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Government ‘nudge’ letters not the answer to drug problem in aged care

The overuse of antipsychotic medication used as chemical restraint has been, for some, a startling revelation uncovered by the aged care royal commission.

It has been estimated that about 80 per cent of people in residential care with dementia are on one form of psychotropic – be that antipsychotics, antidepressants or sedatives – but experts believe that only around 10 per cent of those might benefit.

There are myriad reasons for over-prescription in aged care but one study found that GPs reported feeling pressured to prescribe psychotropics by aged care staff. They said they often prescribed these drugs due to of a lack of staff and training on other ways to deal with these types of symptoms.

Juanita Breen, writing in Aged Care Insite, said that “when these medications are given to older people with less serious symptoms such as calling out, agitation and wandering, the risks associated with use often outweigh any benefit they may offer”.

“To give an example, about one in five residents with dementia experiencing agitation will benefit from taking antipsychotics, yet taking these medications increases the risk of stroke, pneumonia, death from all causes, cardiac problems, falls, tremor and confusion.”

Breen wrote that many staff will request psychotropic medication from prescribers with the aim of ‘providing comfort’ to residents, not for the benefit of the staff. However, when given a psychiatric drug knowledge quiz, Breen found that most care staff and health practitioners were unaware of their adverse effects.

The royal commission interim report identified three areas that need “urgent” attention, one of which was “to respond to the significant over-reliance on chemical restraint in aged care, including through the seventh Community Pharmacy Agreement”.

This prompted the Morrison Government to announce funding for medication management programs to the tune of $25.5 million to reduce use of chemical restraints in aged care.

An unwelcome nudge in the right direction

In December last year, the Department of Health took the first steps to further combat this problem by sending GPs a letter outlining the effects of overuse of these drugs and devising new protocols for problem prescribers.

More than 28,000 health practitioners – mostly GPs – who prescribe in residential aged care facilities (RACFs) were sent the letter with a follow up “nudge” letter to be sent to a smaller group to “assist them to reflect on their prescribing patterns of antipsychotics and benzodiazepines”.

The idea of a “nudge” is a tool of behavioural science which is used to change behaviour: in this case aimed at highlighting the prescriber’s rate of prescription in relation to the average rate of their peers in the hope that this will correct any oversights in prescription.

However, GPs did not react well to the advice, with RACGP President Dr Harry Nespolon commenting that GPs are fully aware of the correct way to prescribe the drugs.

“GPs know that chemical restraints in aged care facilities are the last resort. Those aren’t my words, they’re what GPs who work in these facilities every day have told me,” he said.

“While there has been significant attention on this practice in the wake of the Royal Commission, it’s important to note that chemical restraint is not the norm – it is rare.”

Nudges have been used in trials aiming to reduce antibiotic prescribing in Australian primary care and GPs who were high prescribers of antibiotics were notified via letter that they prescribed antibiotics at rates higher than their peers. The trial showed a reduction in antibiotic prescribing.

A simple fix for a complex system

Academics emphasise that there are many unknowns as to whether the “nudge” method is the best course of action to tackle this issue.

Dr Magda Raban, a senior research fellow at Macquarie University’s Australian Institute of Health Innovation, argues that this approach by the Department of Health may be too simplistic to use in a “complex system” like aged care.

“The interim report from the Aged Care Royal Commission also brings to light a lot of that evidence that facilities also make a lot of the decisions around this. And the GP relies on the facilities in terms of their decision-making about prescribing as well. So, it’s a very complex system to be putting this intervention in place,” Raban tells Aged Care Insite.

According to Raban, there may be unforeseen consequences that come from these letters. GP visits to RACFs are in decline as some GPs feel that they are not compensated well enough for their time in aged care. Further scrutiny may affect whether GPs choose to engage with the aged care system full stop, she says.

“There were similar letters sent about opioid prescribing to GPs last year. And there was anecdotal evidence that GPs were saying, ‘Well, I’m not going to see these high risk patients anymore, or patients in palliative care, because I don’t want to be monitored for my prescribing of opioid use which is in my view appropriate because of the cohort of patients that I have.’ ”

Raban argues that nudge letters as part of a wider strategy to fix the use of drugs in aged care may work, but says the department of health should think about broadening the list of players that it may target and how they approach them, as a threatening approach has been shown to negate nay benefits a “nudge” may have.

“It’s not necessarily that the nudge is not a strategy or a part of a suite of strategies, but we might be going about it the wrong way,” she says.

“So, the people who are receiving these letters, whether it be the facility or GP, need to be confident about that data being accurate, because that’s one of the other concerns … So, there needs to be a certain level of transparency about where the data’s come from, how it has been adjusted for the cohort of patients or residents that the person is treating. And it shouldn’t come across as an aggressive strategy, but obviously it’s one part of the fix.”

Last year the Pharmaceutical Society of Australia (PSA) called for a national program that would see pharmacists embedded in aged care facilities.

A report by PSA showed that 98 per cent of aged care residents have at least one medicine-related incident and 50 per cent are taking one inappropriate medicine.

PSA national president Dr Chris Freeman argued that regular access to pharmacists, for residents and clinicians, will help tackle medical mismanagement and related harm.

“The health of the aged care sector matters a great deal to pharmacists and many pharmacists already contribute to activities and services to improve resident safety and system changes impacting on quality and safety in aged care facilities,” he said.

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One comment

  1. The underlying issue is staffing, I am the charge nurse of a 90 bed aged care facility overnight and the current staffing levels are 4pca’s and 1 RN. If you have 3 out of 30 having a “bad night” with wandering, yelling, intrusive Nd sometimes violent behaviours, up to 15 sensor mat’s for high falls risk residents in use and 1 staff member it’s very difficult not to use pharmacological measures on residents if all other forms of redirection 1:1 ( an impossibility with current staffing levels) cuppa making, heatpacjs etc fail. Look at the staffing ratio. In my belief it is the staffing that is at the core of this issue. Any RN with a conscience tries to do the best they can and resorts to medication as a last resort.