunity to describe the role of a pharmacist embedded and integrated into the multidisciplinary care team to really transform the quality of care for older Australians,’ Ms McBride said.
Embedding pharmacists in RACFs should be ‘seen as an investment, rather than a cost’.
‘If we can make that shift in thinking, pharmacists will be able to lift the quality of care,’ she said.
‘We need to see new approaches in aged care in order to provide a safe environment that minimises medication harm and maximises the role of pharmacists as stewards of medication safety.’
Providing continuing care
Aged care, home care and independent living provider IRT Group has 21 locations across New South Wales, Queensland and the ACT. Of these, only three have an embedded pharmacist, with another currently taking part in a pilot program.
Speaking at PSA21 Virtual, IRT Group CEO Pat Reid said the main challenge was finding the initial funding to get pharmacists on the floor.
‘But when we do, we see massive improvements in outputs for our residents and our staff,’ he said.
‘We need to make sure pharmacists are actually on the floor, burning shoe rubber, face-to-face with residents, because that’s where the bang for buck is, that’s where we’re going to see really good results for people in aged care, and they deserve it.’
Asked what he thought about the current Residential Medication Management Review (RMMR) program, Mr Reid said reviews should happen when a resident enters an RACF and then regularly afterwards.
‘Once in a blue moon RMMRs is not the method,’ he said. ‘We need to find the proper method, which is continuing service by a pharmacist.’
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Associate Professor Juanita Breen, an accredited pharmacist who testified at the aged care royal commission, agreed that RMMRs should be more frequent, particularly as the average resident takes about 11 medicines per day.
‘The average length of time a resident spends in an aged care home is about 18 months, so a lot of them won’t even get round to having one [review],’ she said.
After examining more than 1,200 medicine-related complaints made to the royal commission, A/Prof Breen found many problems weren’t overly complex.
‘We know that people are taking too many psychotropic medicines, that was really highlighted at the aged care royal commission, and many are staying on them for a lot longer than recommended,’ she said.
‘But for the average resident, there are other issues.’
Timing was the problem, particularly for palliative care, pain management and Parkinson’s Disease management, and accounted for more than 25% of all complaints.
‘We need to make sure pharmacists are actually on the floor, burning shoe rubber, face-to-face with residents, because that’s where the bang for buck is.’
Overall medicine management was also an issue, including not having enough trained staff and leaving tablets with residents for them to take by themselves. The third most common complaint related to sedation.
‘As pharmacists we often look for things like drug burden index and a lot of other very complex issues and adverse effects, but sometimes it can be really quite simple,’ A/Prof Breen said.
‘The fact that a lot of people aren’t getting pain management on time is something that’s of real importance.’
For Ms Flavin, access to a pharmacist should be sold as a point of difference for consumers when choosing an RACF.
‘I feel like I don’t have any choice. I’m the customer, I’m paying the bills when I enter residential care, and I should be able to choose a residential care facility that has a pharmacist,’ she said.
‘I feel cheated that I can’t.’