Quality Use of Medicines in Residential Aged Care
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RESEARCH Quality use of medicines in Michael Somers residential aged care Ella Rose Dasha Simmonds Claire Whitelaw Janine Calver Christopher Beer Background Approximately 190 000 people in high risk of ADEs in frail older people. For example, Older people are more likely to be Australia were estimated to have anticholinergic drugs commonly produce adverse exposed to polypharmacy. People dementia in 2006, with the prevalence effects in elderly people and are more likely to be with dementia, especially those living expected to increase to 465 000 by 2031.1 prescribed to people with dementia than those in residential aged care facilities The prevalence of dementia increases without.7 (RACFs), are at particularly high risk of with age, from 6.5% of Australians aged Antipsychotic medications are commonly used medication harm. We sought to describe medications prescribed for a sample of 65 years and over to 22% of Australians to manage the behavioural and psychological 2 people with dementia living in RACFs. aged 85 years and over. Dementia is symptoms of dementia (BPSD), such as associated with a large burden of disease psychosis, depression, agitation, aggression Methods in Australia’s aging population, costing and disinhibition.1,8 There is concern that A total of 351 residents with dementia Australia $1.4 billion in 2003.2 Most of this antipsychotics are used too frequently as a aged over 65 years were recruited from 36 RACFs in Western Australia. burden was associated with residential first line treatment for BPSD, with the risks of 2 Data on all medications prescribed aged care facilities (RACFs). Dementia antipsychotic use outweighing the benefits at their were collected, including conventional is the medical problem most frequently likely level of use.8 For example, risperidone, an medications, herbal medications, managed by general practitioners atypical antipsychotic prescribed frequently for the vitamins and minerals. attending RACFs.3 Ninety-six percent treatment of aggression, has been associated with 9 Results of people with dementia living in care increased risk of cerebrovascular adverse events. Polypharmacy was identified in accommodation in Australia have Recognised experts in clinical geriatric 91.2% (average 9.75 medications per moderate or severe dementia, compared care, clinical geriatric pharmacology, person); one-third were prescribed an to only 7% of people with dementia living pharmacoepidemiology and psychopharmacology antipsychotic medication; and 50.4% in households.1 Therefore people requiring have established the ‘Beers Criteria’, a list of were found to be taking at least one residential care tend to be among the potentially inappropriate medications (PIMs).10,11 potentially inappropriate medication. frailest and sickest in the community, This list was created using a consensus method, The combination of antipsychotics and with substantial physical and behavioural based on an extensive literature review and antidepressants was the most frequently needs and multiple comorbidities. questionnaire.10,11 The Beers Criteria identifies observed drug-drug interaction, being medications that should be avoided altogether, prescribed to 15.7% of participants. Polypharmacy, defined as the concurrent use of five as well as doses, frequencies and duration of Discussion or more medications, can result in an increased other medications that should be avoided in People with dementia living in RACFs are risk of drug-drug interactions (DDIs) and adverse the elderly.10,11 These medications have been commonly exposed to polypharmacy. drug events (ADEs).4 People with dementia are identified as being associated with higher medical Prescription of contraindicated at a higher risk of polypharmacy, with greater costs, increased rates of ADEs and poorer health medications, antipsychotics, medications increased risk as the disease progresses.5 A study outcomes.10,11 with high anticholinergic burden, and combinations of potentially inappropriate of Victorian RACFs found that one-third of drug A considerable number of people in RACFs mediations is also common. There related problems are caused by overprescribing, are exposed to dangerous DDIs, with one study may be substantial scope to improve including unnecessary drugs, duplication of therapy demonstrating that 60.2% of elderly inpatients were prescribing for older people with or inappropriate duration.6 Other causes of drug prescribed potential DDIs.7 The study participants dementia living in RACFs. related problems included dosing errors, suboptimal were most likely to be exposed to DDIs involving 6 Keywords: dementia; polypharmacy; drug monitoring, and underprescribing. Certain psychotropic medications, notably antipsychotics adverse effects classes of drugs are particularly associated with a with antidepressants, which can cause further Reprinted from AUstraLiaN FamiLY PHYsiciaN VOL. 39, No. 6, JUNE 2010 413 RESEARCH Quality use of medicines in residential aged care cognitive deterioration.7 The scope of potential DDIs, and antipsychotic and PIM use in Australia 11 736 165 has only been studied to a limited extent. Potential participants Did not meet criteria Australia’s National Medicines Policy highlights quality use of medicines as a central objective and the Australian Commission on 79 Safety and Quality in Health Care has been 571 Refused participation established to, in part, promote quality use of medicines.12 Despite this, the problem of ADEs persists.12 Prescribing to elderly people 141 is complicated by several factors including 492 Did not participate for changing pharmacokinetics with age, increased other reasons (eg. deceased, likelihood of multiple comorbidities, the need relocated, consent not obtained from next of kin) for polypharmacy to address these conditions, 351 and poor communication between health Eligible and willing to professionals.12–15 This results in an increased participate Figure 1. Participant recruitment likelihood of practitioners failing to adjust medication doses in the elderly, and to monitor and review their medications.12 Consequently, the participants were prescribed at the time of Research Ethics Committee of the University of medications can be used at incorrect doses, data collection, either as a regular or pro re nata Western Australia. for longer durations than clinically indicated, (PRN or ‘as required’) medication. Data on all when they are ineffective, and when an equally medications was collected, including conventional Results effective but safer alternative is available.12 medications as well as herbal medications, Of the 351 participants in the study, the mean This study aimed to describe the patterns of vitamins and minerals. age was 85.24 (SD: 7.87); 75.4% were female. prescribing for a sample of older people with The drug data was cleaned by removing The mean MMSE score was 12.50 (SD: 7.61). dementia living in RACFs, including: items that were not medications (eg. hearing Polypharmacy was identified in 320 • number of medications prescribed aid), removing duplicate drugs, correcting participants (91.2%). The number of medications • extent of psycholeptic use spelling errors, converting all drugs to generic taken by each participant ranged from 1 to 21 • use of potentially inappropriate medications names, and coding all drugs using the World (mean: 9.75, SD: 3.88). • drug-drug interactions Health Organization Anatomical, Therapeutic, One-hundred and seventeen (33.3%) of • anticholinergic burden. and Chemical (ATC) Classification System.16 the study participants were prescribed an The number of drugs was counted, with antipsychotic, with nine of these 117 being Methods polypharmacy defined as five or more drugs. The prescribed two antipsychotic medications A total of 351 people were included in the study number of psycholeptic (ATC code N05, including (Table 2). Risperidone, prescribed to 55 study (Figure 1). Inclusion criteria were: resident of a antipsychotics [N05A], anxiolytics [N05B] and participants, was the most commonly used Western Australian RACF; recorded diagnosis of hypnotics/sedatives [N05C]) and antidepressants antipsychotic. Other commonly prescribed dementia; age over 65 years; Mini-Mental State (N06A) were also counted. The modified Beers antipsychotics were quetiapine (prescribed to 22 Examination (MMSE) score of <24. Residents were Criteria were used to define PIMs (Table 1).10 participants), olanzapine (17 participants), and excluded if the facility staff identified them as A list of potential DDIs was compiled using haloperidol (15 participants). being acutely medically unstable or suffering from previously published data.7,17 The anticholinergic Fifty-five (15.7%) study participants were delirium, or in the terminal stages of dementia or a drug scale was used to determine anticholinergic prescribed a combination of antipsychotics and comorbid illness. burden.18,19 Using the scale, each medicine antidepressants. Consent for trial participation was sought was rated on a scale from 0–3 according to Potentially inappropriate medications were from the participant if able to give consent. their anticholinergic activity, with a rating of prescribed to 177 participants (50.4%). Of these Agreement for trial participation was also sought 0 indicating no anticholinergic potential and 3 participants, 115 (32.8%) were taking one from residents’ surrogates (next of kin or other indicating marked anticholinergic potential,18 and potentially inappropriate medication, 55 (15.7%) identified proxy) and the GP.