‘Too often, for too long, at doses too high and in dangerous combinations.’

elderly couple silhouette made from pills

Pharmacists have created a tool to help diagnose problematic aspects of organisational culture that contribute to psychotropic prescribing in aged care

While the ABC’s Four Corners reveals the second part of its investigation into the failings of residential aged care, a group of pharmacists have come up with an idea which could help.

Last week, the program released a report, Who Cares? which identified that among other significant problems, aged care residents were being given antipsychotics and sedatives inappropriately as a first-line approach to managing their behaviour.

Organisation culture was described as a significant contributor to this and other failings.

But Mouna Sawan and Timothy F Chen from the University of Sydney School of Pharmacy, and Yun-Hee Jeon from the University from the University of Sydney Susan Wakil School of Nursing and Midwifery, are already investigating the problem.

They have written a paper, Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool. A development and content validation study, investigating the issue.

“Psychotropic medicines are continually being used in Residential Aged Care Facilities despite the marginal benefits and increased risk of adverse effects in residents,” says Dr Sawan, a consultant pharmacist and postdoctoral research associate at the Cognitive Decline Partnership Centre, the University of Sydney.

“Psychotropic medicines are not a first-line treatment option in the management of behavioural and psychological symptoms of dementia and should only be considered when non-pharmacological approaches fail.

“Also, psychotropics medicines are recommended to be reviewed, and a trial withdrawal commenced after a certain period.

“However, there is a gap between guidelines for the appropriate use of psychotropic medicines and actual practice. We use them too often, for too long, at doses too high and in dangerous combinations with other medications.”

This prescribing can have a significant effect on aged care residents, she told the AJP, who often have multiple morbidities, are susceptible to geriatric syndromes and take multiple medicines – on average, seven per resident.

“Together, these factors place residents at high risk of adverse events from psychotropic medicines such as sedation, deterioration in cognition and falls,” Dr Sawan says.

“A class of psychotropic medicines which raise particular concern for their harmful effects in residents are antipsychotic medicines.

“Atypical antipsychotic medicines are associated with a 1.5-fold increase in mortality. The causes of death appear to be due to cardiovascular (stroke, heart failure) and infectious (pneumonia) diseases.”

The PRACTICE tool uses a well-known existing theoretical framework of culture for stakeholders, so that they can identify aspects of organizational culture which need improvement in order to reduce psychotropic prescribing.

“Our tool will help RACFs diagnose aspects of culture which are not ideal and could be improved, which if addressed there will be positive spin-off effects on appropriate psychotropic medicines use, as well as other medicines,” Dr Sawan told the AJP.

Organisational culture is the frame by which staff manage perceptions about their work environment—such as limited staffing, their workload, inadequate training and/or inter-disciplinary conflict—and how psychotropic medicines are ideally prescribed.

“In residential aged care facilities, the prescribing of antipsychotics is a result of combined efforts between the on-site staff (managers, nurses and nursing assistants) and visiting staff (general practitioner, specialists, nurse practitioners and pharmacists),” Dr Sawan says.

“RACFs with a negative culture struggled to cease antipsychotics medicines in residents due to staff perceptions of limited resources, increased workload and inter-disciplinary conflict.

“In other RACFs, a positive culture created by managers who coordinated multi-disciplinary teamwork among all members and reinforced goals for the optimisation of medications led to the reduced preferences for antipsychotics among all members.

“For this reason, all stakeholders (nursing home managers, industry leaders, policy makers, clinicians) have an equal responsibility to address factors which contribute to psychotropic prescribing, including the culture of aged care homes.”

She cited their previous qualitative study examining the link between organisational climate and psychotropic use.

She says many stakeholders have an interest in meeting the challenge of appropriately using psychotropic medicines, and that everyone can contribute, including pharmacists.

“All stakeholders including nursing home managers, industry leaders, policy makers, clinicians need to take practical steps to improve the culture of psychotropic prescribing. Approaches to improving the culture should be multi-pronged, multi-disciplinary, patient focused and an ongoing effort.

“The combination of all the elements necessary for culture change will bring about a dramatic reduction in psychotropic prescribing

“Interventions to reduce psychotropic medicines, such as the RMMR, are working but not to maximum effect due to multifactorial influences, including organisational culture,” Dr Sawan says.

“Evaluating and measuring organisational culture is a significant part of the solution as it is the overarching theme for how interventions are implemented in any organisation, including RACFs.

“For any intervention to be successful, it requires a right positive culture. The assessment of organisational culture can identify how RACFs adopt interventions and do it better.”

Further reading:

Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool©. A development and content validation study

Exploring the link between organizational climate and the use of psychotropic medicines in nursing homes: A qualitative study

Shaping the use of psychotropic medicines in nursing homes: A qualitative study on organisational culture

A qualitative study exploring visible components of organizational culture: what influences the use of psychotropic medicines in nursing homes?


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