Medication use in residential aged care facilities

The patients

Who are our patients? AIHW 2012

uk

What does this mean for medications? 60% dementia <2-3 yr life expectancy 4-6 comorbidities 25% hospitalized pa Sedatives, anticholinergics End of life vs preventative Polypharmacy Reconciliation, errors

Their pills

What medications do they take? No medications <1% Snowdon et al Age Ageing 2006

Sydney nursing home medications Snowdon et al Age Ageing 2006

Psychotropic use Snowdon et al Int Psychoger 2011

Medications take lots of nursing time Munyisia J Adv Nurs 2011

What is appropriate? If dramatic increase in use of oxycodone in very elderly is for pain then appropriate, if for sedation is inappropriate Bennet et al BJCP 2013

The problems

Some problems related to medications Adverse effects of polypharmacy Cognition, behaviour, falls, mortality, QOL Cost $1→$1.33 Human rights issues and autonomy Appropriate vs inappropriate use Antibiotics and resistant microorganisms

Polypharmacy and CHAMP: risk per additional medication * and remained highly significant with multivariate analysis Gnjidic et al JCE 2012

Five is a reasonable definition of polypharmacy… and is the norm

10% of hip fractures in Australia are attributable to benzodiazepines Falls and fractures 10% of hip fractures in Australia are attributable to benzodiazepines Cummings Le Couteur CNS Drugs 2003

Antipsychotics in BPSD/dementia: death, strokes, falls, pneumonia Lon Schneider JAMA 2005 Meta-analysis Risk of death 1.65 (1.19-2.29) (pneumonia, stroke)

The solutions

Changing approaches to medications in RACFs Staff turnover rapid Access to GPs often difficult (and specialists, impossible!) Increasing roles Pharmacists Nurse practitioners Government and professional bodies

Residential Medication Management Review RMMR Nishtala et al JECP 2011

Do we still have the right to die as people rather than patients? The Silverbook Do we still have the right to die as people rather than patients?

COCHRANE REVIEW 2013

Polypharmacy Physical function, cognition, falls, institutionalization, hospitalization and death Independent of underlying comorbidities Deprescribing can be considered when Adverse effects No efficacy Change in treatment goals (palliative care, frailty, dementia) DEPRESCRIBING IS A POSITIVE INTERVENTION TO IMPROVE QUALITY OF LIFE, FUNCTION, COGNITION, BEHAVIOUR AND IN MANY CASES, MORTALITY Aust Presc 2011 Reeves JAGS 2013

a single cost-saving intervention that will prevent multiple diseases in older people

Thank you and acknowledgements Prof Andrew McLachlan A/Prof Vasi Naganathan A/Prof Sarah Hilmer Dr Danijela Gnjidic Advocates Margot O’Neill Rodney Lewis Dr Helen Creasey