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Tuesday, August 9, 2022

Polypharmacy is not an issue, inappropriate polypharmacy is the problem

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The Royal Commission into Aged Care Quality and Safety implored government to take a far more active role in monitoring elders’ health and wellbeing within residential aged care facilities (RACFs).

One immediate means of doing this was via the National Aged Care Quality Indicator Program (QI Program), which provides quarterly reporting on a number of health and safety metrics relevant to elders living in RACFs.

Whilst the initial quality indicator program reported on the prevalence of three phenomena — pressure injuries, use of physical restraint and unplanned weight loss — in July 2021, two extra indicators were added, related to falls and medication management.

The latest QI Indicator report, released by the Australian Institute of Health and Welfare (AIHW) this month, details the prevalence of these five metrics for the first quarter of the year.

Some of the most notable statistics this quarter relate to use of prescription medications within RACFs.

According to the AIHW data, more than a third (37.5 per cent) of Australian aged care residents were listed as taking enough medications to constitute polypharmacy (nine or more prescription medications at once).

Furthermore, 20 per cent of aged care residents were found to be on antipsychotic medication, while only half of these residents had a confirmed diagnosis of psychosis.

So, should we be concerned by these figures?

To put the data into context, Aged Care News spoke to Dr Manya Angley, consultant pharmacist and recipient of the Australian Association of Consultant Pharmacy’s 2021 MIMS Consultant Pharmacist of the Year award.

Polypharmacy – a debated definition

Polypharmacy: it’s a complex issue from its very foundation, with the very definition of the word varying depending on the organisation to whom you speak.  

Whilst the World Health Organisation, Australian Medical Association, and the Royal Australian College of General Practitioners all denote polypharmacy as the use of five or more medications concurrently, the Federal Government itself says otherwise.

Reporting within the royal commission, as well current AIHW reporting, both use the threshold of nine or more medications in the context of aged care.

Is raising this definitional bar suspect? Not so, according to Angley.

“I think it is fair that the Department of Health (DoH) are considering nine or more medicines as a threshold. It is not dodgy,” she says.

“There is no consensus as to what number of medicines constitutes polypharmacy.”

Consultant pharmacist Dr Manya Angley says that pharmacists should collaborate closely with RACFs to manage polypharmacy and antipsychotic use.

Angley points to a 2017 systematic review published in the journal BMC Geriatrics which analysed the ever variable definition of the term, with the classification ranging from the concurrent use of two, all the way up to 11 medications.

“Most commonly it refers to five or more medicines, and nine or more is defined as ‘hyper-polypharmacy’,” Angley notes

But there are some nuances that Angley believes are not currently recognised by the AIHW criteria.

“The concerns that I, and many of my pharmacist colleagues, have is with how the DoH are asking us to count the medicines aged care residents are prescribed.

“Some medicines have two active ingredients: Coveram, for example, contains two heart medicines amlodipine and perindopril.

“The DoH want Coveram to be counted as one medicine, which is nonsense.

The concerns that I, and many of my pharmacist colleagues, have is with how the DoH are asking us to count the medicines aged care residents are prescribed.

Dr Angley

“Also the DoH don’t want vitamins and minerals to be counted, eg. calcium, iron, magnesium, ascorbic acid, which is also nonsense because these all contribute to medication burden and have potential to interact with other medicines.

“There are other issues with how the DoH want polypharmacy to be determined such as the fact that oral vitamin B12 is not to be counted, but vitamin B12 by injection is — go figure!”

Is polypharmacy inherently a danger?

With about 80 per cent of older Australians having one or more chronic conditions, and 38 per cent having three or more, it seems a tough task to avoid polypharmacy in the older cohort.

“Polypharmacy per se is not the issue; it is actually inappropriate polypharmacy that is the problem,” Angley explains.

“Polypharmacy doesn’t always increase the risk of harm. Sometimes it does and other times it doesn’t.

“A person with multimorbidity — for example, a person with diabetes, heart failure, asthma and rheumatoid arthritis — would be expected to be on nine or more regular medicines.

“In fact, if they weren’t on nine or more medicines, there is a good chance they weren’t being properly managed.

“If polypharmacy is appropriate, it actually reduces harm and can make people live longer.”

Polypharmacy per se is not the issue; it is actually inappropriate polypharmacy that is the problem. Polypharmacy doesn’t always increase the risk of harm. Sometimes it does and other times it doesn’t.

Dr Angley

With such variable impacts, the presence of polypharmacy emphasises the need for pharmacists to be available as a crucial check and balance within the aged care system.

Research from the Pharmaceutical Society of Australia has found that more than 95 per cent of aged care residents have at least one problem with their medication regimen discovered upon review — with 6 per cent of these denoted as ‘potentially hazardous’ to a resident’s immediate health.

“What really matters is that the data obtained from the polypharmacy QI is put to good use … the data has to be used to improve resident outcomes,” Angley says.

A stronger embedding of pharmacists in aged care is what is required to ensure that polypharmacy can be adequately monitored.

“Aged care pharmacists, independent of the supply pharmacists, are the health professionals best positioned to identify inappropriate polypharmacy and provide the prescribers with suggestions and recommendations to cease/deprescribe medicines that are inappropriate,” Angley says.

What really matters is that the data obtained from the polypharmacy QI is put to good use … the data has to be used to improve resident outcomes.

Dr Angley

“One effective way to do this is through medicines reviews— available through the RMMR Program.

“OAC pharmacists or contracted Quality Use of Medication review pharmacists can also be a driver to reducing inappropriate polypharmacy via clinical governance activities such as audit and feedback.”

In March, the former Government pledged $345 million to fund on-site aged care (OAC) pharmacists in every Government-funded facility from January 2023, igniting hopes that better medication management may be on the horizon.

“It is expected that in 2023, 20 per cent of ACFs will have OAC Pharmacists, 40 per cent in 2024 and 60 per cent in 2025,” Angley says.

Antipsychotic use in RACFs – work ongoing to reduce prevalence

“Antipsychotic medicine continues to be overused, but there is greater awareness of the risks with the antipsychotic QI indicator and the requirement for ACFs to maintain a psychotropic register,” Angley says.

She adds that restrictions to usage of risperidone, an antipsychotic medication indicated for behavioural and psychological symptoms of dementia, is a positive step forward.

“Awareness is an important first step to improvement. Also Pharmaceutical Benefits Scheme restrictions on prescribing risperidone to 12 weeks has helped.”

Importantly, work is ongoing to consider heavy medications a last resort, and to emphasise newer, drug-free alternatives where possible.

“The key is to use the lowest dose of antipsychotic for the shortest possible time and to always have non-pharmacological strategies in place,” Angley says.

“Various programs such as RedUse, NPS Medicine Wise, Aged Care Quality & Safety Commission have been implemented to upskill pharmacists, aged care staff, and GPs who service aged care residents — but there is still a long way to go.”

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