Aged care royal commission: medication management and pill regimes in the spotlight

The complex question of care for older Australians has been under the spotlight since the Royal Commission into Aged Care Quality and Safety began late last year. The commission winds up next April; statistics show that 8 per cent of all Australians aged over 65 receive residential aged care services each year.

Monash University’s Centre for Medicine Use and Safety –within the Monash Institute of Pharmaceutical Sciences – is partnering with aged care providers to offer solutions in the area of medication management, which is under direct scrutiny at the royal commission.

“Medication management can be further optimised,” says the centre’s director, Professor Simon Bell.

“We're working with clinicians, aged care providers and consumers to develop possible solutions. This [the royal commission] is an important opportunity to highlight the value of universities working together with the aged care sector to improve medication outcomes for people receiving aged care services.”

Professor Bell’s main collaborator in the centre’s aged care projects, Monash’s Dr Janet Sluggett, a National Health and Medical Research Council (NHMRC) Early Career Fellow, appears at a commission hearing this week in Darwin to outline the centre’s work carried out in collaboration with aged care provider organisations.

The research is broad in scope but covers medication use in older people. How much medication is taken and how often? How best to streamline the system for administering medicines to residents of aged care services?

The centre’s recent work includes two specific projects.

The first is a systematic review (ie, studying known evidence) on the “process, impact and outcomes” of collaborative medication reviews provided to residents. That is, how the system for reviewing a medication regimen for a resident currently works, and the types of recommendations that pharmacists make.

This review was led by pharmacist and PhD candidate Esa Chen, and is due to be published in the Australasian Journal on Ageing. It shows that medication reviews performed by pharmacists and general practitioners identify between 2.7 and 3.9 “medication-related problems” per resident, and that GPs accept 45-84 per cent of pharmacists’ recommendations to resolve these problems. The researchers said this shows the benefit of pharmacists and GPs working more closely together to improve care.

Professor Bell said studies have shown that up to 63 per cent of residents of Australian aged care services take at least nine different medications regularly.

“Medications are one of the most common reasons for residents and their carers to express concerns,” he said. “Some of these concerns – that have led to the royal commission – are due to ongoing use of medications that are perceived as unnecessary or no longer appropriate.”

Professor Bell said while “particular concern” has been expressed around antipsychotic medicines, the issues are broader than this.

“We're working on strategies to help ensure that a person’s medication regimen is consistent with their goal of care. To do this, we're generating new evidence in relation to the likely benefits and risks of a range of medications in the residential aged care setting,” he said.

The second platform of the Centre for Medicine Use and Safety’s research in aged care focuses on simplifying a resident’s medication regimen.

The research team has previously shown that residents with more complex medication regimens are more likely to be hospitalised, and spend longer in hospital, than residents with less complex regimens.

This research study was published in the Journal of the American Medical Directors Association in late 2016.

The research team has since worked closely with aged care providers, health professionals, consumers, carers and other individuals to develop a practical tool and corresponding clinical trial. This research has been funded through the NHMRC Cognitive Decline Partnership Centre.

“Residents of aged care services take medications four times per day on average. We have seen that, in many cases, residents can take the same medications in a simpler way."

The names of the tool and clinical trial use acronyms. MRS GRACE stands for the "Medication Regimen Simplification Guide for Residential Aged CarE", while SIMPLER refers to "Simplification of Medications Prescribed to Long-tErm care Residents".

The MRS GRACE tool is being evaluated in the SIMPLER trial with a view to consolidating existing medications. The researchers believe this will lessen the burden of medication use for residents and enable aged care staff to spend more time on other kinds of care for residents.

MRS GRACE is a five-step tool for pharmacists and other health professionals to use when working through a resident’s medication list. Before being used in the SIMPLER trial, it was tested and validated by the research team.

Two clinical pharmacists applied the tool to medication charts for a random sample of 50 residents of aged care facilities, and were able to simplify medications for six out of every 10 residents. The findings were published in the Clinical Interventions in Aging journal.

The SIMPLER clinical trial involves 242 residents in eight South Australian aged care facilities. The study protocol was published in the journal Trials last year.

In it, a clinical pharmacist has used the principles outlined in MRS GRACE to identify opportunities to simplify medication regimens for residents. Researchers maintain it will reduce complexity in medication use, which benefits both residents and aged care staff.

Dr Sluggett said: “Residents of aged care services take medications four times per day on average. We have seen that, in many cases, residents can take the same medications in a simpler way.

“We [the researchers] see the medication simplification process as complementary to the existing medication review process in residential aged care, and it's something extra that pharmacists can have in their toolkit when working with residents and aged care providers.

“Simplifying the way medications are administered is particularly important, because having a complex medication regimen has been linked with poor health outcomes for residents.”