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.


Non-pharmacological alternatives to antipsychotic use in people with dementia are not resourced enough to make them easier than a prescription
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