Rapid rise in prescribing ‘quite concerning’

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More medication reviews and education on psychotropic medicines are needed for those entering aged care, with pharmacists ‘best placed’ to provide this, say leading researchers

Dispensing of psychotropic medicines to older Australians is high before they enter residential care but increases markedly soon after entry, a large new study has found.

Researchers examined seven years of national data that included more than 322,000 Australians entering government-subsidised residential aged care.

The data, published in the Medical Journal of Australia, reveal 21% of residents received antipsychotic medication within the first three months of their stay. Of these, 46% had not been prescribed antipsychotics in the 12 months before entering care.

The study also showed 31% of residents were given benzodiazepines and 38% received antidepressants during the first three months of their stay. Of these, 39% and 20% respectively had not received those medicines in the year before going to residential care.

“Dispensing of psychotropic medicines increased markedly after entering residential aged care,” explains author Dr Janet Sluggett, Senior Research Fellow at the University of South Australia and Adjunct Research Fellow at Monash University.

“Psychotropics may be appropriate for some, but are often overused,” Dr Sluggett tells AJP.

“Our findings suggest management could be optimised in both community and residential aged care settings.”

Rapid rise in prescribing: ‘quite concerning’

Pharmacist Dr Juanita Breen, Senior Lecturer at the Wicking Dementia Research and Education Centre at the University of Tasmania, says the study provides “quality research that shows we need to focus attention on reducing psychotropic use in older people in the community setting as well as in aged care.”

“This research replicates findings in the USA and the UK which show that psychotropics are prescribed widely in the community as well, before people move into aged care homes,” says Dr Breen, who was not an author on the study but is considered an expert in the field.

“The rapid rise in prescribing after older people enter into care is also quite concerning.

“It speaks to an environment where medication is prescribed readily – especially prescribing of antipsychotics and antidepressants.”

Lead author Dr Stephanie Harrison points out that use of “chemical restraints” for people in residential aged care has been a key focus of the recent Royal Commission into Aged Care Quality and Safety.

“Antipsychotic medicines are associated with a higher risk of serious adverse events and should only be used in accordance with guidelines, at the lowest possible dose and with appropriate monitoring,” Dr Harrison says.

The role of pharmacists

Pharmacists can play a strong role in optimising use of psychotropic medicines as part of a team approach, argues Dr Sluggett.

She says pharmacists can contribute by:

  • providing regular education about non-pharmacological strategies and dementia-friendly environments,
  • providing advice on management of pain and other conditions,
  • conducting person-centred, comprehensive medication reviews, and
  • participating in psychotropic audit and feedback activities.

Residential medication management reviews (RMMRs) are “valuable” for identifying and resolving medicines-related problems, say the study authors, however it is unclear where every new RACF resident undergoes an RMMR.

Dr Breen says entry to care appears to be a key time to provide medication reviews.

“Also ideally pharmacists need to support community care providers and family caregivers by providing quality information about psychotropic use, about the often quite modest benefits they offer alongside the side effects that can result.

“Quality education about psychotropic use is needed for all caregivers in both the community and residential care settings,” says Dr Breen.

Pharmacists, as the medication experts, are best placed to provide this.

A recent report on medication safety and aged care by the PSA said that one-fifth of people living in aged care are on antipsychotics, and more than half use the medicine for too long.

“We need to do more for our older Australians living in residential aged care and those supported at home,” said PSA national president, Associate Professor Chris Freeman.

See the full MJA study here (open access)

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