Antidepressants not the only answer

The use of antidepressants in aged care homes is rising. It’s not understood – yet – if they’re being overused. But a new study – by the Registry of Senior Australians – highlights the “pressing need” to do more to improve residents’ wellbeing and ensure the safe and effective use of antidepressants, says its lead author.

“This was Australia’s first study looking at the use of antidepressants in aged care homes on a national scale,” lead author Georgina Hughes tells Australian Ageing Agenda. “We found a high level of antidepressant use among aged care homes across Australia.”

Hughes – a pharmacist and researcher – conducted the study as part of the PhD she is undertaking at ROSA and the University of South Australia. ROSA – which is based at the South Australian Health and Medical Research Institute – brings together diverse national and state-based datasets to monitor the outcomes of aged care recipients using existing information.

“My PhD uses big data from ROSA to examine the use of antidepressants in older people who are living in aged care homes across Australia,” says Hughes. “This is important in building the evidence base that calls for us to pay more attention to antidepressant use in aged care.”

Hughes led the study in collaboration with ROSA director Professor Maria Inacio and Dr Janet Sluggett, an associate professor in pharmacy and pharmacoepidemiology. They analysed the de-identified data of 779,659 residents from 3,371 aged care homes between 2006 and 2019.

“Our study found that use of these medicines has been increasing over time, and nearly six in every 10 older people living in aged care homes in Australia were using an antidepressant in 2019,” says Hughes.

According to the results – published in the Journal of American Medical Directors Association – 46.1 per cent of residents were using antidepressants in 2006 compared to 58.5 per cent of residents in 2019.

A growing focus on mental health – spurred by the aged care royal commission – is among factors contributing to this rise, says Hughes. But while antidepressants can have positive effects, they can also cause side effects such as nausea, restlessness and sedation, which can lead to falls and fractures.

“The use of antidepressants in aged care homes is roughly double compared to older people who are of a similar age and living in the community,” Hughes tells AAA. “Moving into an aged care home can have a big impact on a person’s life, and while it may be a positive experience for some people, others may experience feelings of sadness or loss during this transition.”

Researchers are unable to tell whether antidepressants are being overused. But the high use in aged care homes compared to the general population suggests a need for deeper investigation, says Hughes.

“We need to continue to look closely at this area to understand if these antidepressants are being used to treat clinically diagnosed depression or for other reasons.”

Hughes and her colleagues at ROSA are now conducting further studies into “where antidepressants are being started among older people entering aged care homes, and how long they are used for. We are also looking at the safety of antidepressants in older people who are living in aged care homes.”

Action aged care homes can take

On how people working in aged care can respond to the latest findings, Hughes encourages open discussions between residents, their families and healthcare professionals to ensure the safe and effective use of antidepressants.

“It’s important that people living in aged care homes are also accessing non-drug treatments that benefit their overall mental health and wellbeing and not solely relying on antidepressants,” she says.

Hughes also points out that residents with a GP referral can access a free medicines review from a pharmacist. The upcoming program for pharmacists working onsite in aged care homes will also provide opportunity to optimise the use of antidepressants in aged care homes, she says.

So agrees Michael Bonner, a clinical pharmacist and chief executive officer and owner of professional services company Choice Aged Care and registered training organisation Pharmacy Care Academy.

On 10 April this year, Pharmacy Care Academy found out it was approved by the Australian Pharmacy Council to deliver its aged care onsite pharmacist and medication management review program to the future cohort of credentialled pharmacists.

When it comes to supporting a resident’s mental health and optimising their medication, pharmacists are a key element, Bonner tells AAA.

“Antidepressant medication is second line. The first line is cognitive behavioural approaches and therapy. And that’s where you’ve got an onsite pharmacist, who is trusted and well known by the resident. That pharmacist is a key non-drug component of that therapy for depression so that they’re supporting the care staff and the nurses,” says Bonner.

And on a personal level, pharmacists are already very good at developing strong rapport with their customers in the community retail setting, he says.

“In the aged care setting these onsite pharmacists are going to be great at developing a strong relationship and trust with the residents so that they can openly talk about things like how they’re feeling.”

Training onsite pharmacists in aged care facility hubs

Under the latest plan, the government is funding community pharmacies to employ pharmacists to work onsite in residential aged care homes in a clinical role from July. Primary Health Networks will be able to engage pharmacists on behalf of aged care homes to work onsite where community pharmacies are unable or choose not to participate.

It’s not compulsory for aged care homes to take part in the program, but taking up an onsite pharmacist will replace the existing Residential Medication Management Review and Quality Use of Medicines Program services from a visiting pharmacist.

The APC developed accreditation standards and an accreditation system last year for medication management review – MMR – and aged care onsite pharmacist – ACOP – education programs.

The course offered by the Pharmacy Care Academy is a combined MMR and ACOP program that will provide a pharmacist the credentials for both roles. It’s the first ACOP program accredited, and only one on the APC’s list at the time of publication.

Also accredited is Monash University’s MMR pharmacist course. And the Pharmaceutical Society of Australia has an application in progress for a combined MMR and ACOP program, according to APC’s website.

Pharmacy Care Academy’s combined program features 80 hours of learning including onsite training and assessment.

“The program we have developed is unique and industry facing – aged care, not pharmacy,” Bonner tells AAA. “We have already established 40 training hubs across Australia as a mechanism for these pharmacist candidates to have proper and genuine exposure to the aged care setting before they’re put out into the industry in these onsite roles.”

The aged care facility-based training hubs span all states and mainland territories as well as metropolitan, rural and remote regions including indigenous facilities. The course, says Bonner, is built around three specific units of content:

• preparing pharmacists for the regulatory and quality framework in the aged care setting
• the roles, workflows and functions that the onsite pharmacists will be conducting
• leveraging technology to optimise medication safety in the aged care setting.

“Then we wrap all that together with a pretty intense work and integrated learning, getting onsite at the facility, buddying up with existing experienced credentialled pharmacists to perform and have lived experience with things like MAC meetings, handovers and staff education,” says Bonner.

The first cohort of students undertook the course at Regis Sandgate in April. This group included Bonner and Choice Aged Care managing director Christine Muller. Credentialled onsite pharmacists, says Bonner, will mean a significant improvement in the safe and quality use of medicines.

“It enhances exposure and access to a medication safety expert. And in doing that, we’re hoping that the residents and their family will be more engaged around processes like genuine informed consent and high-risk medication use,” he says.

It is also empowering the consumer to be part of decisions and preferences around medication management, says Bonner.

“We want the pharmacist to be educating the consumer about their medications so that they can support the doctors and the nurses and the care providers in approving the clinical care and specifically medication management.”

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