Aged care failings: are RMMRs a solution?


elderly couple silhouette made from pills

Pharmacy stakeholders have criticised the overuse of psychotropic medications in residential nursing homes, following an ABC inquiry

Pharmacists working in aged care settings could do a lot to improve such prescribing and use of medicines, including RMMRs, they add.

Who Cares? reported by Anne Connolly and presented by Sarah Ferguson, aired on Four Corners on Monday night, covering failings of the residential aged care system, including the use of medicines.

Ms Connolly cited data which showed nearly two thirds of aged care residents were given psychiatric drugs, including antipsychotics.

She spoke to Dr Juanita Westbury, Senior Lecturer, Wicking Dementia Research and Education Centre, University of Tasmania, who said that these were only effective in about 20% of people with agitation and that staff appeared to be reaching for them as a first line behaviour management tool, rather than a last resort.

She also spoke to Deanne Morris and her mother, residential nursing home resident Pamela Passlow, who has dementia.

Ms Passlow was prescribed Risperidone on a basis which allowed nurses and personal carers to administer it at their discretion. Her family was not informed.

“Handing it over to a carer that’s been to a three-month TAFE course at best is really inappropriate,” Dr Westbury said. “And you would ask what sort of training they’ve had and I think it’d be very difficult to include comprehensive training on medications and their adverse effects in that period.”

Ms Morris told Ms Connolly that her mother had been given a “cocktail of antipsychotics and sedatives in an attempt to control her behaviour,” and on one occasion was given double her maximum Risperidone dose in 24 hours.

In response to the Four Corners piece, PSA president Dr Shane Jackson said that inappropriate use of medication in aged care has been a concern for many years.

“We’ve seen reports that indicate over 50% of residents in some aged care facilities are receiving sedative type medications, have suboptimal pain control, and are taking medications that are no longer necessary,” Dr Jackson said.

“Crushing of medications puts residents at greater risk of side effects, including falls.”

Reports such as Who Cares? are distressing viewing for PSA’s members, he said.

“Pharmacists are a key group of health professionals who understand how much medicine safety and quality directly impacts the health and wellbeing of vulnerable residents in aged care facilities – both negatively and positively.

“Better co-ordination and greater investment in healthcare professionals like pharmacists needs to be built into the operation and design of aged care facilities.

“Research shows positive health outcomes are delivered in models where pharmacists and pharmacy services are embedded and integrated within aged care facilities.

“These pharmacists support doctors in making the right decisions about the use of medications, guide nurses in the correct administration of medications, and regularly review medications residents are taking.

“Unfortunately, what we see in practice is that all too often they are not there, and it is our aged care residents who pay the price.”

How pharmacists can help

AJP spoke to consultant pharmacist Debbie Rigby, who asked why restrictive program rules on RMMRs and QUM services still exist.

She highlighted Dr Juanita Westbury’s work in demonstrating the value of pharmacist reviews and QUM services reducing inappropriate and unnecessary drugs, especially psychotropic drugs, sometimes used for chemical restraint, in the RedUSe study.

The RedUSe program and Halting Antipsychotic use in Long Term Care (HALT) study have both demonstrated the value of pharmacists in reducing inappropriate use of antipsychotics, she said.

In 2017, the Review of National Aged Care Quality Regulatory Processes by Kate Carnell and Professor Ron Paterson recommended an RMMR must be conducted on admission for residents to an aged care service, after any hospitalisation, upon deterioration of behaviour or any change in medication regimen.

Ms Rigby said that residents in aged care facilities take an average of 9.75 medications, and that polypharmacy is commonplace.

“The incidence of medication-related problems and errors is well documented,” she said.

“RMMRs have been in place for over 20 years now and the Campbell Research evaluation in 2010 concluded the program is meeting its objectives to improve quality use of medicines in aged care homes.

“Many stakeholders consulted in this evaluation identified opportunities to build on what is generally considered a successful and effective program. Issues such as travel costs, barriers to GP involvement, frequency of reviews and targeting high-risk residents were all identified in the evaluation.

“[But] we now have more restrictive program rules that only allow an RMMR every two years, with a resident likely to only have one or two RMMRs during their stay.”

She highlighted the 2015 Atlas of healthcare variation, released by the Australian Commission on Safety and Quality in Health Care, which examined dispensing rates of antipsychotic medicines for people aged 65 and over from the Pharmaceutical Benefits Scheme.

“Data suggest up to one third of residents are prescribed antipsychotics for use in the management of BPSD,” she said.

“The Four Corners investigation identified numerous medication-related issues, especially inappropriate use of psychotropic drugs.

“RMMRs are an established valued collaborative program, supported by evidence; and yet the funding and program rules restrict access to the residential aged care population.

“Instead of this continued restriction, we should be looking to embed pharmacists in aged care facilities to deliver real-time interventions and promote quality use of medicines for this vulnerable population.

“Assuring safety and quality of medicines needs to occur routinely at various points – on admission, after hospitalisation, new diagnoses, deterioration in behaviour and signs, and the new medicines.

“De-escalation of medicines towards end-of-life is gaining attention and evidence-base. These roles could be performed by an accredited pharmacist embedded in the facility, working in close collaboration with medical practitioners and nursing staff.

“Pharmacists are embedded in hospitals – why not aged care facilities?”

Related: Health sector reacts to aged care failings report

Watch the full Four Corners report, Who Cares? here.

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