Potential interactions in aged care

Potential interactions between health service and medicine use in residential aged care

People living in permanent residential aged care are often frail older people with complex care needs who require not only basic assistance with mobility or eating, but also nursing care through health care procedures and medicine management. Many everyday living supports, nursing care and allied health services are expected to be provided routinely in residential aged care. In addition, people often require other health services, such as those provided by GPs and specialists. Use of multiple medicines is also common (AIHW 2019; Elliott & Woodward 2011; Morin et al. 2016; Poudel et al. 2015; Roughead et al. 2008) and use of certain medicines has been shown to increase after people move into residential aged care (Harrison et al. 2020a, 2020b).

Access to care and services is influenced by the workforce available within residential aged care; the interaction aged care has with health services; and the availability of health care professionals in the local area, as well as health care provision, prescribing practices and medicine regimes within facilities (Harrison et al. 2019; Hillen et al. 2016; Somers et al. 2010; Westbury et al. 2018b). The change in living setting itself may be associated with changes in how people access health services.

Residential aged care facilities have difficulty attracting and retaining health care professionals (Eagar et al. 2019; RCACQS 2019a). The staffing profile in residential aged care has changed in the last 12 years: the number of personal care attendants increased by 169% between 2003 and 2016, while the number of registered nurses increased by only 23%. Over the same time period, the number of people living in permanent residential aged care increased by 25% (GEN 2020b; Mavromaras et al. 2017). Personal care attendants can provide some basic nursing care but are not qualified nurses. While some facilities may employ other types of workers, such as allied health staff, access to allied health and dental care in residential aged care is often limited (Hearn & Slack-Smith 2014; Mavromaras et al. 2017).

Regular consultations with a GP can help people transition into residential aged care. GPs assess people’s medical and functional needs comprehensively and plan for their current and future needs, as well as providing a point of liaison between specialists, allied health services and residential aged-care staff (RACGP 2020). But, in practice, GPs may have limited time available to visit a facility or may only be able to do so at less optimal times, such as after-hours (Gadzhanova & Reed 2007; Hillen et al. 2016; Pearson et al. 2018). People can also leave a facility to attend a GP at a practice, but frailty and medical complexity may make this difficult.

Regular and timely access to GPs can improve not only the interactions health care professionals have with each person and their representatives, and their ability to fully assess people’s care needs, but also the interactions between various health care professionals (Hillen et al. 2016; RACGP 2020). Whether this is coordinated or happens by chance, collaboration is important to planning for people’s care needs (Harrison et al. 2019; RACGP 2020)—particularly as direct access to certain health care professionals, such as specialists, is relatively rare for people living in permanent residential aged care (AIHW 2019).

GPs also play a central role in prescribing medicines for older people in residential aged care and access to medicines can be relatively straightforward in these settings. For example, where facilities use National Residential Medication Chart (NRMC)-compliant systems to record the ordering and administration of medicines, pharmacies are able to dispense the medicines directly from information on a person’s medicine chart without the need for a traditional paper prescription. This also allows the pharmacy to make streamlined PBS claims (ACSQHC 2014).

There has been considerable interest in how medicines are used within residential aged care. Most recently, in delivering its October 2019 interim report, the Royal Commission into Aged Care Quality and Safety (RCACQS) highlighted issues around the aged-care workforce and potentially problematic use of certain medicines. It recommended immediate action to reduce the use of antipsychotic medicines as a chemical restraint (that is, the use of medicines to influence people’s behaviour, other than medicines prescribed for relevant health conditions) (RCACQS 2019a, 2019b).

Specific legal requirements were already in place for providers regarding physical and chemical restraint, as part of the quality standards for residential aged care (ACQSC 2019; Quality of Care Principles 2014). From 1 July 2019, the Quality of Care Amendment (Reviewing Restraints Principles) 2019 further amended the Quality of Care Principles 2014 to state that chemical restraint should only be used as a last resort.

In general, medicines that act on the central nervous system have been of particular interest due to their effects on older people, and many are prescribed at high rates in residential aged care (AIHW 2019; Harrison et al. 2019; Morin et al. 2016; Westbury et al. 2018b). Medicines that act on the central nervous system are a broad group within the Anatomical Therapeutic Chemical (ATC) Classification System, and this group covers many different types of medicines that have an effect on the brain or spinal cord. These medicines can be taken for different reasons, such as to reduce fever, suppress nausea or relieve pain, or to manage particular health conditions and their symptoms (this group includes many common treatments for mental health and neurological conditions).

Certain medicines within this group are problematic for older people as the risks of harm increase with increasing age, frailty and medical complexity (AGS 2019; Elliott & Woodward 2011; O’Mahony et al. 2015; Box 7.3). In particular, anti-dementia, antidepressant, antipsychotic, benzodiazepine and opioid medicines are all associated with dizziness or drowsiness and this brings an increased risk of falls (AGS 2019; Cox et al. 2016; Epstein et al. 2014; Fraser et al. 2015; O’Mahony et al. 2015). Partly as a consequence of this, many of these medicines are also associated with other adverse health outcomes, such as fractures and hospitalisations, as well as being associated with an increased risk of death—they also commonly interact with other medicines and health conditions (AGS 2019; O’Mahony et al. 2015; Shash et al. 2016).

At any time, around half of people living in permanent residential aged care have diagnosed dementia (GEN 2020c), and many others live with other similar degenerative illnesses or may have undiagnosed dementia. (See ‘Dementia’ for more information.) The behavioural and psychological symptoms of dementia (BPSD) are varied, but can include sleep disturbances, depression, disruptive behaviours and agitation or aggression (see glossary). Some degree of BPSD is experienced by most people with dementia (RANZCP 2016). BPSD may reflect stress, unmet need or pain (and the inability to communicate these clearly) or it may relate to the biological neurodegenerative processes of the dementia itself (Arvanitakis et al. 2019; RACGP 2020).

Instead of pharmacological treatments such as antipsychotics, the recommended primary approaches for addressing BPSD are one-on-one care; individualised behavioural management; and occupational therapy strategies (ACSQHC 2018; Arvanitakis et al. 2019; GAC 2016; Marx et al. 2017; RACGP 2020; RANZCP 2016; Westaway et al. 2018). Targeted interventions that address the prescribing culture within facilities, particularly through education and interdisciplinary involvement, have been shown to reduce reliance on medicines and to improve care (Harrison et al. 2019; McDerby et al. 2018; Poudel et al. 2015; Westbury et al. 2018a).

Considered against the background of frailty and medical complexity, the health care provided to people living in permanent residential aged care and the prescribing practices within it become increasingly crucial. This chapter examines access to GPs and specialists through the Medicare scheme, and PBS-reimbursed prescriptions dispensed for selected medicines in the 6 months before and after people first enter permanent residential aged care. In addition to looking at these broad patterns, the chapter also looks at people who were ‘new users’ of these medicines, to examine when anti-dementia, antidepressant, antipsychotic, benzodiazepine and opioid medicines were initiated.