We know that there are high levels of medicines use in the aged care setting, which is not surprising given the demographics of residents and prevalence of multimorbidity.
We also know that there are problems with medication management in this setting, including alteration of dose forms (e.g. crushing of tablets), potentially inappropriate prescribing and polypharmacy. A 2013 literature review prepared for the Commission for Quality and Safety in Healthcare, suggested that up to 50% of residents could be receiving potentially inappropriate medications, such as sedatives and highly anticholinergic drugs.
Alarmingly, recent reports have suggested that the use of psychotropic medications in aged care is very common.
A report from Dementia Australia indicated that about half of all aged care residents, and up to 80% of residents with dementia, were receiving at least one psychotropic medication. This is despite evidence showing that only about 20% of patients with behavioural and psychological symptoms of dementia will receive benefit from antipsychotics and that these medicines can be associated with significant adverse outcomes, including falls, cognitive impairment and increased risk of stroke.
A Senate Committee report published in 2014 also made a number of recommendations including the need for training for aged care staff on the behavioural and psychological symptoms of dementia and appropriate non-pharmacological management strategies, regular review of psychotropic prescribing, and trend reporting within facilities for psychotropic use.
A study conducted at the University of Tasmania as part of the 4th Community Pharmacy Agreement Research and Development Program, saw a coordinated effort between community pharmacy and aged care facilities to tackle the use of psychotropic medicines. This program of work included education, audit and feedback to nurses and prescribers, as well as specific psychotropic medication reviews conducted by an accredited pharmacist. There were relative reductions in the use of benzodiazepines and antipsychotics by 19% and 12%, respectively, and importantly, more residents had their benzodiazepines reduced or ceased in the intervention group (40% compared to 18%) and more residents had their dose of antipsychotic reduced or ceased in the intervention group (37% compared to 21%).
It is therefore frustrating to see that late in 2017 a Review of National Aged Care Quality Regulatory Processes commissioned by the Minister for Aged Care, Ken Wyatt, was released which highlighted ongoing difficulties in the management of medicines within the aged care environment. This review was commissioned in part as a response to problems at the Oakden Older Persons Mental Health Service in South Australia, which had significant failures of care, that unfortunately the regulatory framework did not detect.
One of the key statements and recommendations to come out of this review was the following:
“Polypharmacy and medication errors were frequently raised in our consultations. We recommend conducting resident medication management reviews on admission to a nursing home, after any hospitalisation, upon any worsening of medical condition or behaviour, or on any change in medication regime.”
Of particular concern noted in the report was that:
“Despite these issues, the number of claims for Residential Medication Management Reviews has decreased by approximately 18% between 2008–09 and 2015–16.”
I would encourage all accredited pharmacists who are working within the aged care environment to develop processes, in collaboration with their aged care facilities, which address the above recommendation.
The current program rules for funding for Residential Medication Management Reviews (RMMRs) are aligned to being able to provide medication reviews based on clinical need, including recent hospitalisation, worsening of a medical condition or behaviour and after any change in medication regimen.
The key here for accredited pharmacists is to work closely with the aged care facilities and general practitioners who are caring for these residents to develop a process that identifies, in a timely manner, any resident who is at high risk of medication misadventure so that a medication review can be conducted.
PSA will be developing updated standards and guidelines for the RMMR program in 2018, along with tools to assist pharmacists in delivering RMMRs within the aged care environment. Pharmacists must accept the responsibility of becoming the driver in improving medicines management in aged care, because for too long patients have received suboptimal outcomes from medication use.
A review of the QUM program for aged care facilities is also being completed as part of the 6th Community Pharmacy Agreement. Services delivered by pharmacists at the system level of the aged care facility are vitally important to improve quality use of medicines. But, it is important that these activities target areas of significant issue within aged care, such as polypharmacy, psychotropic and antibiotic use, and deprescribing. Interventions comprising drug use evaluations, as well as benchmarking, provide a solid evidence base of effectiveness within aged care, and pharmacists are well placed to lead this work.
The general frailty of residents who live in the aged care environment means that frequent reviews may be necessary, and that funding needs to be allocated to support this, now and in the future. We cannot sit by whilst residents in aged care facilities suffer because our current funding structure does not match the needs of aged care facilities and residents. We must improve this. It will be important leading into the next Community Pharmacy Agreement that we establish a strong evidence base for pharmacists’ role within aged care, and that this impacts on medication use within this environment in a positive way.
Pharmacists are best placed to improve medication management in aged care, and it should be a priority for our profession.