Managing medication in aged care

These days, pharmaceuticals and aged care tend to go hand in hand, but with 95% of aged-care residents living with a medication-induced problem, the relationship is far from harmonious.

On average, aged-care residents consume 9.75 medications at any given time. More than half of these are believed to be inappropriate, or prescribed longer than necessary — many of them doing more harm than good. In fact, medication harm leads to hospitalisation for one in five people living in residential aged-care facilities (RACF).

Aside from the direct health impact, overmedication can cause psychological problems. Sedatives and antipsychotics are often used to restrain behaviour and help people with complex mental health issues co-exist. However, being sedated for the benefit of other staff and residents can impact quality of life for the individual.

As told in the Royal Commission Interim Report last year, overprescribed aged-care residents are often left “drowsy and unresponsive to visiting family”. With family members known to visit less when their perceived ‘return on time investment’ drops, this could have devastating consequences for the resident.

Many medications, particularly those used to manage dementia, may also accelerate cognitive decline or enhance symptoms like depression and apathy. Suicidal ideation is a well-documented side effect of treatments like mirtazapine, which are commonly prescribed to the elderly.

Pharmaceuticals are everywhere, but pharmacists are nowhere

Despite the pharmaceutical-intensive nature of aged care, pharmacists currently play a minimal role in the system. Often, prescribing decisions come from resident nurses or outsourced GPs that don’t know the residents intimately.

Additionally, the ongoing consumption of medications is rarely reviewed on a routine basis. This could mean that antibiotics are taken longer than necessary, predisposing residents to antibiotic resistance, or that drugs with harmful side effects are continued, despite better-suited alternatives.

Associate Professor Christopher Freeman of the Pharmaceutical Society of Australia (PSA) believes routine pharmacist intervention should become a regular fixture of the aged-care system. He recently made a submission to the Royal Commission calling for systemic change.

“I’d like to see pharmacists permanently embedded in residential aged-care facilities — almost like a resident pharmacist,” Associate Professor Freeman said.

“At the moment, the majority of prescribers in RACFs are GPs that work in general practice and consult with nurses on an ad hoc basis, rather than being there consistently.

“If pharmacists play a more central role — as part of a whole-of-team approach — they could provide personalised consultation on the initial supply and carry out routine assessments, say, every six weeks.

“They could also act as a clinical resource for problem-solving and decision-making, For example, if a patient is unable to swallow their slow-release medicine, the pharmacist could find an alternative way to administer the medication safely without dumping a high dose into the body all at once.

“Given that elderly people can be physically frail and tend to have a lot of accumulated medicines over their lifetime, it’s really important that regular reviews take place,” he added.

Pharmacists could also reverse the trend of retroactive problem-solving. Often, medication discrepancies are looked at in hindsight and then corrected — by which time harm is already done. With a more proactive approach, pharmacists, doctors and nurses could work together to prevent medication discrepancies happening from the outset.

No magic pill

Although the solution may seem clear, the reality is that, without addressing root causes like understaffing, aged-care workers may need to continue using sedatives to restrain residents.

Aged-care worker, Lisa Stewart* explains that inadequate support on the ground makes it challenging to manage complex mental health problems without medication.

“It can be really hard on residents and staff when, for example, there are people with varying degrees of dementia placed together in an aged-care facility. As much as we would like to give all of our time to provide psychosocial support and mediate challenging or distressing situations, it isn’t always possible to give residents the attention they need,” she said.

“Patients with advanced stages of dementia can at times become violent and aggressive, and without the right support and training it can be very hard to know how to manage these situations without medication. Although it might not be the best option for the individual, we also have to think about the safety and wellbeing of staff and residents.”

Relieving the high burden of care could pave the way for different forms of intervention, like de-escalation strategies, as and when conflict arises.

“As a last line resort, medication can be effective. But it is currently being used as a first line solution and it shouldn’t be,” Associate Professor Freeman said.

“There are lots of ways to manage mental health problems and it is now up to government to provide the right enabling environment for workers to enact those solutions.”

*Name changed for privacy.

Image credit: ©stock.adobe.com/au/perfectlab