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New call to action on minimising chemical restraint


A funded complete-cycle-of-care approach would help address the overuse on antipsychotics in aged care, writes Natalie Soulsby.

The interim report of the aged care royal commission provides a damning indictment into what is happening in both the residential and home aged care sectors. Of note was the whole section dedicated to restrictive practices and the role medications play.

One of their findings was that the use of psychotropic medications was not clearly justified in 90 per cent of cases they were prescribed.

Natalie Soulsby

It also identified a lack of knowledge among personal care workers, nurses and GPs about restraints and their impacts, alternatives to their use and safe and appropriate management of dementia-related behaviours.

Evidence clearly supports that regularly reviewing these medications is vital to reducing the risk of harm to the person receiving these drugs.

In the current Community Pharmacy Agreement and Medicare Benefits Scheduled funded system, there is little emphasis placed on the importance of this step in the treatment regimen.

Current funding for Quality Use of Medicines services, which are designed to build capacity and capability within aged care providers through services such as staff education and medication audits, provide about four hours of clinical pharmacist support per month in an aged care home.

In addition, Residential Medication Management Reviews are only available for residents when they enter the facility or every two years unless a clinical incident has occurred.

The interim report suggests that regular and targeted reviews of residents taking medications is an evidence-based way of reducing psychotropic use, preventing medical complications that can arise from taking multiple medications, and promoting the quality use of medicines.

The Federal Government responded to the interim report by announcing $25.5 million to fund more frequent medication reviews.

This equates to one extra review per resident over the next six months until the new 7th CPA starts. We don’t yet have the detail on how this will work.

Ideally this funding will be for targeted reviews for residents prescribed medications considered chemical restraint with capacity for accredited clinical pharmacists to follow up their suggestions every three months to ensure the prescribing of these medications is appropriate.

If this is how the money is spent, then it is a step in the right direction for providing the best possible care for our vulnerable residents with behavioural issues due to their dementia.

However, ideally this would not be restricted to only those residents prescribed medications for the purposes of chemical restraint.

Evidence-based approach

The concept of a ‘complete cycle of care’ is long recognised as the best practice model of clinical care.  A full cycle of care in this context includes:

  • identify the individual’s medication related issues and create a solution to those issues in the form of a medication plan
  • collaborate on the medication plan between all parties involved in the person’s care
  • regularly monitor and update plan to tailor to the needs of the person
  • ultimately resolve the issues identified at the outset of the process
  • prevent the recurrence of issues by building capacity and capability amongst care team.

Although the ability to complete the cycle of care for an individual is considered best practice, current funding arrangements do not support this model.

If someone’s altered behaviour warrants pharmaceutical intervention, the accredited clinical pharmacist who services the aged care home is best placed to support the resident staff, and the GP to ensure the resident receives the best possible care because of their specialist knowledge in medications for the elderly.

To deliver better targeted support via a full cycle of care and empower aged care providers, three simple enhancements are needed to the current funding arrangements:

  1. The supported involvement of both a clinical pharmacist and supply pharmacist in collaborative case conferences with the GP to discuss the medication plan.
  2. The additional category ‘Medication Plan Updates’ to give the accredited clinical pharmacist the capacity to both implement and monitor recommendations.
  3. Accredited clinical pharmacists spending more time on the ground in aged care homes to provide education and support activities such as chemical restraint audits.

The 7th Community Pharmacy Agreement is currently being negotiated and this is an opportunity for us to ensure that the optimal cycle of care model is put into place and to support one of our most vulnerable populations.

I suggest you write or speak to your local MP and state and federal ministers for health, aged care or ageing to advocate for the safe and effective use of medicines to ensure the elderly in our care are not forgotten.

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