Are young people in aged care being overprescribed?

Young people in aged care are on more medications and psychotropics than they have been in nearly a decade, and half of them are missing vital medication reviews that could improve their health outcomes.
 
GP consults are the most accessed MBS item for this group, so what role does general practice play in this situation?
 
The number of young people, under the age of 65, in aged care has decreased from around 6000 in 2019 to just 1900 at the end of September 2023.
 
On paper, it appears the Australian Government’s 2020 response to an interim report from the Royal Commission into Aged Care Quality and Safety is working – aiming to get young people out of aged care and into more appropriate, supportive accommodation.
 
But a recent report from the Australian Institute of Health and Welfare (AIHW), which followed 5600 younger people in aged care across 2020–21, has unveiled a somewhat different picture.
 
The Health Services Used by Younger People Living in Residential Aged Care report shows only 5.7% of young people during that period left residential aged care to live in other suitable accommodation, such as returning to their families or home.
 
In most cases (42%), they died in care, while another 40% turned 65 years old during that period.
 
The report also found increasing levels of antipsychotic prescriptions and polypharmacy could be a worrying indication of care quality, highlighting that GPs play a pivotal role in this prescribing.
 
GPs were the most frequent medical professional seen by this cohort, with an average of 25 consults in the year studied, and play ‘a central role in providing coordinated care’, the report states.
 
RACGP Expert Committee – Quality Care Deputy Chair, Associate Professor Paresh Dawda, a GP working in aged care, says he has seen two of his patients transition out of aged care and into disability group homes with some improvement.
 
‘Aged care is slowly improving but I think the connection between the disability care system and primary healthcare has got a longer way to go,’ he told newsGP.
 
‘All that said, [aged care homes] are not the right environment for younger people.
 
‘As a society, we’re letting young people with complex chronic care needs down by not having an alternative structure for them where they can be cared for.’
 
Associate Professor Dawda said the levels of prescriptions is constant across aged care, for both younger and older patients, and so the data is explainable in context.
 
‘By the very nature of young people living in residential aged care, there’s a level of complexity around their healthcare needs which may explain the polypharmacy,’ he said.
 
The most common health condition for young people in aged care is dementia, with one in three people experiencing the early onset condition, according to the AIHW report.
 
Other common causes for younger people to end up in these facilities are stroke, cancer, and brain injury.
 
The 2020–21 data analysed shows 52% of younger people living in residential aged care were dispensed nine or more different medications across the year at ATC level 5.
 
‘This underestimates the total number of medicines used, as over-the-counter medicines are not included,’ the report states.
 
It also highlights that more than nine prescriptions per person, also labelled polypharmacy, can be an indicator of poor health outcomes.
 
Based on National Integrated Health Services Information figures contained within the report, the number of antipsychotic prescriptions dispensed per person increased from 12 in 2015–16, to 15 in 2020–21.
 
‘People using multiple medicines are at higher risk of adverse drug events and a poorer quality of life,’ the AIHW report reads.
 
Professor Dimity Pond, a GP with a special interest in aged care, said GPs sometimes feel pushed to prescribe ‘instant-fix medication’ for behavioural issues that can be dealt with through other approaches, but are not practical due to staffing issues.
 
‘The whole sector is terribly understaffed,’ she told newsGP.
 
‘For example, I had a patient who had dementia that was crying on the ward because she was missing her husband.
 
‘She didn’t know why he wasn’t there, she was disturbing the other patients, and I was asked if I could please give her something – but that’s not the right thing to do for people with dementia.’
 
Professor Pond said instead, a nurse was called to come in and talk to the patient for five minutes every hour, resulting in improvements in her behaviour.
 
‘It worked and it was all documented,’ she said. ‘But they said they just didn’t have enough staff on the ward to keep doing that.’
 
Professor Pond said GPs and residential aged care facilities can use services like Dementia Support Australia, who can come in to provide advice and assistance.
 
However, the report also states medication reviews are not being conducted as recommended.

It found residential medication management reviews usually occur once every two years, or when a referrer believes another review is clinically necessary.
 
This can be due to a change in the person’s medical condition, following a hospitalisation or when the person first enters residential aged care.
 
Of the 5600 younger people in aged care, 52% had their medication reviewed in the two-year period from 2019–21.
 
Aboriginal and Torres Strait Islander patients were even less likely to have been reviewed, with only 39% getting their medication checked.
 
‘All circumstances that indicate a medication management review could be helpful,’ the report states.
 
‘Of those entering residential aged care, less than one in four (23%) had a medication management review in the same year.
 
‘It is likely that a medication management review in the previous two years would have been helpful for more than one in two younger people reported here.’
 
Associate Professor Dawda said there are a ‘lot of factors’ behind why these reviews are not happening.
 
‘One of them may be a cultural thing, so people aren’t thinking about it,’ he said.
 
‘But some of them are workforce related.’
 
He said the report emphasised that GPs need to recognise the opportunities to improve patient care in terms of checking and referring reviews.
 
‘General practice can work to improve the quality of care despite the systematic problems, which [it] seems to do in lots of places,’ he said.
 
‘GPs will often advocate for patients and whilst there’s a reality, which is far from ideal, this is another example of one of those places where we can take the bull by the horns and improve what’s within our circle of influence, despite the system barriers.’
 
Professor Pond said although she loves working in aged care, the challenges, and lack of renumeration for the kinds of non-patient-facing work needed to address these issues, has left her questioning whether to leave the industry.
 
‘It’s very tricky, it’s a unique problem,’ she said.
 
‘It’s really sad.’
 
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