The aged care dilemma

Medicines are intended to prevent and treat disease and illness. Yet, in many cases, particularly those involving older Australians, medicines may be doing more harm than good

As masters of medicine safety, pharmacists are in an important and privileged position to help minimise medicine harm and maximise the benefits of treatment.

Certainly, recent reports have highlighted the need to improve medicine use among older Australians, particularly those living in aged care.

According to the PSA’s Medicine Safety: Aged Care Report, 20% of unplanned hospital admissions for aged care residents are a result of inappropriate medicine use.

It reveals that more than 95% of people living in aged care facilities have at least one problem with their medicines, detected at the time of a medicines review; most have three problems.

One in six medicine-related issues are due to adverse medicine reactions and more than half of all people living in aged care facilities are prescribed medicines that are considered potentially inappropriate for older people.

The report also reveals 50% of people with dementia are taking medicines with anticholinergic properties, which can worsen confusion and other symptoms of dementia.

What’s more, one fifth of people living in aged care are on antipsychotics, with more than half of them using the medicine for too long.

The growth of polypharmacy

Of course, it’s not just older Australians living in residential facilities that are at risk of medicine-related issues. Polypharmacy is widespread among older Australians in general, and the number of people taking multiple medicines is increasing as the population ages.

While polypharmacy is appropriate in many cases, there is much evidence to support the need to cease the use of unnecessary medicines, particularly in older people.

Dr Janet Sluggett, senior research fellow at the School of Health Sciences, University of South Australia, explains, “Some of the medicines-related problems that we see in older people include taking a medicine that is no longer providing benefit or that is causing an adverse event. Prescribing cascades can also occur; this is when an adverse drug event is misinterpreted as a symptom of a new health condition and a new medicine is commenced to treat the ‘new condition’.

“Older people often take multiple medicines, which can increase the risk of drug interactions. Conversely, sometimes a condition may be undertreated, and additional therapy might be required.”

She explains that the high risk of medicines-related problems in older Australians can be due to frailty, multimorbidity and polypharmacy. For those people living in aged care, there are also frequent care transitions to take into account.

The main culprits

Dr Sluggett tells the AJP, “Diabetes medicines, anticoagulants, opioid analgesics and antipsychotics are considered to be high risk medicines in older people. These medicines are among those most commonly involved in emergency department visits for adverse drug events in older people.

“A recent US study reported that diabetes medicines, anticoagulants or opioids were implicated in six in every 10 emergency department visits for adverse drug events among individuals aged 65 years and over.”

A survey by Graeme Miller et al into drugs causing adverse events in older people in Australia showed that 13 commonly prescribed drug groups accounted for 58% of all adverse drug events, opioids being the group most often implicated.

The data, selected from 7518 patients of randomly selected general practitioners across Australia, revealed that alongside opioids, salicylates and non-steroidal anti-inflammatory drugs (NSAIDs) were popular causes of hospitalisations for adverse drug events.

Other commonly identified drugs are:

  • antidepressants;
  • lipid-modifying agents (statins);
  • ACE inhibitors;
  • penicillins;
  • selective calcium channel blockers;
  • beta blocking agents;
  • hypoglycaemic agents (excluding insulins);
  • bisphosphonates;
  • proton pump inhibitors; and
  • anti-epileptics.

The authors highlight that adverse drug events are one of the most important causes of morbidity in the Australian community. The largest category of adverse drug events is adverse drug reactions—“occurring in patients on appropriate dosages of medication, prescribed for appropriate indications”.

The authors state, “Reducing the number of drugs taken by older patients is paramount in efforts to reduce adverse drug reactions”.

Home medicines reviews

PSA national president Associate Professor Chris Freeman says, “Medicine-related problems lead to 250,000 hospital admissions each year costing $1.4bn annually.

“Medicine review services undertaken by accredited pharmacists, such as HMRs, are a key way in which problems with medicines are identified and resolved in partnership with consumers and their general practitioner.”

Indeed, the monthly cap increase from 20 to 30 is testament to the important role HMRs play in improving quality and optimal use of medicines.

A/Prof Freeman adds, “Our members have told us of significant delays consumers have experienced waiting for the calendar to tick over to the next month before being able to receive a HMR from their pharmacist who has hit their HMR cap for the month”.

He says the cap of 20 HMRs per month is particularly unfavourable to consumers living in rural communities, as often there are no other accredited pharmacists available to provide the service.

Consultant pharmacist Karalyn Huxhagen tells the AJP, “The HMR cap increase was introduced about a week before coronavirus hit. However, COVID-19 made it very difficult to conduct HMRs, as patients didn’t really want to see us.

“The cap increase is a welcome improvement and the introduction of two follow-ups was an enormous part of what needed to happen to ensure the recommendations are looked at by the GP and are actioned.

“Going forward, if we can keep the follow-up aspect of HMRs, even if they’re done on a telehealth basis for rural and remote patients, that would be very welcomed.

“While there is always a place for conducting HMRs via telehealth, I would always advocate seeing the patient face-to-face as much as possible. But certainly, in my part of the world there’s a place for it as many of my patients live quite some distance away. There’s also the time element; sometimes I can’t reach the patient within the GP’s preferred time frame. For example, if a GP has severe fears for the safety of the patient and I can’t get to them for three weeks this would be a reason to use telehealth.

“There are also things like flooding that might prevent you from getting to a patient. If there’s a case like this and the GP is particularly concerned about the person, I can do the HMR by telehealth in spite of the flooding.

“While we don’t really want a cap on HMRs, we recognise that the funding comes from a limited bucket of money. The ability to do 30, but also to be able to follow-up your patients is an amazing improvement to the HMR program. I think most pharmacists look at this as being a realistic work option.

“Practitioners like myself, who work in rural and remote areas of the country would welcome no cap. When you travel large distances to reach your patients, you want to be able to see as many as you can in the one visit.”

With regards to other areas in which pharmacists can assist older people to avoid adverse medication events, Ms Huxhagen says, “The placement of pharmacists in to aged care facilities is an evolving role but a very important role. Being on the ground when the nurses and other allied health team members that are embedded into aged care are involved is an immense benefit. It looks at the problem when it happens and it also teaches the nurses and others team members what to look out for.

“Embedding a pharmacist into the broader aged care team is definitely something we’re working towards. However, it’s also important to have pharmacists very much involved in age care programs in the community—so working with aged care assessment and palliative care teams.

This is a HMR role to a degree, but we need Enhanced Primary Care numbers so that we can also work much closer with these teams and become more involved in team care arrangements, such as team meetings and conferences, which we’re not reimbursed for at present.

Simplifying the medicine regime

“Sometimes it can be difficult to deprescribe medicines because of patient reluctance, lack of resources or time constraints, or because a prescriber may be reluctant to deprescribe a medicine that was initiated by another prescriber,” Dr Sluggett explains.

“Under certain circumstances, pharmacists are now able to provide follow-up consultations after a home medicines review or residential medication management review. This is a fantastic opportunity for pharmacists to support deprescribing of medications that are no longer necessary, For example, through monitoring for withdrawal symptoms or recurrence of symptoms, and advising on dosing changes.

“Older people are increasingly exposed to complex medication regimens. Polypharmacy can increase the complexity of a medication regimen, but other factors such as multiple dosing times, additional instructions (e.g. crushing, taking with food) and multiple formulations (e.g. injections, patches) can make regimens more complex.

“Together with colleagues, clinicians and aged care providers, we co-developed and validated a tool that pharmacists and other health professionals can use to simplify medication regimens: MRS GRACE (the Medication Regimen Simplification Guide for Residential Aged CarE).

“We have trialled the use of MRS GRACE in South Australian residential aged care facilities and among older people living at home who receive community aged care services, and found that in many cases, medications can be taken in a simpler way.”

She explains, “Medications could be simplified through strategies such as administering medications at the same time and/or switching to combination or longer-acting formulations.

“In the SIMPLER study, most simplification strategies suggested by the pharmacist focused on changing the time a medicine was administered (65%) or changing the formulation (27%).

“The likelihood that a person can take their medicines in a simpler way is increased among people taking medicines multiple times per day. Simplification is deemed possible for nearly all those people taking medicines four or more times per day.”

Asking the questions

While services such as home medicines reviews or residential medication management reviews are important in supporting the appropriate use of polypharmacy in older people, pharmacists can also assist older people on an informal basis by asking a few simple questions.

  • Ask the person if they know what their medicines are for and if they ever have difficulty remembering to take their medicines.
  • Ask if they have any concerns or questions about how to take their medicines. For example, is dexterity an issue? Do they have any problems swallowing? Can they read the dosing instructions?
  • Discuss dose administration aids, such as Webster Paks and/or medicine trays, if appropriate.
  • Consider whether a home medicines review would be beneficial.
  • Inform the prescribing doctor if a person is not collecting medicines and repeat prescriptions regularly.
  • Encourage the person to ask their general practitioner for a medicine review if they are experiencing any difficulties with their medicines or have had any adverse reactions.

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