Improving Quality Use of Medicines in aged care

We know there’s 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 there are problems with medication management in this setting, including alteration of dose forms (crushing of tablets), potentially inappropriate prescribing and polypharmacy.

A 2013 literature review prepared for the Commission for Quality and Safety in Healthcare suggested up to 50% of residents could be receiving potentially inappropriate medications, such as sedatives and highly anticholinergic drugs.

Alarmingly, recent reports have suggested the use of psychotropic medications in aged care is very common. A report from Alzheimer’s Australia showed 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 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 study by the University of Tasmania as part of the 4CPA Research and Development Program saw a coordinated effort between community pharmacy and aged care facilities to address the use of psychotropic medicines. This 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’s frustrating to see the new Review of National Aged Care Quality Regulatory Processes commissioned by the Minister for Aged Care Ken Wyatt was recently released highlighting 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 SA, which had significant failures of care that unfortunately the regulatory framework did not detect.

One of the key recommendations from this review included: ‘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 per cent between 2008–09 and 2015–16.’

I encourage all accredited pharmacists 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 aged care facilities and general practitioners who are caring for 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’s important these activities target areas of significant issue within aged care, such as polypharmacy, psychotropic and antibiotic use, and deprescribing. We cannot sit idle while 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 and it will be important leading into the next Community Pharmacy Agreement.