‘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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9 Comments

  1. Apotheke
    23/05/2019

    Nursing homes are using chemical restraint to manage the behaviours of dementia patients. Australia unlike the USA has no legislated medication guidelines that regulate the prescription of such dangerous drugs in Aged care facilities.The major risks of these drugs are over sedation leading to patients sleeping all day and failing to eat and drink, increased incidence of falls due to hypotension and increased risk of stroke.

    The USA has the Federal OBRA Guidelines which set out the maximum recommended daily doses for such medications in the elderly. Why doesn’t Australia legislate such standards into the Aged Care Act.? As well as immediately commencing a compulsory education programs for GPs, Pharmacists, RN Div1s and RNDiv2s about the appropriate prescribing and administration of such dangerous medications in the very old.

    Also staff in the Aged Care sector desperately need to be given training in the use of non drug tools to manage the behaviours of demented residents. Considering that at least 50% of residents in Aged care facilities have a diagnosis of dementia this is a major part of their work.

      • And, worryingly, consent is NOT required before psychotropic medication is prescribed. In these very principles linked to above. Please check for yourselves. This is against basic human rights. The reason? Our chief medical officer said that it was unfeasible for doctors to obtain consent from residents or relatives before use. So the question is who are these principles for? One would hope for the protection of human rights of old frail residents but alas, no, we can’t make it any more difficult for the doctors. Nor can we delegate any of their responsibility and ensure aged care homes obtain consent.

        see: https://hellocaremail.com.au/consent-required-prescribing-psychotropic-medication-not/

        • Hi Dr Westbury, that’s fair to call and thank you for your representation and your work re: the RC.

          I would imagine that consent is not legislated due to the fact that sometimes an agent is needed in emergency cases (ie. safety to self or others.) I have experienced this first hand.

          The need to inform before administration in clause 15G tries to make up for this as a protection of resident rights.

          But you are definitely right, more can always be done to protect our most vulnerable and we can play a huge role in this.

          • Andrew, ‘inform’ is NOT ‘consent’. It is not shared decision making. It does not align with basic human rights. This is not in an emergency this applies in ALL cases.

            In 15G it also says inform ‘if practicable’. And we all know how much time GPs have to track down relatives or spend time with residents.

            Imagine you were informed you were now going to be given quetiapine in your hot milky drink at night because you are too loud – or you are informed that your nan is now wearing a zydis patch because she was upset when you left – taking note you are your nan’s legal proxy.

            Dr thinks this is best. CMO of Department of health thinks this is best. What the resident or their legal proxy thinks or says is not even factored into the decision.

            This will be Ok after 1 July 19.

          • 23/05/2019

            Can I clarify what you mean by after 1 July 19?

            “Conclusion

            The Amending Principles are compatible with the human rights and freedoms recognised or declared in the international instruments listed in section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011. It promotes the consumer’s rights to the enjoyment of the highest attainable standard of physical and mental health, and to protection from exploitation, violence and abuse. The Amending Principles will also assist in promoting a key object of the Aged Care Act, namely to protect the health and well-being of recipients of aged care services.”

            I believe the difficulty is legislating consent whilst allowing the flexibility to utilize the agents in emergencies. Legislating consent is also a very contentious issue.

          • The principles come into force 1 July 2019.

            Alexander, they don’t abide with human rights. These principles for chemical restraint apply to all situations not just emergencies.

            Read what the principles are for physical restraint. They talk about emergency use there. Not in chemical restraint. Please recognise the nuance.

            The marked difference between what is required for physical and chemical restraint was raised in the RC again and again. The aged care quality and safety commission recommended that the requirements for chemical restraint be strengthened as did the Australian Commission for safety and quality in health care. If you get a chance read Brendan murphy’s transcript on Tuesday last week and then the thursday transcript from 11am.

            The principles say they follow human rights but the actual principles dont.
            Restraint is restraint and informed consent should be required except in emergencies for BOTH physical and chemical restraint. The two types have been separated. This is the issue the RC highlight. and its a violation and requires correcting.

          • 23/05/2019

            Thanks Dr Westbury, I see the distinction that you are putting forth and I also agree that an amendment is needed to make it also applied to the use of chemical restraints.

            Clause 15F Use of Physical Restraint:

            “(e) the approved provider has the informed consent of the consumer or the consumer’s representative to the use of the restraint, unless the use of the restraint is necessary in an emergency.”

            It is certainly perplexing as to the reason why this was omitted for chemical restraints. I certainly understand your points and frustration now. I also agree with a proposed time-frame stated for monitoring as stated to Prof Murphy. There needs to be far greater accountability from all parties.

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