Geriatric medicine loses its way

GERIATRIC medicine has lost its way in Australia, according to a geriatrician who says it is time specialists were more actively involved in treating residents of aged care facilities.

Dr Ludomyr Mykyta, a geriatrician in private practice in South Australia, said that when he visits his patients in residential aged care facilities “I’m not meeting any of my colleagues”.

He was responding to a Perspectives article in this week’s MJA on the rate of psychotropics prescribing for patients in residential aged care facilities. (1)

Geriatrician Dr Sarah Hilmer, from Royal North Shore Hospital, Sydney, and Dr Danijela Gnjidic, of the University of Sydney’s Faculty of Pharmacy and Centre for Education and Research on Ageing, wrote that psychotropics were being prescribed to residential aged care residents “too often, for too long, at doses that are too high, in dangerous combinations with other medications and without adequate consent”.

“There is growing evidence on the risks associated with psychotropics in [residential aged care facility] residents, including falls, pneumonia, hospitalisation and mortality”, they wrote.

The authors called for high-quality economic evaluations of non-pharmacological and pharmacological management options for residents with a range of conditions, to determine the effects and total costs of each approach.

“Non-pharmacological management options have some evidence of efficacy … and do not carry the risks of psychotropic medications”, they wrote.

“However, non-pharmacological management is constrained by requirements for more intensive, skilled nursing and allied health staff — limited resources in the aged care sector.”

Dr Mykyta told MJA InSight the problems in residential aged care were exacerbated because the facilities were outside the mainstream health system.

“Residential care facilities are seen as accommodation, even though 80% of the residents have dementia, many of them with advanced dementia”, Dr Mykyta said.

“These patients are at the nth stage of the disease and this is where the expertise is desperately needed, but the expertise doesn’t show up”, Dr Mykyta said.

“Where are the geriatricians? Where are the psychogeriatricians?

“The system should follow the patients wherever they are.

“Geriatric medicine in this country has lost its way — we think we’re too important and too busy. The whole system is sick.”

Professor Gerard Byrne, head of psychiatry at the University of Queensland and of the older persons' mental health service at the Royal Brisbane and Women's Hospital, agreed that the aged care system was in dire need of a “fix”.

“The proper solution is a reorganisation of the care of the elderly, particularly those with dementia”, Professor Byrne said.

“GPs are very busy and they don’t need this sort of work unless it is funded adequately, which it’s not. It’s not the fault of the aged care facilities or the GPs. It’s the structural reality of the current funding system”, he said.

“This is about how we feel about the elderly. We love the care of children, and that’s appropriate, but when it comes to [funding] the elderly, we hit trouble.”

The authors of the MJA article wrote that appropriate use of psychotropics in aged care facilities relied on adequate education and training, but cost pressures within facilities often favoured inappropriate use of the drugs, which required more complex policy solutions.

“Appropriate psychotropic use could be achieved through carefully considered financial incentives to equalise the costs of different management strategies. Investment could be made in recruiting and training staff to provide non-pharmacological therapies, and in research to develop better pharmacological and non-pharmacological management strategies.”

Dr Mykyta said he didn’t care whether psychotropics “worked” in dementia patients.

“Even if they do nothing, they make a huge contribution because in order to be prescribed, the patient must be assessed and that leads to more positive outcomes for these people”, he said.

“Management is more than treatment.”

- Cate Swannell

1. MJA 2013; 198: 77

Posted 4 February 2013

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