1. Medication use in residential aged
care facilities

2. The patients

3. Who are our patients?
AIHW 2012

4. uk

6. 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

7. Their pills

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

9. Sydney nursing home medications
Snowdon et al Age Ageing 2006

10. Psychotropic use
Snowdon et al Int Psychoger 2011

11. Medications take lots of nursing time
Munyisia J Adv Nurs 2011

12. 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

13. The problems

14. 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

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

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

17. 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

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

19. The solutions

20. 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

21. Residential Medication Management Review RMMR
Nishtala et al JECP 2011

24. 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?

26. COCHRANE REVIEW 2013

27. 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

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

29. 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