Medicine safety for older Australians is a game of “Russian Roulette,” says one pharmacy stakeholder, as moves to reduce inappropriate chemical restraint take shape
The PSA has released a new Medicine Safety: Aged Care report which according to national president Association Professor Chris Freeman, “sounds an urgent alarm that medicine safety in aged care must be tackled without delay”.
Following the recent Royal Commission into aged care and a number of disturbing media reports about the treatment of residents, the PSA’s report also found that “we are neglecting vulnerable older Australians when it comes to protecting them from medicine-related harms,” A/Prof Freeman said.
PSA describes medicine safety for older Australians as a game of “Russian roulette”, with those most vulnerable being unnecessarily put at risk every day.
The report, launched at Parliament House in Canberra, found that half of all residents are taking medicines that cause sedation or confusion, with 20% taking antipsychotics and up to a third taking benzodiazepines. Overall half of people with dementia are taking medicines with anticholinergic properties.
PSA’s report says that more than half of these residents taking these medicines for far too long.
“One of the most shocking findings of our report is that 20% of unplanned hospital admissions for aged care residents are a result of inappropriate medicines use,” A/Prof Freeman said.
“While medicines are meant to help patients, in many instances these types of medicines can make symptoms worse, cause excessive drowsiness and make residents more likely to experience significant injury from a fall,” A/Prof Freeman said.
The report also found 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 – and most have three problems.
It found that 6% of people living in aged care were administered at least one potentially hazardous medicine combination.
Up to a third of people living in aged care facilities have their medicines altered; 15% to 32% should not have been altered.
The PSA has detailed a 10-point plan to deal with medicine safety in aged care (see below).
In his introduction to the report, A/Prof Freeman wrote that the Australian Government must respond with appropriate support including funding and structural reform to keep older Australians safe – and that pharmacists are key to this.
“Pharmacists are medicine experts and in collaboration with other health professionals and carers can help identify and diminish the risk of medicine side-effects and harmful interactions,” he said. “One way pharmacists already do this is through medication reviews.”
However he pointed out that these can generally only be conducted once every two years.
The PSA says that the Government has gone some way to addressing this by providing $25.5 million to improve medication management programs to reduce the use of medication as a chemical restraint on aged care residents and at home, and new restrictions and education for prescribers on the use of medication as a chemical restraint.
However, the Government’s commitment to medicine safety, declared as the 10th National Health Priority Area, needs to translate into actions and sustainable funding, says PSA – including supporting pharmacists to spend more time in aged care and enable them to conduct more frequent medication reviews and follow-ups.
“Pilot programs which have embedded pharmacists in the aged care team have achieved demonstrable improvements in medicine safety and quality use of medicines,” A/Prof Freeman said.
Minister for Aged Care and Senior Australians Senator outlined in Parliament this week how the Government is addressing the delivery of care for older Australians, including medicines safety.
He noted that the Chief Medical Officer is chairing a Clinical Advisory Committee to consider non-regulatory activities to reduce the inappropriate use of chemical restraint in residential aged care, and work underway to address the Committee’s recommendations and to reduce the inappropriate use of chemical restraint.
He said that this includes:
- “establishing an additional Pharmaceutical Benefits Scheme (PBS) authority code for repeat prescription of the antipsychotic risperidone after an initial 12-week period. This was a recommendation of the Pharmaceutical Benefits Advisory Committee. From 1 January 2020, the PBS listings for risperidone for the treatment of Behavioural and Psychological Symptoms of Dementia (BPSD) of the Alzheimer type will change. This change involves the addition of a new ‘continuing’ listing that will require prescribers to seek a telephone authority from the Department of Human Services prior to prescribing risperidone beyond 12 weeks of ‘initial’ therapy, when appropriate;”
- “awareness raising activities for prescribers of antipsychotics and benzodiazepines in residential aged care and targeted letters to high prescribers. The Chief Medical Officer in the Department of Health will be writing to all prescribers in December who have been identified as prescribing PBS medications to residents of a residential aged care home between 1 April 2018 and 31 March 2019. The letter and accompanying factsheet ‘Six steps for safe prescribing’ will provide information and resources that support the appropriate management of dementia in a residential aged care setting;”
- “development of education messaging about the appropriate use of antipsychotic medications and benzodiazepines in residential aged care for doctors and other prescribers, pharmacists, nurses and personal care workers, and families and decision makers;”
- “workforce training initiatives addressing: continuing professional development for doctors, nurses and other prescribers;” and
- “expanding a trial of embedded pharmacists to all residential aged care homes in the Australian Capital Territory. Funding has been provided to the ACT Primary Health Network who will work partner with the University of Canberra to conduct the trial. It is anticipated that the first cohort of pharmacists will be placed in aged care homes by February 2020.”
“This program of work promotes cultural change within aged care homes, which can best be achieved by a person-centred care approach in residential aged care facilities,” said Senator Colbeck.
“It is complemented by the new restrictions on the use of restraint by providers, which impose restrictions, safeguards and conditions on the use of restraint.
“Together, these measures work to protect the rights of vulnerable senior Australians within the aged care sector.”
Meanwhile, pharmacists and other stakeholders welcomed the report.
At the launch of the #MedicinesSafety in #AgedCare report at Parliament House this morning. A profound quality & safety issues for consumers.
Sound recommendations from @PSA_National @topherfreeman @MarkCoultonMP pic.twitter.com/6EuusIJJrs
— Leanne Wells (@LeanneWells63) February 25, 2020
‘I used to take great joy at going into aged care [as a doctor] & striking out unnecessary or harmful medicines.. medicines started with good intentions but used for too long or not properly reviewed“@RichardDiNatale#deprescribing #medicinesafety #agedcare @PSA_National pic.twitter.com/CGbXPIyJII
— Peter Guthrey (@pguthreyRx) February 25, 2020
Honouring the role of pharmacists in #agedcare with @PSA_National today at Parl House. Embedded pharmacists in care facilities are a benchmark for medicine safety @lieselwett @richardmcolbeck #medicinesafety pic.twitter.com/UncY0AvuGg
— Goodwin (@goodwincare) February 25, 2020
The Society of Hospital Pharmacists of Australia also welcomed the PSA’s report and supported the majority of its recommendations.
SHPA Chief Executive Kristin Michaels says the mechanism through which pharmacists provide on-the-ground clinical services is crucial to improving the safety and quality of care.
“We are mindful that research shows, in many cases, the majority of pharmacy recommendations made through Residential Medication Management Reviews (RMMRs) do not translate into action by prescribers,” she warned.
“As detailed in SHPA’s response to the interim report of the Royal Commission into Aged Care Quality and Safety, we will continue to advocate for investment in clinical pharmacy services for aged care residents so pharmacists can identify and manage medication-related issues and reduce harm, while ensuring identification of deprescribing opportunities and high quality clinical handover as patients move between care settings.
“We believe this is best achieved through increased funding for aged care packages supporting direct employment, to ensure the highest standard of integrated, multidisciplinary care where it is needed most.”
PSA’s 10-point plan
- Physically embed pharmacists within aged care facility teams by increasing funding allocations to Residential Medication Management Reviews and Quality Use of Medicine Services, sufficient to provide at least 0.6FTE per 100 aged care residents.
- Provide the opportunity for pharmacists to engage in a cycle of care through the delivery of follow-up medication reviews to patients at risk, and remove the caps on the number of medicines reviews that pharmacists can perform to ensure that those elderly patients at risk of medicine harm receive appropriate care.
- As a matter of priority, the Commonwealth Government should adopt the recommendations of the MBS review taskforce by ensuring that pharmacists are remunerated to participate in case-conferencing for residents within aged care facilities.
- Provide targeted activities delivered by pharmacists, such as the RedUSe program, funded under the QUM program. This would allow pharmacists to undertake audits of prescribing and provide feedback, and enable education to aged care facility staff and GPs in core medicine areas such as psychotropic medication use, opioids, deprescribing and antimicrobials.
- Provide funding to aged care facilities to implement contemporary electronic medication management solutions, including prescribing, dispensing and administration.
- Establish a Medicine Safety in Aged Care Resource and Support Program by allocating $8.7m over four years to support clinical governance of medicines management within aged care.
- Allocate $2m for the implementation of Clinical Governance Principles for Pharmacy Services within Residential Aged Care Facilities. This robust framework can be used by pharmacists to guide service delivery that is safe, of high quality and clinically appropriate.
- Similar to patients in the community, residents of aged care facilities should have equitable access to subsidised DAA services where clinically warranted and where the use of a DAA is mandated by the facility.
- Allocate $15m through a targeted call for proposals through the Medical Research Future Fund (MRFF) to reduce harm associated from medicines for older Australians.
- Develop a standard comprehensive set of safety and quality use of medicine indicators for aged care facilities, and require facilities to regularly report outcomes against these measures.
The PSA’s full report can be accessed here.