A review of aged care patients’ medicines can reduce harm.

Welcome change is coming for government-funded residential aged care facilities (RACFs) with the investment in on-site pharmacists and pharmacy services from 1 January 2023.¹ But what will pharmacists in these facilities do?

Several recent PSA-facilitated trials have involved pharmacist interventions aimed at reducing harms from medicines. In one, the Pharmacists in Residential Aged Care project funded by the Country SAPHN, 12 pharmacists were recruited across regional South Australia.

The project² ran for 2 years to 30 June 2021, during which 2,611 residents received patient consultations and RACF staff received 225 education sessions. In total, 426 cases of medicine reconciliation were conducted, with 60 significant discrepancies identified. The project also identified and resolved 123 chemical restraint cases, and pharmacists conferred in 1,379 episodes of collaboration with other healthcare providers in the RACF. Referrals from GPs and other RACF staff or medicine reviews and patient consults grew from the start. A total of 305 GP referrals were received, suggesting confidence and trust in pharmacists on site increased as they became more accepted within the multidisciplinary team of GPs, nursing staff and allied health at each RACF.

Currently underway in the Australian Capital Territory is another study, the cluster randomised controlled trial integrating pharmacists into aged care facilities to improve the quality use of medicine (PiRACF Study). On-site pharmacists are spending 2–2.5 days a week in a minimum of 13 RACFs integrated into healthcare teams to improve medicine management for 1,188 residents.³ The study also involves cost-consequence and cost-effectiveness. Results in 2023 are expected to aid policymakers with recommendations for further implementation in RACFs. AP spoke with three pharmacists involved in these trials.

ANDREW KELLY MPS

Pharmacist, Jindalee Aged Care
Residence, Narrabundah, ACT

Case 1

Mrs MW, an 84-year-old resident, had difficulty managing her chronic pain. Her doctor had started reducing dosages of some of her medicines, but she was terrified further reduction of her pain relief may cause it to become unmanageable.

Previously, she had been on pregabalin 75 mg twice daily, but was now down to 25 mg twice a day and was worried about stopping altogether. Hydromorphone slow-release tablets 8 mg daily, had been her dose for over 12 months, reduced from 12 mg daily. She also had an order for 2 mg hydromorphone tablets up to 4 times a day when needed. She took one tablet every night before bed and, occasionally, one during the day. But the before-bed tablet was in anticipation of pain. She agreed to trial not taking it regularly, knowing staff would give it to her if needed.

Pregabalin was another discussion, and, after talking about how to distinguish neuropathic pain, she realised it was no longer a concern and was confident about finally ceasing it.

Soon, Mrs MW had broken the 2 mg hydromorphone bedtime tablet habit. Once the pregabalin was ceased, she admitted to not recognising any rebound pain at all. The next step was to go to a buprenorphine 15 mcg/hour patch after switching off the hydromorphone to rotate medicines while she was still fairly mobile and independent. This was another convenient reduction in opioid dose. She still experiences some pain, but uses topical treatments, heat applications and frequent massage therapy from nursing staff rather than increased opioid doses.

During a recent holiday in Brisbane with her family, Mrs MW sent a lovely card with a photo of her on the back of a rickshaw-type bicycle tootling around the city, and a note in appreciation of the work to help manage her pain more effectively. It had allowed her to enjoy her holiday.

Now back in the RACF, she stops me in the hallway with updates on her progress and questions and requests to look at other deprescribing. A win for everyone!

DEE-ANNE HULL MPS

Aged care pharmacist, rural South Australian RACF
(also servicing smaller towns)

Case 2

During my time with the PSA-facilitated Pharmacists in Residential Aged Care Facilities project, funded by Country SA Primary Health Network, I was interested in the anticholinergic burden of medicines and how it impacted residents.

Many pharmacists would instantly think of oxybutynin. However, many medicines exhibit a smaller anticholinergic effect with a lower individual risk, but when they are prescribed together can impact greatly on the resident.

A facility-wide audit allowed evaluation of the medicines of 52 residents, providing information based on individual anticholinergic burden scores and the potential impacts on the health of each resident based on the many bodily systems that can be affected.

I reviewed the drug chart of every resident at the facility, recording their medicines and determining ananticholinergic score. There is no ‘great’ resource for this, so I used about five different resources to calculate the burden, assessing each drug and the likelihood of anticholinergic properties. The medicines assessed in the audit included benzodiazepines, opioids, antipsychotics, antidepressants, prednisolone, antihistamines, antiemetics, diuretics – basically any drug that was likely to exhibit anticholinergic effect.

The common medicines in this audit with a lower anticholinergic burden included metoprolol, atenolol, digoxin, hyoscine butylbromide, benzodiazepines (oxazepam, temazepam particularly), metoclopramide, frusemide andvenlafaxine. Intermediate load was seen with sertraline, prochlorperazine, loratadine, prednisolone and cetirizine.

The higher load was experienced with paroxetine, quetiapine, oxybutynin and olanzapine, to name just a few examples for each category.

I detailed the potential effect on each bodily system and broke this down for each resident according to symptoms I had already noted. GPs for the high-risk residents were contacted with information about the burden and effects seen, with the aim to review the resident. Drug chart reviews alone took about 4 hours once a month, but calculation of the anticholinergic burden was more than 10 hours’ work in total.

One resident, a 76-year-old female with strong history of depression and dementia, had regular falls. She took high-dose sertraline 150 mg daily, quetiapine 100 mg twice daily and regular risperidone 500 mcg.

Added to this were PRN medicines, including oxazepam 15 mg, risperidone 500 mcg and oxycodone 5 mg, often used due to high levels of anxiety and pain. After discussion with her GP on the effects of the anticholinergic load, dose reduction occurred.

Post-reduction reviews indicated anxiety and confusion did not change, however her falls reduced significantly – by at least 50%.

While the project concluded before another audit could be conducted to assess facility-wide progress, the individual responses for the residents where interventions were trialled showed great success.

JAYLEE LEWIS

Embedded pharmacist, IRT Kangara Waters, ACT

Case 3

Mr X, aged 81, had a history of heart failure, depression, vitamin D deficiency, constipation, osteoarthritis and Parkinson’s disease. He reported fitful sleep and back pain, and family members noticed his discomfort and agitation during visits.

Mr X had fallen twice in the past 6 weeks and his appetite had waned. During a routine medication competency assessment for a staff member, I was told Mr X had trouble swallowing his tablets. I witnessed staff crushing all his tablets together and placing them in a cup of water to assist him.

A follow-up consultation with Mr X’s GP allowed a change of his controlled-release paracetamol and levodopa+carbidopa tablets to conventional tablets which can be safely crushed and/or dispersed. The unpleasant-tasting crushed docusate+senna was also changed to macrogol 3350 sachets, and the colecalciferol capsules were changed to a liquid formulation.

Mr X’s mobility, pain management and appetite all improved, resulting in better sleep quality and fewer falls.

This and other interventions led to more widespread education for care staff about the possible effects of altering solid-dosage forms and using appropriate food-based vehicles and thickening agents. This was communicated individually to staff members, usually as part of a medication administration competency assessment or at afternoon handover, which also included reminding staff to check the primary medication chart before crushing any medicines (or to double check with me if not sure).

The pandemic did not lend itself to group education sessions. I found that while I send emails to RNs and staff, it is not an effective way of communication or learning, given their current time pressures. In addition, I helped implement and educate staff via a quick overview at the monthly RN meeting and other ad hoc individual sessions, including a demonstration. There is also a poster with instructions in the medicine room near the new SafeCrush pill crusher devices within the facility to replace an old manual crushing device that could cause injury.

References

1. Ministers. Department of Health. On-site pharmacists to improve medicationmanagement in RACFs. 2022. At: https://bit.ly/3mdc6pT
2. Country SA PHN Annual Report 19/20. Aged care. p.22. At: www.countrysaphn.com.au/wp-content/uploads/2020/11/CSAPHN_Annual-Report-1920_eAW-hi-res.pdf.
3. Kosari S, Koerner J, Naunton M, et al. Integrating pharmacists into aged care facilities to improve the quality use of medicine (PiRACF Study): protocol for a cluster randomised controlled trial. BMC Trials 2021. Epub 2021 Jun 11. At: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-021-05335-0#citeas