‘Pharmacists often encounter real resistance to reduce use.’

elderly couple silhouette made from pills

Leading pharmacist researcher draws attention to prescribing of psychotropics in aged care settings

Pharmacists can improve medication safety by drawing attention to high doses and following up on interactions, Dr Juanita Westbury from the Wicking Dementia Research & Education Centre, the University of Tasmania, told the Royal Commission into Aged Care Quality and Safety this month.

Dr Westbury was called by the Commission to give expert evidence, having led research into the use of sedatives in Australian aged care homes.

She was asked about a recent case before the Commission regarding the prescription and administration of the antidepressant psychotropic drug mirtazapine to an 85-year-old resident at a Sydney aged care facility.

The resident had been prescribed the medicine on 4 July 2018 at a dose of 45 milligrams every night to assist with what the doctor labelled depression and anxiety.

However the patient had never been given a diagnosis of depression, nor had the doctor carried out any tests before prescribing the medicine.

“She was prescribed 45 milligrams as a starting dose. You wouldn’t give that dose to a young 25-year-old who had never been exposed to it,” Dr Westbury told the Commission.

“The normal starting dose – probably the maximum would be 15 milligrams.

“With all the psychotropics in general it’s recommended that because they are more sensitive to them and they stay in their systems longer that you generally start them at a lower dose than you would in a healthy young adult.

“The rule of thumb is about half the dose, but you really should be monitoring the effect. If they’re excessively sleepy you really should be, you know, changing that dose quite quickly.”

During the hearing, the prescribing doctor told the Commission that in hindsight she was not happy with her choice of prescription.

She explained that a pharmacist had told her there had been several studies that showed the 15-milligram mirtazapine could cause more sedation than the higher dose.

Ms Westbury told AJP this is correct: “It is this weird property of this medication that the antihistamine effect is more predominant at lower doses. But psychotropic medication has varying effects on people. This is well known but I have seen people where low doses don’t cause more sedation.”

Did the pharmacist give the wrong advice?

“The doctor wasn’t clear what it was for. [As a pharmacist] I would have asked what it was for. The starting dose for an older person with dementia is 15mg. In practice I see 7.5mg given,” she told AJP.

“Mirtazapine should only be prescribed for depression or/and anxiety. The woman was crying and very anxious. No tests of depression were done.

“Medication shouldn’t have been given first up. The family should have been consulted and mental health team should have assessed her properly first. There should be a psychologist available for the home.”

If you were the pharmacist…

Counsel assisting Paul Bolster asked Dr Westbury: “If you were the pharmacist who was given the script for that particular drug, even if the doctor did not consult with you, what would your reaction have been?”

“As a pharmacist in a community pharmacy, you have prescribing software and really, with these sort of drugs, you should check whether they’ve been given out before,” she said.

“If they haven’t, it’s important to ring up and check – [ask] is this the first dose?

“If I found out that this was for an 84-year-old (sic) person who was a resident in a nursing home first off, I would be ringing up the doctor and just saying that the recommended dose is 15 milligrams and that I’m just informing her of this.

“Usually the doctor would go ‘whoops’ and change it.”

Mr Bolster asked: “In practice, have you had to do that?”

“I have done,” said Dr Westbury. “I’ve practiced as a community pharmacist and as an accredited pharmacist working in aged care, and we do draw attention to high doses.

“It’s not only about high doses, it’s about interactions. For example, some antidepressants interact with statins, which are cholesterol drugs, I have encountered that and I’ve contacted the prescriber. And generally, you know, 99% of cases, they’re really happy to have this drawn to their attention because it protects them. Usually they’re trying to do the right thing for their patient.”

Dr Westbury explained that in her PhD, she interviewed GPs, pharmacists, nursing staff and relatives to look at the reasons why psychotropic medications are prescribed.

“Doctors in general had a strong belief that they were probably more effective than the evidence suggests,” she said.

“Some of the doctors told me that they felt a lot of the risks were overblown, overpublicised, and they justified use by saying that they only used a small amount.

“Most of the [nursing] staff were very supportive of their use and they felt that they were necessary to provide comfort and to calm residents.

Meanwhile she said “pharmacists who worked in the sector often said that they encountered real resistance to actually reduce the overall use, because a lot of the staff were quite concerned that behaviours would return or be escalated if the use was reduced.”

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