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BETTER continuity of GP care for people with dementia when they enter residential aged care facilities (RACFs) could reduce inappropriate prescribing, particular of psychotropics.
That’s one suggestion from a retrospective data linkage study published in the MJA.
Researchers from UNSW Sydney examined the 45 and Up Study participants in New South Wales with dementia who were admitted to an RACF from January 2010 to 2014.
On entering residential care, 44% of 2250 new residents with dementia saw a new GP and 29% saw a GP that was known to them but who wasn’t their regular GP. The rest saw their usual GP.
The researchers found those who saw a different GP when they entered residential care were more likely to be prescribed antipsychotics or benzodiazepines. They were also more likely to receive an increase in the mean number of dispensed medications.
Of particular concern was the increased antipsychotic prescribing for patients seeing a new GP. Antipsychotics are usually prescribed for agitation and aggression and their overuse as chemical restraint was a major issue identified by the Royal Commission into Aged Care Quality and Safety. They can also be prescribed for roaming behaviour or screaming even though they are not indicated for those conditions.
Professor Henry Brodaty, Scientia Professor of Ageing and Mental Health at the Centre for Health Brain Ageing, and one of the article’s authors, said that “generally, we advise not to prescribe antipsychotics because they’re associated with side effects”.
“The most worrying one is the increased risk of death. It’s about a 1% increased risk. Also, there is an increased risk of stroke.”
“You have to know the person,” Professor Brodaty said, in an exclusive podcast.
“When you think about the reality for a person entering a residential aged care home, it’s probably not surprising they’re agitated.
“Imagine if you’re an 80-year-old person, you’re confused, you’re disorientated, you’ve moved into an unfamiliar environment. You don’t know the people. The environment seems strange, the routine is foreign to you, and you don’t have any control over what’s happening.
“It’s quite understandable such a person might get agitated, anxious, or even lash out. Agitation is a frequent symptom that occurs when people move into a nursing home,” Professor Brodaty said.
Most times, patients may have had a crisis which led to their entry into the RACF. The MJA researchers linked hospital records to determine who had received emergency hospitalisations prior to entering residential care.
“Even though having a crisis such as an emergency hospitalisation was an important predictor of antipsychotic dispensing, we found the relationship with a new GP was the same in both groups whether they’d had an emergency hospitalisation or not,” said lead author Ms Heidi Welberry, from the Centre for Big Data Research in Health.
When a person enters residential care, there are a few reasons they may not see their own GP, the authors said. The patient may have moved to a different geographical area closer to their family members, or if their new residential home is near where they used to live, there may be other barriers for their regular GP to continue their care.
“It’s not always practical or efficient for a GP to visit lots of different patients distributed across different residential care facilities,” Ms Welberry said.
“Not only is there the travel time, but there are also many logistical issues such as the time needed to find the right staff member to talk to or not being able to access records in a timely manner. As a result, it can be financially prohibitive for GPs.”
The Australian Government has recently announced extra incentives for GPs who are providing services in residential aged care. The four-tier payment system will hopefully reduce some of the financial burdens for GPs to help them continue care when their patient enters residential aged care.
When a patient must see a new GP, Ms Welberry said there are a few practical things that could help the transition.
“We acknowledge that it’s a very difficult situation and there is no ideal way of smoothing out this process,” she said.
“But one practical thing that could be done is supporting patient handover through improving access to electronic medical records across different settings. It certainly doesn’t help when a GP is taking on a patient they haven’t seen before and can’t access all of their medical history and can’t see their medication history and don’t know what has been tried before.
“Support could also be provided to GPs by encouraging multidisciplinary care and other support structures such as medication management reviews.”
One recommendation from the Royal Commission was a new primary care model which would see GPs with an interest in geriatric medicine applying for accreditation.
There is the fear that this change might further fragment GP care. However, if done right, it could improve care, Professor Brodaty told InSight+.
“In some countries such as the Netherlands, they have subspecialisation for doctors who do a 2-year training course and they become geriatric GPs. They do an excellent job,” he said.
“So even though the people would change GPs, having specialised GPs interested in aged care would make a big difference.”
The authors also believe families need to advocate for their relatives in aged care.
“The same way a family would advocate for a child in hospital, families need to be informed about their loved one. They need to be involved and they need to be the advocates for the person. They need to look at the medications and be insisting that they provide the consent as required,” Professor Brodaty said.
As the Royal Commission into Aged Care report highlighted, improving quality of aged care is a complex issue with many considerations.
“It’s a combination of top-down with regulation, proper subsidisation and compensation for time spent, and training. As we know from the Royal Commission, adequate staffing [is vital] as well. That’s as well as bottom-up from public attitudes and family taking some responsibility,” Professor Brodaty concluded.
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Nobody has mentioned the amount of staff working in these places, why is it said that the staff are not adequately trained. You tell me how on one shift when you have a ratio of one nurse and 5 carers to 43 residents you are supposed to be able to deal with anything other than basic care needs. STOP BLAMING OVERWORKED UNDERPAID AND UNDERVALUED STAFF
As a doctor, I have witnessed how they started my mother on antipsychotics and benzos soon after she entered the nursing home. As this study reports, they purposely transferred her care to that of a new GP who had no inhibition to prescribing pschotropic medications. All this when her regular GP was also visiting the nursing home unbeknownst to us. Often these nursing homes will employ a GP who is often very happy to prescribe at the nurses request. My mother developed serious side effects of tardive dyskinesia, falls and delirium. They didn’t care. I was interstate so I was not able to monitor her regularly, bit caught on to what they were doing during a visit.
I fought the nursing home tooth and nail. I reported the nursing home to the Aged Care Quality and Safety Commission. They were investigated and found to be in breach of clinical care. Not just that, the nursing home was sedating almost every resident in the dementia wing. I also reported the GP to AHPRA. Much came out of my reporting.
This dastardly practice of sedating elderly residents in nursing homes is atrocious. Family members of residents are often clueless about the initiation of these medications. Often, lay people don’t even understand what these medications are. Nursing homes prey on medical ignorance of families. You must always find a GP that you personall know and who won’t start such medications at whims of nursing staff. Report them of they do to the ACQSC. None of these antipsychotics used in elderly is evidence based.
This is a great study and I hope a further nail in this horrendous practice that even Human Rights Watch report called it for 2 years ago.
A subset of residents are transferred from acute hospitals and arrive on heavy doses of antipsychotics. Withdrawing then can take some months. Additionally residents with dementia can be agitated and even aggressive on admission to an RACF. That initial aggression has to be managed even though it is understandable. When two or three staff have workers comp injuries and are unable to work the often recommended headphones and pot plants don’t anywhere meet the urgency of the situation. Lack of qualified staff has been shown to be the problem for decades yet all we are seeing is the metastatic growth of inexperienced staff who stay in aged care for a few months while looking for a better job.
The data in the study you mention is years out of date(2010-2014). Since then more patients stay longer out in the community (better/more care packages) and are therefore more complex and frail when they are admitted to RACF’s. Most of them comes via hospital, or had a major health insult triggering admission. Very few of them have a planned smooth transition from home.
It makes management complex to stay the least. We need all the components of care including GP access and expertise, time, good and enough trained staff, non pharmaceutical interventions and medication including antipsychotics in the right(low) dose if the patient is aggressive and threatens other residents or staff apart of their own health risk when agitated(falls, injury, refusal of essential meds or care). Only the treating GP can make those decisions and review doses. To regulate prescription away from GP will cause more complex problems as access to geriatricians/psychogeriatricians are very limited. I support a system of allowing GP’s to be accredited in age care as it has became more complex and demanding. (same as for GP obstetricians and GP anaesthetists).
In the meantime GP’s doing mainly aged care are significantly discriminated against as they are benchmarked against GP Practice from private practice(same consulting fees as sitting behind your desk at the practice etc.)
The only way to increase and improve GP care in aged care is to acknowledge their skill set and expertise, accredit this type of practice and set different accreditation standards.
LOTS OF DEMENTED PERSONS NEED ANTIPSYCHOTIC MEDICATION WHEN THEY REACH AGED CARE TO CONTROL THEIR PSYCHOSIS.OFTEN THIS CAN BE WITHDRAWN WHEN THEY HAVE SETTLED IN.IT IS DANGEROUS NOT TO TREAT PSYCHOSIS FOR BOTH THE PATIENTS AND THE STAFF. ELECTRONIC RECORDS OFTEN SHOW THAT THE DEGREE OF PSYCHOSIS HAS BEEN NEITHER RECOGNIZED OR TREATED BY THEIR PREVIOUS GP WHICH IS WHY THEY END UP IN AGED CARE.
Professor Brodaty describes the important role that family members have in advocating for persons with dementia in residential aged care. Previous research suggests that family members may benefit from educational and coaching interventions that address healthy literacy and seek to prepare families for an advocacy role. One mechanism that may help explain the association between continuity of GP during the transition to residential aged care and less prescribing of antipsychotic medication is the relationship between the GP and older person pre-dementia. This is about respect for the person who is struggling to adjust to changes in their circumstances.
Professor Brodaty speaks with compassion. Dementia doesn’t mean that a person is ready to relinquish their autonomy, or their desire to move freely in their environment. Yet we struggle to meet the needs of this cohort who desire connection, movement and a sense of purpose.
all too often behaviourally disturbed aged care residents are sent to the Emergency departments, particularly on weekends, after 5PM, or public holidays, to be seen by an Emergency doctor who has never seen this person before who is now more distressed being in an unfamiliar, noisy, chaotic environment.
I regularly visit residents in rural and remote Aged Care Facilities as a Consultant Geriatrician (as well as metropolitan areas. I have always done this throughout my very lengthy career, including throughout the COVID crisis, as recently as last week. I undertake a Comprehensive Biopsychosocial Assessment on every new patient irrespective of the setting: home visit, clinic, rooms, hospital etc.
I rarely offer a clinical opinion on an individual that I have not at the very least sighted, and attempted to engage privately. I interview the Life Partner (often dismissively referred to as “the informal carer”)/relative/friend privately. I interview staff. I leave the facility with a doggy-bag of Essential Information that is assembled from the comprehensive records now available in most facilities. I observe and recognize the crisis that pertains at the facility and the impossible burden being put on the nursing and other care staff as well as the heightened anxiety and real fear amongts other residents. Above all, I observe the distress that the subject resident is experiencing. In the preparation of my report, I assemble all the available evidence that I can loate and study it exactly in the same way as I do in a medico-legal report. Many, if not most of these distrubed residents are in the palliateive stage of their lives (as defined by the WHO). They are in the RACF because they need 24-hour car and supervision, not because they have chosen the facility as a residential option. They need expert HEALTH CARE. If they are severely anxious, depressed, delusional or all of the above, they need the relevant psychotropic medication adjusted for pharmaco-dynamic factors, organ failure etc as pertains to any other medication, They do not become members of another species when they pass the age of 65. Their partner/relative/substitute decision-maker must be informed, educated and taken through a risk/benefit assessment and counselled at arriving at a management plan. The GP must be given reasons for the particular choices of specific medications that are made, and exactly how to introduce them. Distress of any kind can not be tolerated. Telemedicine cannot replace face-to-face care for this generation of elderly people. The application of stereotypic generic advice that is contained in reports that are pre-written before anything vaguely resembling an assessment takes place are discrimination and what they offer is dogma not “person-centred care”.
One of the other factors dissuading GPs from following their own patients into residential aged care is the lack of enough facility staff trained in behaviour management in many venues. For example I know GPs who refuse to work in nursing homes where there is not a registered nurse on the floor 24 hours a day, in part to assist with behaviour management.