Increase in psychotropic meds linked to GP changes

People with dementia entering aged care experience higher increases in medication when changing GPs, a recent study has found.

UNSW researchers analysed data from 2,250 people with dementia who had entered residential care from the Saxs Institute's 45 and Up study in NSW.

Almost half of residents who changed to a new GP were associated with an increase in initiation of medicine, including antipsychotics and benzodiazepines.

High rates of hyper polypharmacy, the prescribing of ten or more medications, was also linked to changes in primary health carers. 

“We knew that polypharmacy is an issue with older people, and particularly in aged care settings,” said lead author Dr Heidi Welberry.

“It's not that being on multiple medications is necessarily a bad thing, but the more medication somebody is on, the higher the risk of interactions or medication mistakes.”

While appropriate in some cases, the prescribing of multiple medications in aged care facilities has been linked to higher rates of hospitalisation among the elderly.

The study did not investigate why a change in GP had led to an increase in medication. According to Dr Welberry, a lack of knowledge and understanding towards a residents prior medical history is a potential factor.

“I guess it's a really difficult situation when somebody enters residential care,” she said.

“The fact that they have a much briefer period of time to have built a relationship with the patient at that entry point, so they don't have that long history with them.

“The GP taking over care may have stronger relationships already with the residential care facility itself, and the staff there, so there might be influences.”

Underlying trauma

Concerns over the dispensing of psychotropic medications to aged care residents came to a head during the royal commission, which called for stricter requirements to reduce prescriptions.

Adverse risks associated with such medicines in people with dementia include increased sedation, strokes, falls, Parkinson’s disease-like symptoms, and higher rates of mortality.

A recent report found that of the 100,000 aged care residents thought to be living with dementia in Australia, up to 48 per cent are receiving antipsychotics. 

Co-director of the UNSW Centre for Healthy Brain Ageing, professor Henry Brodaty, said the use of drugs like risperidone to treat dementia-related behaviors should remain a last resort option.

“It’s easier to prescribe than to institute a regimen of person-centred care.

“In general, always try non-pharm strategies first; work with families, rule out dementia cause…[..] always obtain consent before giving meds, monitor for effects,” he said.

Several environmental and psychological factors, including high levels of stress and confusion, have been linked to the entry period into aged care. 

For residents with a prior diagnosis of dementia, this transition may exacerbate behavioral changes and trigger an increase or initiation in psychotropic medications.

“For anyone going into a nursing home it is a wrench from their usual life,” said Brodaty.

“Imagine you did not make that decision yourself, or that you forgot you agreed to being admitted or you have just been transferred from hospital to a nursing home – it would be traumatic.”

GPs and transitions into aged care

Prior to this study, little was known by researchers about the prevalence of GP changes during aged care entry. These findings raise questions around how changes in primary carers affect prescribing patterns and overall care.

Ensuring that GPs are supported during the transition process is crucial to avoiding potential medication errors, according to Royal Australiasian College of Practitioners (RACP) spokesperson Dr Mark Morgan.

“The research reflects that continuity of care is really important,” he said.

“When I see someone in a residential care facility often all I have to go on is what a person can tell me, and diagnoses that might or might not be correct, and a list of pills.”

More streamlined access and unified transfers to health records, promoting more medication reviews and improving financial support to facilitate more time during evaluations, are potential solutions to better assist general practitioners.  

“It is medically complex work, it is relatively underpaid, and GPs often need to take a significant amount of time away from their clinic to see people in residential facilities,” said Dr Morgan.

“There’s a great frustration in the care that you would like to see a person receive not always being available in the setting that you find them.”

Shortages in registered nurses and workers in aged care facilities is another core factor influencing prescription decisions, said Dr Morgan.

“The nursing staff are so few and far between, particularly out of hours, that it is difficult to prescribe medicines that are to be taken only if needed under certain circumstances”

“Your way of prescribing has to change according to the staffing levels of a nursing home that you have no personal control over at all.”

In early July, GPs were offered doubled pay as part of government efforts to incentivise them towards the aged care workforce. Around 40 million dollars was allocated towards improving primary care access for elderly and immobile patients.

Investments have been welcomed, however there have been concerns that the incentives do not recognise the complexities of the work.

“It doesn't really encourage continuity of care with a GP that knows you," said Dr Morgan.

“It encourages a sub-specialisation and kind of efficiency of scale of frequent ward round-style visits to multiple recipients on a particular site.”

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