Prescribing under the spotlight

Doctor admits she is not happy with her prescribing of high dose mirtazapine to an aged care resident, which landed her before Royal Commission

Psychotropic prescribing in residential aged care facilities has been called into question during the Royal Commission into Aged Care Quality and Safety this week.

A Sydney hearing held on Wednesday focused on the prescription and administration of the antidepressant psychotropic drug mirtazapine to an 85-year-old resident at a Sydney aged care facility, referred to simply as Mrs CO.

She 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.

The first dose was delivered on 6 July.

According to reports of the facility’s pastoral care workers, Mrs CO had been crying and was “very upset” thinking about painful memories.

However counsel assisting Paul Bolster pointed out that Mrs CO had never been given a diagnosis of depression, nor had the doctor carried out any tests before prescribing the medicine.

“Mrs CO was advanced in her dementia which makes it more difficult to make the test reliable,” explained the doctor.

“I didn’t want to leave my patient distressed and in a distressed condition.”

Mr Bolster questioned the appropriateness of the doctor’s prescription mirtazapine for a person with dementia, as well as her choice of dose.

He said that an appropriate starting dose of mirtazapine for an elderly person with dementia would be less than the 15 milligrams.

The doctor agreed.

When asked why she had prescribed mirtazapine at 45 milligrams, without any other intervention that may have assisted Mrs CO behaviourally, the doctor responded: “I really have no explanation why I did that.”

When asked about the level of dosage, she said a pharmacist had told her there had been several studies that showed the 15-milligram mirtazapine could cause more sedation than the higher dose.

“Sitting there today, are you happy with your prescription on that occasion?” Mr Bolster.

“No, I’m not,” she said.

Mrs CO’s family was not informed about the prescribing of mirtazapine until three days after she was given her first dose.

After Mrs CO had been on the medication for several days, one of her daughters came to visit and found her fast asleep in the middle of the day, unable to be roused.

Her daughter told the Commission that she was never informed that mirtazapine was an antidepressant, nor what the dosage or side effects might be.

“We Googled it and realised it was a fairly heavy-duty drug, but I felt that I’m not a doctor. I didn’t know what it was exactly, so I put my faith in what was happening on their end, that this is what Mum needed,” she said.

“And I feel so bad about it.”

The residential care manager of the facility at which Mrs CO stayed told the Commission that as at 1 July 2018, 112 out of 197 permanent residents were being prescribed psychotropic drugs.

Of these, 109 (55%) were on a regular prescription and a further 21 on PRN.

When asked whether he thought the numbers were too high, the residential care manager said: “No.”

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1 Comment

  1. “When asked about the level of dosage, she said a pharmacist had told her there had been several studies that showed the 15-milligram mirtazapine could cause more sedation than the higher dose.” The level of evidence is weak and definitely not applicable to the older population.

    This pharmacist should also be liable. And perhaps also the dispensing pharmacist if they did not follow through with their due diligence.

    In hospital, every prescription is reviewed and it is signed off with your initials before dispensing. This means that you have endorsed the prescription to be safe and effective for this patient. If something goes wrong, you will be answering to an incident tribunal. This should also be the case in aged care where we service the most vulnerable (and ideally to the whole of pharmacy).

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