Engaging pharmacists in geriatric medicine in hospitals and elderly care facilities will help reduce the high rates of unplanned drug-related hospitalizations in Australia, according to a prominent advocate.
Kristin Michaels of the Society for Hospital Pharmacists of Australia writes below that it is high time to support this specialized and targeted care.
Kristin Michaels writes:
Medication errors have a huge impact on our health and well-being. Having a disproportionate impact on older Australians, medication errors account for around 20-30% of all hospital admissions among people aged 65 and over.
After the damning testimony of Royal Commission on the Quality and Safety of Elderly Care, the worthy recommendations of its Final Report: Care, Dignity and Respect highlighted the need for greater involvement of pharmacists in the clinical management of drugs.
What follows five priorities for reducing the risk of drug-related harm in older Australians provide an action plan, supporting Quality use of medicines and safety of medicines, which was declared in 2019 as Australia’s 10th National Priority Health Area.
1. Pharmacists in Geriatric Medicine
Medicines are essential in the treatment of chronic health problems in the elderly and, when used safely, are effective and improve health outcomes and quality of life.
However, studies indicate that 20 percent of all drugs used in older Australians are potentially inappropriate. Importantly, up to 30 percent of hospital admissions for the elderly are drug-related, and about half of them are preventable.
If over-prescribed, poorly monitored, or poorly managed, drugs can cause or worsen common geriatric syndromes and symptoms such as dementia, delirium and incontinence, and increase the risk of falls.
As pointed out in Care, dignity and respect, pharmacists are essential in providing medication management services, and geriatric medicine pharmacists are uniquely qualified to manage the more complex medication and treatment needs of older Australians.
Their expertise includes adapting care to the decline in physiological reserve and resilience; define different goals of care, in particular for frail people; and the treatment of limited evidence on the effectiveness of drugs, as the elderly are often excluded from clinical trials.
To fully utilize pharmacists in geriatric medicine in the prevention of hospitalizations (or rehospitalizations) and harm, they must:
- Integrated into hospital medical teams to support fast and responsive prescribing and deprescribing decisions;
- In place to facilitate safer care transitions upon discharge; and
- Integrated, on-site, into all senior care facilities to ensure equity of access to essential pharmaceutical services (including regular medication reviews and medication optimization for residents in senior care ).
Courses of action:
- Specifically recognizing medication management services as a need of residents of elderly care facilities under the Australian National Classification of Care for the Elderly (AN-ACC) funding model of the Australian Government;
- Dedicated funding for these geriatric medicine pharmacist positions and services by state and federal governments (this could potentially be incorporated into senior care packages and home care packages}; and
- Legislate on the minimum ratios of pharmacists in geriatric medicine / residents in care of the elderly; the Society of Hospital Pharmacists of Australia (SHPA) and the Pharmaceutical Society of Australia (PSA) support at least 1 FTE pharmacist per 200 residents.
2. Expanded care teams
As discovered by Royal Commission on the Quality and Safety of Elderly Care, the elderly are most vulnerable when traveling between hospitals and care facilities for the elderly. Amidst the logistics, paperwork and emotion, there is an urgent need for a multidisciplinary care team to surround each individual and their family.
The geriatric pharmacist must be part of these teams – whether the care is provided in an institution or at home – to ensure better care for the elderly while requiring less hospital emergencies.
Course of action:
The Australian government should work with state and territory governments to develop a model of outreach geriatric service and funding and a multidisciplinary approach that includes pharmacists, which aims to prevent preventable hospitalizations for older Australians.
3. Interim drug administration tables
Patients discharged from nursing homes are prescribed an average of 11 drugs, including 7 new or modified during their hospital stay. Up to 23 percent of these patients experience delays or errors in receiving this new drug regimen after their care transition.
Sometimes elderly care residents returning from hospital are given medication according to their old medication schedule (which may have caused the hospital admission in the first place).
The Interim Medication Administration Table is a key document that must accompany the patient to their senior care facility.
- Is filled in with patient details and discharge medication information, usually completed and signed by the hospital pharmacist;
- Help ensure medications are administered safely immediately upon arrival at the facility; and
- Fills in the information gap while the patient’s GP prepares a long-term care medication chart (which can take up to seven days).
Course of action:
- Elderly care standards and guidelines should reflect the need to use interim medication schedules for the elderly transitioning from hospital to elderly care facilities to ensure timely and safe access drugs.
- Provide training to physicians, pharmacists and nurses to increase uptake and use of interim medication schedules.
4. Sort psychotropic drugs
Psychotropic drugs affect our mind, behavior and emotions, and are recognized as high-risk drugs by the Australian Commission for the Safety and Quality of Health Care.
Unfortunately, the inappropriate use of antipsychotic drugs in the elderly is common. Care, dignity and respect identified overreliance on antipsychotics as a chemical restraint in the so-called “care” of the elderly in elderly care, and the subsequent recommendation to restrict the use of these drugs was supported by the Australian government.
This is another area where the skills and experience of hospital pharmacists can be best used, just as pharmacists specializing in geriatric medicine can:
- Lead or shape psychotropic drug management programs, a proven and effective drug governance strategy to prevent inappropriate use and reduce the risk of harm associated with psychotropic drugs;
- To determine if the prescribing of psychotropic drugs is appropriate and in accordance with clinical practice guidelines;
- Determine whether antipsychotic drugs are used for therapeutic or chemical restraint purposes, as part of facility-wide audits; and
- Identify quit dates or determine a de-escalation plan to prevent unnecessary long-term use of psychotropic drugs.
The course of action is simple: generalized integration of pharmacists in geriatric medicine in all settings where the elderly receive care.
5. Comprehensive care of the person
As in all areas of health, prevention is better than cure.
Although medication-related issues are very common in older people preparing to enter a retirement home, multidisciplinary teams that assess care needs and eligibility for eldercare services typically do not include a pharmacist. .
As recommended by Care, dignity and respect, older people should have better access to medication reviews that are performed upon entering senior care facilities, and repeated annually or more often if there has been a significant change in their condition or medication regimen.
The inclusion of a geriatric pharmacist in the Elderly Care Assessment Teams (ACAT) will ensure:
- People with drug-related problems or at high risk of drug-related harms are identified; and
- Appropriate services are in place to reduce damage, improve independence, and prevent decline in health, function and well-being.
The clearest course of action is once again simple: dedicated funding by state governments so that these positions are integrated into ACAT teams.
Now that we are equipped with overwhelming evidence, it is time to act.
The shocking testimony of the Royal Commission on the Care of the Elderly underscored with stark clarity the need for new strategies to ensure that older Australians are taking the right medicine, at the right time and in the right way.
These five measures identified by the SHPA Geriatric Medicine Leadership Committee will ensure that specialized and targeted care is readily available to improve the health and well-being of this vulnerable cohort of Australians, while aligning with recommendations 38, 58 and 65 of the Final report of the Royal Commission.
It is more than good policy – it is the right thing to do, and it is long overdue.
Kristin Michaels is CEO of the Society for Hospital Pharmacists of Australia.
Read more about Croakeystories about caring for the elderly.
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