Roles for pharmacists in improving the quality use of psychotropic medicines in Residential Aged Care Facilities

The major psychotropic drug classes are antipsychotics, antidepressants and anxiolytic/hypnotics. Professional guidelines advise that these agents should only be prescribed to manage behavioural and psychological symptoms of dementia (BPSD), anxiety and insomnia in older people after non-drug measures have proved ineffective. Psychotropic medications, particularly antipsychotics and benzodiazepines, are associated with significant risks, yet they only offer modest benefits to treat these conditions. Consequently, these medications should be initiated at the lowest effective dose, monitored regularly and administered for time-limited periods. Despite this advice, many researchers have reported high rates of psychotropic drug use in Residential Aged Care Facilities (RACFs) both in Australia and internationally over the last three decades. Moreover, rates of psychotropic use in RACFs appear to be increasing, a trend which most likely reflects the growing proportion of residents with mental health conditions. The main focus of this thesis was on antipsychotic and benzodiazepine use as the prescribing of these particular psychotropic agents is widespread, there are doubts over their effectiveness and they are strongly associated with significant risks in older people. There has also been considerable attention from both professional and regulatory authorities directed at rationalising the use of these medications. Although antidepressants are also associated with risks, there is strong evidence for their effectiveness in this population and many experts in the psychogeriatric field feel they are underutilised in the RACF setting. For this reason, the research was targeted at promoting guideline-based use of antipsychotics and benzodiazepines. Aside from their traditional supply role, pharmacists are increasingly becoming involved in promoting Quality Use of Medicines or ‘QUM’. In Australia, at the time of this research, community pharmacies were funded to provide Residential Medication Management Reviews (RMMRs) and associated QUM strategies to each facility, such as medication audit, formulary development and nurse education. Although RMMRs were shown to improve medication use in one large controlled trial, the effect of pharmacist-led QUM strategies on RACF psychotropic prescribing has not been evaluated. Therefore, the key objective of this thesis was to assess if pharmacists could positively influence RACF psychotropic utilisation through the use of a series of facility-focused QUM strategies delivered in a dedicated intervention project. However, before the intervention project could be developed, some vital background research was required. This is why the research for this thesis was conducted in three chronological stages. An evaluation of current psychotropic usage was initially needed to identify the main areas of concern and gauge the overall pattern of prescribing; thus, the first stage involved a retrospective cross-sectional study of prescribing data in a large representative sample of 40 RACFs throughout Roles for Pharmacists in improving the quality use of psychotropic medicines in Residential Aged Care Facilities Juanita L Westbury iv Tasmania. As professional guidelines recommend that psychotropic medications are reviewed on a regular basis and dose reductions attempted routinely, the cross-sectional measure was repeated 12 months later to evaluate the extent of review in the RACFs. Previous studies had shown a high rate of psychotropic use in Tasmanian RACFs. This trend was also evident in this study, with an average of 42% of residents taking regular doses of benzodiazepines and 20% of residents taking antipsychotics during 2006. Although the rate of antipsychotic prescribing was similar to rates reported in Sydney and New Zealand in the same time frame, the rate of benzodiazepine use in Tasmania was three times that reported in these other studies. Further, when the RACFs were re-audited a year later, over 60% of antipsychotic and benzodiazepine medications and doses were unchanged; a finding which strongly implies a lack of review of these psychotropic agents, contrary to current professional guidance. After obtaining an overall picture of prevalence, inappropriateness and the extent of review of antipsychotics and benzodiazepines, the second stage of this research thesis sought to gain a greater understanding of the determinants underlying their use in RACFs. A qualitative approach involving thematic analysis of semi-structured interviews with health professionals and relatives was chosen to answer the key research questions of this second stage, including why these medications are used and who is influencing their initiation and review? As there is a paucity of qualitative research related to psychotropic use in the residential aged care setting, this study not only provided valuable insight but also strongly informed the methodology of the subsequent intervention project. It became evident that many health professionals had limited knowledge about the risks associated with psychotropic use in older people, and that reviews were conducted infrequently, if at all. Of all health professionals, nursing staff were the most influential when psychotropic medications were initiated and utilised. As a consequence of this qualitative research, the key strategies of the intervention project were primarily targeted at nursing staff and designed to offer feedback on psychotropic use to individual RACFs, provide education about the risks associated with these agents, promote professional guidelines and encourage regular review and dose reduction. The main objective of the thesis was to design, conduct and evaluate an intervention project, trialling QUM strategies provided by community pharmacists, to facilitate the quality use of antipsychotic and benzodiazepine medications in RACFs. This third and final stage involved a large controlled trial run in 25 RACFs in the two major cities of Tasmania and was termed the ‘Reducing Use of Sedatives’ (RedUSe) project. Thirteen Hobart RACFs were recruited as the intervention group, with 12 Launceston RACFs acting as the control group. The RedUSe intervention was run over six months during 2008 to 2009. A series of QUM strategies were offered in the intervention RACFs, including two dedicated psychotropic medication audits, nurse education and feedback, and an interdisciplinary sedative review process. Roles for Pharmacists in improving the quality use of psychotropic medicines in Residential Aged Care Facilities Juanita L Westbury v At the conclusion of the project, the prevalence of benzodiazepines was significantly reduced in intervention facilities (31.8% to 26.9%, p < 0.005), whereas a small non-significant increase in use was found in control homes. Likewise, antipsychotic use was significantly reduced in intervention facilities when compared to control facilities, although to a lesser extent than benzodiazepines (20.3% to 18.6%, p < 0.05). Over the six months of the intervention project, the proportion of dose reductions of both benzodiazepines and antipsychotics in intervention facilities was almost double the proportion recorded in control facilities. Although several intervention projects aimed at improving RACF psychotropic use have been published, few research teams have reported cost effectiveness data, clinical outcomes for residents or evaluated the sustainability of the intervention project over the long term. Consequently, various post-analyses of intervention data were conducted to evaluate the clinical impact of the project on residents in terms of falls and behaviour, and assess cost effectiveness. In order to determine the sustainability of the intervention, a final follow-up audit measure was performed 12 months after the project was completed. The post analyses indicated that the reduction in sedative use had limited impact on falls; however, there was a significant decrease in challenging behaviours in those facilities recording a significant reduction in antipsychotic use. Some cost savings were achieved resulting from the reduction in benzodiazepine prescribing, but savings were not observed in antipsychotic costing. Finally, the repeat 12- month audit measure demonstrated that the reduction in benzodiazepine use in the intervention RACFs was sustained, with the mean daily dose of benzodiazepines continuing to reduce even further. In contrast, RACF antipsychotic use returned to pre-trial levels and doses remained static. The RedUSe intervention led to a statistically significant reduction in the proportion of residents in RACFs receiving benzodiazepines and antipsychotics, and the number of dosage reductions of these agents in intervention facilities was double that reported in the control facilities. These findings suggest that QUM strategies coordinated through community pharmacies, and incorporating the dissemination of local data on medication use, offer an effective approach to reduce antipsychotic and benzodiazepine use in RACFs.