‘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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  1. Debbie Rigby

    Thought-provoking articles, thanks. I’m wondering if Mouna or Tim can give some practical ideas on implementation for pharmacists doing QUM services in RACFs. The scope of QUM services by community and accredited pharmacists varies considerably, from tidying cupboards to complex interventions such as described here.

    The 4Corners series has raised awareness of inappropriate use of psychotropic medicines, especially for BPSD. Pharmacists conducting RMMRs and QUM services have a real opportunity and responsibility to improve this, but little guidance or support is provided by pharmacy organisations.

    • Mouna Sawan

      Thank you for your comment Debbie.
      Our team has been conducting research and engaged clinical service delivery in RACF for over a decade. As reported, in our recent published studies we have conducted in-depth qualitative evaluations of the influence of culture on practices within RACF. Specifically, we have sought to understand how and why the effectiveness of interventions which are designed to optimise the use of psychotropic medicines in RACF, may vary across different facilities. Hence our investigation into culture. Our research has shown that some RACFs used QUM interventions for their intended clinical purpose/s whilst others used these services more as a ‘box ticking exercise’. This played a significant role in whether QUM interventions such as RMMR were effective or not in achieving the quality use of medicines. Hence our studies are explanatory in nature. Given the variation, as a practical starting point, it is important to outline in RACFs standards and policies, how RMMRs and other QUM activities need to be operationalised to enhance their adoption and improve outcomes. For example, do MAC meetings include discussion on the level of psychotropic medicines prescribed in the RACFs? Are they attended by various health professionals that are representative of both on-site and visiting staff? Are RMMRs initiated by on-site staff when there is a concern with residents experiencing adverse drug reactions or used by RACF on-site staff to highlight to GP the need to review medications? A more holistic approach is to attain RACF managerial support for QUM and its successful adoption in RACFs. Managers are essential for creating connections among health professionals and reinforcing priorities among both staff and GPs, which is important for successful implementation of QUM.
      Mouna & Tim.

  2. juanita westbury

    I was the pharmacist interviewed for the four corners program. I have been researching psychotropic use in aged care homes for over 15 years and the university of Tasmania has been funded over $3.4M to address inappropriate use in a program called RedUSe (reducing use of sedatives). The Guild actually administered the first grant for the RedUSe program for $149,000 as a 4CPA investigator initiator grant. RedUSe has been recognised by two international awards, a NPSMedicinewise award and funded $3M for expansion to all 6 states and the ACT during 2014-2016.

    Organisational culture is a big part of this – YES – but other qualitative research has also shown that most staff who request antipsychotics and other sedating medications (benzodiazepines, mirtazapine, carbamazepine etc etc – lets not forget the substitute practice..) believe that they are providing comfort and relieving distress for residents. Staff and medical practitioners (also pharmacists because I’ve interviewed them for 12 years) also believe that adverse effects (falls, strokes, infections etc) are minimal or even overblown.

    Effective behaviour change (in this case reduction of psychotropic rates of use – both regular and prn) can only be achieved by challenging these types of beliefs. One way to do this is through interactive education, awareness raising (audits and benchmarking) and collaboration where key prescribing influencers (ie. CARE STAFF, GPs and pharmacists) meet and review psychotropic use.

    Influencing overall organisation culture and understanding its influence is part of the solution – but extremely difficult to alter especially by pharmacists (is there evidence of the tool’s impact on use?). Unless you educate and challenge the beliefs of the staff working on the floor and provide a structured approach to reduce psychotropic use there will be little change. Pharmacist-led QUM strategies of nurse education, audits and targeted review have been the only demonstrated effective intervention to reduce antipsychotics and benzodiazepine use in Australia. QUM works (MJA – RedUSe: https://www.mja.com.au/system/files/issues/208_09/10.5694mja17.00857.pdf).

    The 4CPA, 5CPA and 6CPA QUM program came about to address psychotropic use in nursing homes. Let’s actually use these services effectively to reduce the inappropriate use of antipsychotics (and their substitutes) and take the professional lead in this issue.

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