Call to lift RMMR cutbacks

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Pharmacists are calling for restrictions on RMMRs to be lifted after study results reveal “concerning” levels of psychotropic overuse in aged care settings

A new study published in the Australian and New Zealand Journal of Psychiatry, has found “concerning” levels of ‘as required’ (‘prn’) prescribing of psychotropic medications.

Analysing data from 150 residential aged care facilities across Australia during April 2014 to 2015, which comprised 11,368 residents, researchers found nearly two-thirds (61%) were taking psychotropic agents regularly.

Over 41% were taking prescribed antidepressants, 22% antipsychotics and 22% of residents were taking benzodiazepines.

Use of two or more psychotropics was common, with a quarter (23%) of all residents taking two or more agents concurrently.

And notably, almost a third (30%) of residents taking a regular antipsychotic were also taking benzodiazepines daily.

A third of all residents (30.5%) were also charted for ‘prn’ benzodiazepines, with approximately half of residents prescribed regular doses of benzodiazepines also prescribed these agents on a ‘prn’ basis.

While prevalence of regular antipsychotic use was lower than in previous years – following an increase in safety warnings and tightened prescribing restrictions – researchers found the frequency of ‘prn’ antipsychotic prescribing has risen markedly and is the highest reported to date in Australia.

They also found benzodiazepine prevalence is higher, particularly in South Australian residential aged care facilities.

Lead author Dr Juanita Westbury says the issue is not new, but pharmacists are currently held back from helping to their full potential by conducting Residential Medication Management Reviews (RMMRs).

“Overuse was first highlighted in the media 1995, then in 2000 and again in 2013. Overuse has resulted in a NSW Taskforce, numerous government enquiries, two national roundtables and prescribing restrictions,” she told AJP.

“Medication reviews in residential aged care were funded in 1997 – primarily because they were endorsed as an effective way to reduce psychotropic use in this setting.

“Unfortunately, these services were cut back in 2014,” she says.

“Pharmacists can now only perform a medication review for a resident once every two years – instead of annually. Given the average length of stay for a residents in an aged care home is only 18 months, many residents will receive a medication review service when they are admitted to care -and that’s it.”

PSA President Dr Shane Jackson agrees that the situation is not ideal.

“I can’t believe that we continually face these issues of prescribing in aged care,” he said on Twitter.

“Restrictions on RMMRs are not helpful in this process either. We need a coordinated response to deal with sedative use in aged care.”

Dr Westbury says funding is not adequate for the amount of work required in this area.

In addition to RMMR funding, “pharmacists are also funded for Quality Use of Medicines (QUM) services for aged care residents – this funding equates to about $1500 a year for an average home of 60 beds, and for this sum they are expected to provide advice about medications, training sessions for staff, audits of use, check storage, attend medication advisory meetings and other quality improvement activities.”

Pharmacists can be more involved in aged care if they are funded appropriately to provide an adequate level of service provision, she says.

“Given adequate remuneration, training and support pharmacists can positively impact the health of aged care patients immensely. The average number of medications that an aged care resident takes now exceeds 10 medications a day.

“Pharmacist involvement could enable de-prescribing so that only medications that are needed are prescribed. Adverse effects due to medication can be identified.

“Such changes would not only benefit residents and those that care for them but there are potential health economic benefits as well, resulting from medication cost savings, reductions in adverse effects such as falls and pneumonia and lowered hospital admission rates.”

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