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A strategy for polypharmacy: six tactics to consider

The harms of polypharmacy in residential aged care are well known, but how can they be managed?

Polypharmacy is a hot topic, as it is highly prevalent and well known to contribute to a range of harms, including adverse drug reactions and hospitalisations. In the residential aged care setting, up to 74 per cent of residents regularly take nine or more medications. It is important to note that polypharmacy is not always inappropriate and may often be necessary, particularly to manage multimorbidity. Each medication should be assessed for its overall risk and benefit with consideration for individual goals of care and predicted life expectancy.

Although much is known about polypharmacy and its harms, little is known about what strategies are needed to effectively manage polypharmacy. A study, funded by the Victorian Department of Health and Human Services, was conducted to identify what interventions might be required to manage polypharmacy in residential aged care services (RACS). A sample of 19 clinicians, researchers, managers and representatives of consumer, professional and health policy organisations were invited to participate in two structured discussion groups. Sixteen potential interventions were identified, six of which were prioritised highest for potential implementation.

Polypharmacy is a major concern in aged care: Natali Jokanovic.

  1. Pharmacist-led medication reconciliation service for new residents.

A resident entering RACS typically receives a new general practitioner (GP) who often does not have access to the resident’s complete medication history. This poses potential problems as medications whose original indications are unclear, and may no longer be appropriate, may be left unreviewed.

The service proposed would target new residents and involve a pharmacist compiling an accurate medication history and determining indications for each medication. This would enable a focus on reducing polypharmacy and simplifying medication regimens.

There was debate whether this service would be distinct from the currently funded residential medication management reviews (RMMRs), which are performed by a pharmacist in collaboration with the GP. These reviews are funded every two years for residents, or more frequently if clinically indicated.

  1. Facility-level audit and feedback to staff and healthcare professionals on high-risk medications.

The use of audit and feedback has been used successfully to improve clinical practice. This proposed intervention aims to facilitate benchmarking by conducting facility-level audits and feedback to healthcare professionals on the usage of high-risk (for example, opioids and anticoagulants) and/or highly prevalent medications. Providing facility-specific feedback can assist healthcare professionals to identify these medications and trigger a medication review to be performed if needed.

  1. Develop de-prescribing scripts to assist GPs and other clinicians to discuss medication discontinuation.

De-prescribing is the reduction or cessation of unnecessary or inappropriate medications with consideration of individual goals of care and predicted life expectancy. Commencing a discussion about de-prescribing with a resident and/or families can be challenging and in some cases confronting. The aim of de-prescribing scripts is to provide healthcare professionals with sample phrases that can assist with initiating this conversation with residents and their families.

  1. Develop or revise prescribing guidelines specific to older people with multimorbidity in RACS.

Clinical practice guidelines are often disease-specific and based on clinical trials which typically exclude older people with multimorbidity. Together with a need for greater participation of older people in clinical studies, developing up-to-date evidence-based prescribing guidelines will promote appropriate prescribing in this population.

  1. Implement electronic medication charts and records.

The implementation of electronic medication charts and records at RACS would ensure access to up-to-date information for all relevant healthcare professionals including medical, pharmacy and nursing. Although costly and challenging to implement, an electronic system aims to improve communication, minimise medication discrepancies and allow clinicians to readily identify medications suitable for desprescibing.

  1. Investigate the current role of the Medication Advisory Committees (MACs) at each RACS and better support MACs to address medication appropriateness.

MACs are recommended at all RACS and may consist of representatives from a range of healthcare professions, RACS management and residents. The MACs aim to review medication management policies and procedures within their service to improve the quality and safe use of medicines. The potential for MACs to play a role in reducing the impact of polypharmacy appears promising, however it is currently unclear what role existing MACs play and what characteristics are needed to perform this role.

What next?

The interventions suggested are just some of many which may be needed to manage polypharmacy in RACS. Moving forward, we need to further explore these strategies to determine their feasibility and impact following implementation into practice. It is likely that a broad, multifaceted strategy is needed to effectively manage polypharmacy.

Natali Jokanovic is a hospital pharmacist and is undertaking a PhD at Monash University in polypharmacy in residential aged care services.

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