Aged care residents missing vital medication reviews

MANY people in aged care facilities are missing out on a crucial medication review program designed to reduce medication-related harm, researchers have reported in the MJA.

An analysis of residential medication management review (RMMR) services – a federally funded program – found that two years after entry into a residential aged care facility (RACF), less than half of the residents had had RMMRs (49.7%).

The high rates of polypharmacy and potential medication-related harm in residential aged care facilities in Australia was highlighted in the Royal Commission into Aged Care Quality and Safety in 2019.

Speaking to InSight+, lead author Dr Janet Sluggett of the University of South Australia said a previous systematic review led by her PhD candidate had shown that, on average, a medication review would identify between 2.7 and 3.9 medication-related problems per resident and between 45% and 84% of recommendations were accepted by GPs.

“Medication-related problems can include doses that are too high or low, side-effects, medications that are no longer needed, or conversely the need for a new medication,” Dr Sluggett said. “There might be need for therapeutic drug monitoring or education.”

In the MJA study, researchers analysed the timing of residents’ first RMMR using data from South Australia’s Registry of Senior Australians.

More than 176 000 residents from 2799 RACFs were included in the study and followed up for a median of 479 days. The median age at entry was 84 years, and almost half of participants were living with dementia (48%).

The researchers found that in the year before entering an aged care facility, residents were receiving a median of 11 prescription medications, with 62% of residents receiving at least one high risk medication. Also, they reported, just 4.5% of aged care residents had received a home medicines review in the year preceding their entry into an aged care facility.

In the first three months after entry into an aged care facility, 19.1% of residents had received an RMMR, 11.8% had died without an RMMR, and 5.7% had left the facility for other reasons without an RMMR.

One year after admission, 43.1% of residents had received RMMRs, 20.6% had died without RMMRs, and 9% had left without receiving RMMRs.

Two years after entry, 49.7% had received RMMRs, 25.8% had died without RMMRs, and 10.2% had left their first RACF for other reasons without receiving RMMRs.

“The potential underuse of the program may be a missed opportunity for identifying and resolving medication-related problems in Australian RACFs,” the authors concluded.

A spokesperson for the Department of Health said that between July and December 2020 there were 62 905 RMMR services delivered by pharmacists, in collaboration with GPs, in eligible residential aged care facilities.

They noted that the number of RMMR services provided by pharmacists had remained steady during the COVID-19 pandemic.

“Residents of aged care facilities are referred by medical practitioners on the basis of clinical need for an RMMR service. This may be seen as a barrier; however, it is important that there is a clinical need for the RMMR service,” the spokesperson said.

Dr Sluggett said geographical location can impact on provision of RMMR services.

“Our previous research found that residents from facilities in rural and remote areas are 25-33% less likely to receive an RMMR than those living in major cities,” she said.

Dr Melanie Wroth, Chief Clinical Advisor of the Aged Care Quality and Safety Commission, said while it was difficult to single out the impact of the RMMR program alone from other contributing factors, “RMMRs have the potential to help deliver benefits for individual consumers and also at a whole-of-facility level through strengthening the systems and processes for medication management”.

She noted that, alongside the RMMR program, the Commission had a project underway to look more closely at some of the challenges and barriers experienced by remote and very remote residential aged care services in accessing pharmacy services and advice, including RMMR and Quality Use of Medicines.

“Clinical pharmacists contracted by the Commission are visiting these services to explore medication management issues in general, gather information about their experiences, and provide in-service education to address any needs identified by and for each service,” Dr Wroth said.

“At the beginning of last year, the Commission commenced its Better Use of Medication in Aged Care Project, which aims to reduce – and ideally eliminate – the inappropriate use of medicines in aged care settings.

Dr Wroth said there were a number of steps required in providing an RMMR, which could present barriers to service provision.

“The GP has to make the referral or request and this requires GP awareness and willingness. The pharmacist needs to be available in a timely manner and the consumer’s consent is now required before the pharmacist can access their records,” she said.

“After deciding which medications to focus on in terms of priority, the pharmacist will produce a report with comments and suggestions and provide this to the GP. The value placed on the report by individual GPs may differ, and may also influence whether and how often they make RMMR referrals to pharmacists.”

Dr Wroth said engaging pharmacists earlier in the medication review process could result in more useful reports.

“Such early engagement could give the pharmacist a better understanding of the resident’s goals and wishes, and could also provide a more complete picture in relation to potential side effects, drug burden etc,” she said, adding that the Commission was working with the Older Persons Advocacy Network (OPAN) to develop resources, including an animation explaining consumer rights/role in medication management.

The Department of Health spokesperson said that under the Seventh Community Pharmacy Agreement, signed in June 2020, the federal government boosted its investment in pharmacy programs (up $100 million to $1.2 billion over five years) to support older Australians and the expansion of medication review programs.

“This builds on the investment of $25.5 million to improve medication management programs, announced on 25 November 2019 in response to the Interim Report of the Royal Commission into Aged Care Quality and Safety,” they said. “As part of this additional funding, the RMMR and Quality Use of Medicine programs were expanded, including introduction of up to two funded follow-up services by pharmacists after an initial RMMR has been delivered.”

Dr Sluggett welcomed the funding of follow-up services.

“From April 2020, accredited pharmacists can provide up to two follow-up visits to assist with implementation and monitoring, and provide extra education to the residents and aged care facility staff,” Dr Sluggett said. “This will be key to helping implement the resident’s medication management plan.”

Dr Sluggett also said an Australian Capital Territory trial that is embedding clinical pharmacists in aged care facilities could help to improve medication management, as would tabling discussions about RMMRs in Medication Advisory Committee meetings at the facilities.

“Having good working relationships between stakeholders – GPs, accredited pharmacists and senior nursing staff at the aged care facility – and opportunities for face-to-face discussions between GPs and pharmacists around expectations and preferences can help facilitate timely, high-quality RMMRs.”

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