Report highlights need for improved medicine management

A new report investigating polypharmacy among older Australians emphasises the need for greater pharmacist involvement in medicine management.

The report, led by the University of Western Australia and University of New South Wales, estimated rates of polypharmacy in people aged 70 and older across an 11-year period (2006–2017) after analysing Pharmaceutical Benefits Scheme data. In 2017, the authors found that 36% (935,240) of older Australians were impacted by continuous polypharmacy, where five or more medicines are dispensed to an individual concurrently.

Rates of polypharmacy were higher among women than in men (36.6% versus 35.4%) and highest in patients aged aged 80–84 years (43.9%) or 85–89 years (46%). Older Australians had higher rates of polypharmacy than previous research had found for older people in the United Kingdom and the United States.

The report found that the proportion of older people using polypharmacy had risen by 9% since 2006. The study’s lead author, Dr Amy Page, PSA Victorian Branch Committee Member, Adjunct Research Fellow at Monash University and Adjunct Senior Lecturer at the University of Western Australia, said: ‘The increase in polypharmacy can partially be attributed to the fact that more people are living into older age, which is obviously a wonderful thing. But we were also able to show that the prevalence of polypharmacy was increasing as well, which is not such a wonderful thing.’

While polypharmacy may be appropriate in some instances, careful medicine management to mitigate the risk of adverse health outcomes in older patients is necessary found the report, funded by the National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Medicines & Ageing, led by Professor Andrew McLachlan.

Pharmacist involvement

PSA National President Dr Chris Freeman said the report highlighted the need for pharmacists to have greater involvement in medicine management. 

‘As the report states, older people are likely to be using several medicines at once, which places them at greater risk of medicine-related harm,’ Dr Freeman said.

‘It is therefore vital that all people taking multiple medicines have regular medicine reviews with the added ability for the pharmacist to follow up with the patient as clinically indicated. Pharmacists, with their unique expertise in medicines and medicine management, are the best placed to conduct these reviews to identify and resolve any issues.’

The consequences of inaction were detailed in PSA’s Medicine Safety: Take Care report, which found that:

• one in five people suffer an adverse medicine reaction at the time of receiving a Home Medicines Review
• 1.2 million Australians had experienced an adverse medicine event in the last six months
• almost one in four older people prescribed medicines cleared by the kidneys are prescribed an excessive dose.

In order to address these issues, Dr Freeman said the pharmacy profession must be granted the authority to take the lead. 

‘The evidence is clear, pharmacists have significant potential to reduce the number of medicine-related hospital admissions and adverse medicine events in Australia but are prevented from doing so due to barriers in how medicine reviews are funded and the program rules governing their delivery,’ he said.

 ‘It is PSA’s firm view that pharmacists must be more involved in the care of patients whenever medicines are part of their health management plan, and particularly in the context of chronic disease management.

‘Access to additional funding models, such as the Medicare Benefits Schedule, will ensure pharmacists can fulfil this vital role in Australia’s healthcare system,’ Dr Freeman said.

‘PSA and the pharmacy profession stand ready to work with government and consumers to ensure medicine safety is addressed for the benefit of all Australians.’

Looking forward

Dr Page said individual pharmacists and doctors could assess whether a particular patient’s medicines were appropriate. However, at a systems level more awareness needs to be generated around the risks of taking five or more medicines through campaigns such as the Choosing Wisely initiative. 

To help healthcare professionals reduce the number of people taking more medicines than necessary, supporting strategies need to be put in place, she said.

Dr Page listed some examples of strategies, such as:

• Clinical guidelines for deprescribing, being developed by geriatrician Associate Professor Christopher Etherton-Beer and pharmacists Ms Xaysja Hill and Dr Page through the University of Western Australia
• National Strategic Action Plan to Reduce Inappropriate Polypharmacy led by geriatrician Professor Sarah Hilmer and pharmacist Dr Lisa Kouladjian through the University of Sydney in collaboration with the NHMRC Cognitive Decline Partnership, Australian Deprescribing Network and NPS MedicineWise.

There is also continued research activity continues by members of the Australian Deprescribing Network, Dr Page said. Examples include deprescribing trials such as AusTAPER that she is undertaking with geriatrician Associate Professor Christopher Etherton-Beer and fellow pharmacists Professor Rhonda Clifford, Ms Deirdre Criddle, Ms Xaysja Hill and Ms Marnee Eames. AusTaper promotes integration of pharmacists at the point of hospital discharge to accompanying the patient to general practitioner visits. This integration of pharmacists into multi-disciplinary teams aims to address polypharmacy, with an emphasis on shared decision making. 

Dr Page also emphasised the need for ongoing medicine reviews. 

‘Every time a medicine is dispensed or prescribed, the patient’s medicines should be reviewed. The use of multiple medicines may be appropriate in some people, but appropriate medicine management is really the key,’ she said. 

‘Undertreatment means that people may be missing out on the potential benefits of using multiple medicines, whereas over treatment puts them at increased risk of harm.’

Dr Page said that every healthcare professional should have medicine reviews front of mind at all times. 

‘We need pharmacists, doctors, nurses and patients to be advocating for medicines to be reviewed on a regular basis, because at the moment there is too much evidence that these conversations aren’t happening. Everyone is waiting for someone else to start the conversation.’

Pharmacists should raise consumer awareness about the reasons for taking certain medicines, how to manage them and why they need to be reviewed on an ongoing basis. 

‘Making sure that every consumer has a current and up-to-date medicine list with them at all times is really important – it’s an ideal role that pharmacists can support people to fulfil,’ Dr Page said.

There are several sessions at the upcoming PSA19 conference dedicated to aged care, medicine management and deprescribing. Register here to attend the conference, held in Sydney from 26–28 July.

References

1.  Page A, Falster MO, Litchfield M, Pearson S, Etherton-Beer C. Polypharmacy among older Australians, 2006–2017: a population-based study. Med J Aust 2019. At: https://www.mja.com.au/journal/2019/211/2/polypharmacy-among-older-australians-2006-2017-population-based-study?utm_source=carousel&utm_medium=web&utm_campaign=homepage