Collaboration key to addressing overuse of medication in aged care

Today’s Royal Commission into Aged Care Quality and Safety preliminary hearing into the treatment of residential aged care facility (RACF) patients and whether they are being over medicated builds on new regulations set by the Government.
 
Federal Minister for Senior Australians and Aged Care Ken Wyatt announced new regulations in all RACFs to monitor the excessive use of restraints.
 
‘Incidents of overuse of physical and chemical restraint will not be tolerated and draft changes to regulations are expected to be released within weeks,’ Minister Wyatt said.
 
The Department of Health has provided all RACFs with a number of resources to assist in the quality use and safe management of medicines, including the Guiding principles for medication management in residential aged care facilities and the Decision-making tool: Supporting a restraint free environment in residential aged care.
 
The royal commission’s New Quality Standards for Better Aged Care – the first upgrade in 20 years – will come into effect on 1 July.
 
‘The use of antipsychotic medicines must be a clinical decision made by medical practitioners with the care recipient, and their carer or family involved at all times,’ Mr Wyatt said.
 
Dr Juanita Westbury is a senior lecturer in dementia at the University of Tasmania and researcher at Wicking Dementia Research and Education Centre with a PhD in addressing the over use of psychotropic medicine in RACFs.
 
She is all too familiar with RACFs dispensing large doses of medication.
 
As an accredited pharmacist doing medication reviews, Dr Westbury recalls one RACF asked for a pump pack to dispense medication, similar to the ones used to measure out exact doses of methadone.
 
‘These are pretty sophisticated pump packs,’ Dr Westbury told newsGP. ‘The home told me that everyone was on the same anti-psychotic medicine and that it would be much easier to just pump out the doses to them every morning.
 
‘I was horrified. That stayed with me for a long time, because I thought, surely that would be reserved for [those residents who have] dementia or aggressive behaviour.’
 
Dr Westbury has conducted research over the last decade to look at raising awareness and developing intervention strategies in Australian RACFs, following models similar to those in the UK and US, where mandatory reporting laws are in place to monitor medication doses.
 
Dementia Australia has been calling for that same reporting of rates for some time, Dr Westbury said.
 
‘Raising awareness [of medication use] was the first part of my research, because one thing that is very apparent here in Australia is that a lot of nursing homes don’t know how much medication they are using – there is no measurement,’ she said.
 
‘It’s all fine and good to highlight areas of difficulty, but the next step is to have a look at why, and to see if we can do something.’
 
The next step of Dr Westbury’s research was intervention, measuring how much medicine RACFs were using and presenting at staff training sessions along with comparisons to other facilities in the intervention study.
 
‘We were able to benchmark to show how much other homes were using as well,’ Dr Westbury said.
 
‘So [for example], we would tell them, “30% of your residents are taking anti-psychotics, but the average we are finding is about 22%”.
 
‘One of the things that was really apparent was that a lot of the [RACF] staff believed that the medication was very effective and they believed that it calmed and comforted, and was necessary to improve the quality of life of their residents.
 
‘That was the underlying belief; they are not trying to harm, they actually have a strong belief in medication and a lot of them believe that this medication helps.’
 
Dr Juanita Westbury’s research involved raising awareness of medication use in RACFs and implementing intervention strategies.  

Dr Westbury found that staff-intervention studies encouraged debate and opened up the discussion about use of medicines in RACFs and raised awareness, which she believes is a major part of why the program that stemmed from her research – the Reducing Use of Sedatives (RedUSe) – was so successful.
 
In addition to RACF staff training, individual assessment of residents and collaboration with nurses, GPs and pharmacists are integral to addressing and managing medications, according to Dr Westbury.
 
‘One of the last parts of my research was trying to get three people on the same page,’ she explained.
 
‘We got a pharmacist to give an evidence base of every person taking the medication and for how long and their condition. Then the nurse who was involved in the process would submit their notes on whether the patient was stable and whether they supported the process. Then that would go to the GP.
 
‘So the GP was informed by the nurse and the pharmacist.
 
‘We were told by the nursing homes that if you could get those three people in the same room, that would have a massive effect. With most people who were reviewed, the used of medications was reduced.’
 
Professor Dimity Pond, a GP with a special interest in dementia and aged care, also advocates for collaboration and places great importance on the GP’s role in supporting RACF residents.
 
‘GPs are vital in residential aged care,’ Professor Pond told newsGP.
 
‘We provide most of the medical services there, and with the decreasing level of training required for nurses – who are no longer required to be registered nurses in most places – there is an increasing need for this level of medical input.’
 
Professor Pond believes there is a need for more processes to streamline the way RACFs operate.
 
‘GPs should be able to work with registered or enrolled nurses who have enough background to understand what the GPs are trying to do,’ she said.
 
‘Ideally, the nurse should be available to come around with the GP, or at least discuss the patients they have seen. The nurse should also know why the GP has been called to see a particular patient and, if not, notes should be thoroughly documented.’
 
Dr Westbury recognises the pressures that RACF staff and GPs have regarding where onus lies for managing residents’ medications, and believes a large part of the issue can be addressed via partnership and education through intervention strategies like her research project.
 
‘I think this is such a significant problem, there isn’t a single fix – it’s complex and multifactorial,’ she said.  
 
‘Often it’s the [RACF] staff who are asking the doctors for the medication. So the people who need to be educated and have their beliefs influenced are the staff.
 
‘It is a complex issue but it needs people working together to deliver duty of care for the residents.’

aged care Aged Care Quality and Safety Commission dementia royal commission