Older Australians – can we do better?

Featured
By
Mary O'Malley
-
aged care

The interim findings of the aged care royal commission, the horrific bushfire season and the COVID-19 pandemic have all highlighted – in one year – the critical role pharmacists can play in the lives of older Australians.

A ’shocking tale of neglect’. And, ‘unsafe, unkind and uncaring’.

These are some of the damning descriptors of the country’s aged-care system found in last year’s interim report of the Royal Commission into Aged Care, Quality and Safety.1

Sadly, such findings are not news to pharmacists, who have long been advocating for better care for older Australians, whether living independently or in residential aged care facilities (RACFs). COVID-19 has simply shone a spotlight on issues that have long existed, particularly those relating to medicine supply and management and palliative care.

The PSA has continued to call for better outcomes, beginning in February with the launch of its Medicine Safety: Aged Care report,2 a sobering read that found more than 95% of people living in RACFs had at least one problem with their medicines at the time of a medicines review. Most had three. Up to 20% of unplanned hospital admissions for aged-care residents were a result of inappropriate medicine use, and 60% of people in RACFs were administered at least one potentially hazardous combination of medicines.

In August, PSA submitted its final report to the royal commission outlining eight recommendations set against the impact of COVID-19 on aged-care services.3 Those recommendations included:

  • systematic and coordinated medicine supply management
  • increased investment for follow-up medication management review services
  • data collection and monitoring to refine policies and procedures
  • the continuation of medicine management review services via telehealth beyond the pandemic
  • access to Medicare Benefits Schedule Item 903 via telehealth for medical practitioners
  • the freedom for pharmacists to administer vaccines in any environment
  • inclusion of pharmacists in all government public health messaging around COVID-19-related healthcare
  • Inclusion of PSA’s clinical governance framework for pharmacy services when implementing mandatory aged care standards.

This year has been one of challenges – from legislative amendments affecting prescription arrangements, to supply limits, medicine shortages and restricted access for pharmacists to RACFs. But there is positive change too. After signing the Seventh Community Pharmacy Agreement (7CPA),4 federal Health Minister Greg Hunt said more funding for professional programs would promote medicine safety, particularly for elderly Australians via dose administration aids and medicine checks.

Follow-up visits

One encouraging outcome of the royal commission’s interim report in October was the uptake in April this year of a recommendation to provide up to two funded follow-up visits by pharmacists within 9 months of a Residential Medication Management Review (RMMR) or Home Medicines Review (HMR). Until then the next RMMR had to wait 2 years. Yet PSA’s Medicine Safety report found that half of all aged-care residents are taking medicines that cause sedation or confusion, with 20% of them prescribed potentially dangerous antipsychotics.

Melbourne-based consultant pharmacist Zachary Sum MPS, is one who has seen immediate benefits from follow-ups, mostly around risk from medicines changes.

‘Patients get to ask more questions and develop a relationship with the consultant pharmacists as they would with their GP,’ he said. He believes this provides greater public recognition for the role of pharmacists, closer links with doctors, better patient outcomes and greater job satisfaction overall.

‘Critically, and relevant to the royal commission findings, is the reported observation that there have been increased reviews of psychotropic medicine use and trial reductions of dose/use being implemented by doctors,’ the final PSA submission reports.

Jo McMahon, a NSW rural pharmacist with a special interest in palliative care, told AP: ‘Since I commenced work as an embedded pharmacist on the South Coast in 2018 in three RACFs, we have got rates of antipsychotic use down to 3% in two facilities and down to 8% in the third, compared to 23.5% quoted by the Registry of Senior Australians (ROSA). One facility is almost sedative-free – ‘only benzodiazepine prescriptions when needed for epilepsy’.

Under the 7CPA, funding for two follow-up visits is guaranteed for 1 year. PSA wants permanent funding to be committed for the life of the agreement, and beyond.

PALLIATIVE CARE

Jo McMahon
Pharmacist, Moruya, NSW

Jo McMahon is a proud rural pharmacist from Moruya on the New South Wales South Coast with a strong interest in palliative care and geriatrics.

‘I find palliative care very rewarding,’ says Ms McMahon.

‘You can make a huge difference to an individual and to their family by doing good palliative care.’

Since 2018 she has provided weekly sessions of 3–4 hours to three RACFs in Moruya, Batemans Bay and Narooma, all on the coast.

‘My role involves implementation of Quality Use of Medicines principles across the facilities,’ says Ms McMahon.

‘This ranges from antimicrobial and opioid stewardship to reducing polypharmacy and inappropriate use of medicines such as antipsychotics, sedatives and anticholinergics.

‘The pharmacist in an aged care facility is in an ideal situation to liaise with the GP and nursing staff as well as the palliative care team and community pharmacy to ensure implementation of tools such as the Clinical Excellence Commission Last Days of Life flowcharts.

‘The use of Caring@home resources simplifies care for the registered nurse who may have the charge of many residents,’ Ms McMahon says.

She believes community pharmacists should be called on regularly to be part of palliative care teams.

‘They can play a pivotal role, in deprescribing recommendations, advising patients, families and nurses on symptom management, drug compatibilities for syringe drivers, dose modification, home delivery, safe drug storage in the home, staged supply to the home to keep costs down and how to dispose of medicines after the person has passed away.’

As part of a team, Ms McMahon believes it helps to deal with the pressures that come with palliative care.

‘Sharing the care and responsibilities in supporting rural palliative patients – who may also be known personally to us – can reduce the risk of professional and carer burnout.

‘Decisions are not made in isolation. ‘We all have each other on speed dial and will talk through options, decisions, calculations,’ she says.

‘The very nature of the palliative approach: meticulous assessment, always sharing decisions with the patient and the family, and making small changes which are always monitored before the next step means any disappointments are shared and addressed,’ Ms McMahon says.

The approach involves good communication and preparation with the patient.

‘Hoping for the best but planning for the rest.’

Palliative care

Many older Australians want to end their days in their own homes. Yet community pharmacists are not widely recognised as members of the palliative care team and are often an underutilised resource.

Last year the Clinical Excellence Commission worked with pharmacy organisations, including PSA, to usefully apply the pharmacist’s role in medicine management and to establish a NSW Palliative Care Core Medicines List to assist end-of-life care in the home. This followed a 2018 NSW Government survey that showed the need to improve medicine access for people who spend their last days where they feel most comfortable.

Now PSA is leading a project within the NSW South Eastern Primary Health Network (SEPHN) to improve that access and to build pharmacy networks into multidisciplinary teams and care coordination.

‘This project intends to target community pharmacists within two to three key regions within the SEPHN,’ says PSA NSW State Manager, Simone Diamandis.

‘It seeks to strengthen the support for residents wishing to die at home and support equitable access to palliative care medicines as well as to standardise management strategies through awareness and utilisation of the NSW Palliative Care Core Medicines List.’

‘The planned SEPHN project – building capacity in the community pharmacy setting to improve access to appropriate end-of-life medicines, is an ideal opportunity to support local residents,’ says Jo McMahon.

An identical list has been implemented in South Australia to help pharmacists manage each of the common six symptoms that occur in the last days of life. The five core medicines include clonazepam, haloperidol, hyoscine butylbromide, metoclopramide and morphine.

‘Pharmacists can support the delivery of medicines to those receiving palliative care at home; they provide advice on appropriate drug doses, alternative routes of administration, review medicines, reduce medicine misuse, and ensure the pharmacy has the injectable medicines that may be required during the terminal phase,’ Ms Diamandis says.

HMR

Zhiyong Zachary Sum MPS
Consultant pharmacist, Melbourne, VIC

Problem at initial review

Connie* is a new patient at the general practice. She recently relocated and her previous medical records have not yet been received. Connie comes to the general practice for a regular check-up with her new GP. Her in-clinic blood pressure reading was 182/100 mmHg. She doesn’t know what tablets she is taking.

From there, Connie has been referred for an HMR for interim medication reconciliation while awaiting transfer of her old medical records.

Advice

An HMR identified that she is on antihypertensives (lercanidipine 10 mg, olmesartan 20 mg and hydrochlorothiazide 12.5 mg). However, due to financial constraints and not ‘feeling’ the effects of hypertension, she has been intentionally non-compliant with her medicines for the past 15 months. The review recommended she restart her antihypertensive regime immediately, with regular blood pressure reviews by the GP.

Recommendation

The importance of hypertension control and compliance with antihypertensive therapy for improved clinical outcomes was discussed with Connie. A follow-up HMR visit was scheduled to ensure compliance and to identify strategies to help achieve comprehensive therapeutic outcomes including lifestyle changes in exercise, diet and risky health behaviours.

Follow-up 1

The first follow-up service was conducted 4 weeks after Connie’s HMR. Her blood pressure had reduced significantly. However, the blood pressure monitor picked up an irregular heart rhythm, which prompted an immediate referral to the GP, followed by an immediate transfer to the local hospital emergency department. She was diagnosed with silent myocardial ischaemia.

Follow-up 2

A month after the first follow-up service, Connie has optimal blood pressure control and is compliant with her medicines. She adopted healthier lifestyle habits in nutrition and exercise and now regularly visits her GP for a comprehensive health check, including a heart health assessment and team care arrangement involving a consultant pharmacist.

Comment

If not for the follow-up service, Connie would not have been screened and referred to the right specialist care in a timely manner, leading to possible morbidity and/or mortality from undiagnosed cardiovascular disease. The follow-up service gives consultant pharmacists responsibilities towards patients under their care and provides immense job satisfaction when a recommendation to a GP has been followed up leading to positive patient outcomes.

*not her real name

Impact of the pandemic

Throughout this pandemic, pharmacists have been a combination of carer, procurer, monitor, advocate and friend to older people isolated by COVID-19. The home delivery service provided by many pharmacists around the country has provided the only fleeting point of social contact for some elderly Australians.

Earlier this year, Australian Psychological Society President Ros Knight described loneliness as a ‘psychological epidemic in Australia’. Alongside their medical role, the pandemic has underscored – in the most poignant terms – the valuable role pharmacists play in the social dimension of caring for elderly Australians. How do we continue to play our part in relieving that loneliness? Are we equipped as a profession for the additional roles we find ourselves playing?

According to the PSA’s submission to the aged care royal commission, it starts with recognising the broad contribution of pharmacists in aged care services, now and beyond the COVID-19 pandemic. It means understanding that pharmacists can play a vital role in everyday medicine management, whether that’s supporting carers in a patient’s home or the rotating, stretched workforces in RACFs.

‘From the outset of COVID-19, many individual pharmacists experienced challenges through lack of recognition as essential health workers,’ says the final PSA report. ‘This view or perception seems to filter through many aged care facilities.’

Says Julian Soriano MPS, who is on the ground in aged care: ‘I feel that this pandemic has really highlighted the crucial work that pharmacists do every day.

‘Our skill sets have been vital in ensuring that an already stretched medical system does not have an increased burden due to medicine-related harm. At a time where much of the health system’s focus has been on the pandemic, it is crucial that pharmacists continued their vigilant watch over the quality use of medicines by reducing medication-related problems and ensuring our older Australians are well looked after.

‘I found this most relevant in the palliative care work we are doing in aged care. We spent time ensuring that our residents had access to all appropriate terminal symptom management medicines and assisted in implementing thorough assessments and staff training on how to use these agents.

‘This helps our residents to remain comfortable in their own home for longer and made it possible for loved ones to be with them through their last days in a familiar environment.’

HMR

Dr Natalie Soulsby MPS
Advanced practice pharmacist Head of Clinical Development, WardMM, based in Adelaide, SA

Problem at initial review

Mary* requested I conduct an HMR for her during a heart failure education session I run as part of a heart failure rehabilitation program. She had been started on multiple medicines after she had a NSTEMI and an LV thrombus, leaving her with a reduced EF of 37% and was unsure about the indication of her medicines.

On further discussion she complained of lethargy and diarrhoea. For diabetes, she was taking metformin as well as insulin. Her most recent pathology was only for urea and electrolytes.

Advice

The HMR was an opportunity to educate her and provide CMIs for each of her medicines.

With no recent full blood counts, her lethargy may have been due to vitamin B12 deficiency. The metformin may have caused diarrhoea as the dose had been increased recently.

She had been taking clopidogrel for her stent since May 2019. She was also prescribed warfarin for her LV thrombus but did not have a MedicAlert bracelet.

Recommendation

At the review we discussed, at length, her medications and the need for a MedicAlert bracelet, which she agreed to organise. She has a dose administration aid but would forget to take her bed-time medicine as she had medicines in the pack for dinner.

I contacted her pharmacy and asked staff to change her bedtime medicine to dinner time.

I contacted the GP about possible anaemia and told Mary the metformin may be causing her diarrhoea.

Follow-up 1

The first follow-up service was 6 months later as the initial review was conducted prior to the new rules. This visit was initiated by the patient as there had been some changes to her medicines.

The changes to allow for follow-up enabled me to book in a visit without the need to contact her GP.

The GP had conducted blood tests and discovered she had iron deficiency anaemia and she had been started on iron supplements.

Her diarrhoea had settled and she was now tolerating the higher dose of metformin.

The doses of some of her medicines had been increased. She was confused about her heart failure management plan which I went through again, explained its importance and that she would be on it for life.

She was still taking the clopidogrel, so I recommended to the GP that this needed to be reviewed and suggested a PPI in light of her anaemia, especially if the clopidogrel was to be continued.

Follow-up 2

Mary now has a MedicAlert bracelet and her clopidogrel has been ceased.

Comment

Without the follow-up visits and ability to reinforce the importance of continuing to take her medicines Mary may well have ceased some, if not all of them, which would have resulted in a hospital admission.

She may also have continued on clopidogrel indefinitely, with the increased risk of gastrointestinal bleeding and the diagnosis of iron deficiency anaemia.

References

  1. Royal Commission into Aged Care, Quality and Safety. Interim report: neglect. 2019. At: https://agedcare.royalcommission.gov.au/publications/interim-report
  2. Pharmaceutical Society of Australia. Medicine safety: aged care. 2020. At: psa.org.au/advocacy/working-for-our-profession/medicine-safety/aged-care/
  3. Pharmaceutical Society of Australia. Royal Commission into Aged Care, Quality and Safety: Impact of COVID-19 on Aged Care Services, July 2020. At: https://my.psa.org.au/s/article/Aged-Care-RC-COVID-19
  4. Australian Government Department of Health. New (7th) Community Pharmacy Agreement. 2020. At: www1.health.gov.au/internet/main/publishing.nsf/Content/New-7th-Community-Pharmacy-Agreement
  5. Australian Psychological Society. Australian Loneliness Report. 2018. At: https://psychweek.org.au/wp/wpcontent/uploads/2018/11/Psychology-Week-2018-Australian-Loneliness-Report-1.pdf