Exploring Medication Risk among Older Residents in Supported Residential Services: A Cross-Sectional Study

The extent of antipsychotic use in Australian residential aged care facilities and interventions shown to be effective in reducing antipsychotic use: A literature review

At least half of all residents of Australian residential aged care facilities have dementia. Most residents living with dementia will at some stage experience behavioural and psychological symptoms of dementia (BPSD), which can be challenging to manage and distressing for the resident, their family and carers. This literature review examined the prevalence of antipsychotic use in Australian residential aged care facilities, which may be used to manage BPSD only after non-pharmacological treatments have failed. Sixteen studies assessing care between 2000 and 2017 were identified and reviewed. The proportion of residents prescribed an antipsychotic ranged from 13% to 42%. Evidence from six Australian interventions showed that the antipsychotic use can be reduced, especially when non-pharmacological interventions that are individualised to the person and the behaviour are implemented. Research has shown that antipsychotics can be tapered and ceased without re-emergence of behavioural symptoms in many instances. Multidisciplinary, multi-strategic approaches have demonstrated effectiveness in reducing antipsychotic use by up to 3% (absolute reduction) in the aged-care setting.

Medicines Management, Medication Errors and Adverse Medication Events in Older People Referred to a Community Nursing Service: A Retrospective Observational Study

BACKGROUND

Increasing numbers of older people are receiving support with medicines management from community nursing services (CNSs) to enable them to live in their own homes. Little is known about these people and the support they receive.

OBJECTIVES

To explore the characteristics of older people referred for medicines management support, type of support provided, medication errors and adverse medication events (AMEs).

METHODS

A retrospective observational study of a random sample of 100 older people referred to a large non-profit CNS for medicines management support over a 3-month period was conducted. Measures were: demographics, referral source, current medical problems, medicines, medication aids, types of medication authorisations used by nurses, frequency of nurse visits and type of support provided, medication errors, AMEs and interdisciplinary teamwork among community nurses, general practitioners and pharmacists.

RESULTS

Older people (median 80 years) were referred for medicines support most often by hospitals (39 %). Other referrals were from families/carers, case-managers, palliative care services and general practitioners. Multiple health conditions (median 5) and medicines (median 10) were common; 66 % used ≥5 medicines; 48 % used ≥1 high-risk medicines-most commonly opiates, anticoagulants and insulin. Medication aids were frequently used, mostly multi-compartment dose administration aids (47 %). Most people received regular community nurse visits (≥4 per week) to administer medicines or monitor medicine-taking. Only 16 % had a medication administration chart; for other clients nurses used medicine lists or letters from doctors for medication authorisation. Medication errors occurred in 41 % of people and 13 % had ≥1 AME requiring medical consultation or hospitalisation; 9/13 (64 %) AMEs were potentially preventable. There was little evidence of interdisciplinary teamwork or medication review.

CONCLUSION

CNS clients had multiple risk-factors for medication misadventure. Deficiencies in medicines management were identified, including low use of medication charts and interdisciplinary medication review. Strategies are needed to improve medicines management in the home-care setting.

Evaluation of a support worker role, within a nurse delegation and supervision model, for provision of medicines support for older people living at home: the Workforce Innovation for Safe and Effective (WISE) Medicines Care study

Background

Support with managing medicines at home is a common reason for older people to receive community nursing services. With population ageing and projected nurse shortages, reliance on nurses may not be sustainable. We developed and tested a new workforce model: ‘Workforce Innovation for Safe and Effective (WISE) Medicines Care’, which enabled nurses to delegate medicines support home visits for low-risk clients to support workers (known as community care aides [CCAs]). Primary study aims were to assess whether the model increased the number of medicines support home visits conducted by CCAs, explore nurses’, CCAs’ and consumers’ experiences with the CCAs’ expanded role, and identify enablers and barriers to delegation of medicines support.

Methods

A prospective before-after mixed-methods study was conducted within a community nursing service that employed a small number of CCAs. The CCAs’ main role prior to the WISE Medicines Care model was personal care, with a very limited role in medicines support. CCAs received training in medicines support, and nurses received training in assessment, delegation and supervision. Home visit data over two three-month periods were compared. Focus groups and interviews were conducted with purposive samples of nurses (n = 27), CCAs (n = 7) and consumers (n = 28).

Results

Medicines support visits by CCAs increased from 43/16,863 (0.25 %) to 714/21,552 (3.3 %) (p < 0.001). Nurses reported mostly positive experiences, and high levels of trust and confidence in CCAs. They reported that delegating to CCAs sometimes eliminated the need for duplicate nurse and CCA visits (for people requiring personal care plus medicines support) and enabled them to visit people with more complex needs. CCAs enjoyed their expanded role and were accepted by clients and/or carers. Nurses and CCAs reported effective communication when medicine-related problems occurred. No medication incidents involving CCAs were reported. Barriers to implementation included the limited number of CCAs employed in the organisation and reluctance from some nurses to delegate medicines support to CCAs. Enablers included training and support, existing relationships between CCAs and nurses, and positive staff attitudes.

Conclusions

Appropriately trained and supervised support workers can be used to support community nurses with providing medicines management for older people in the home care setting, particularly for those who are at low risk of adverse medication events or errors. The model was acceptable to nurses, clients and carers, and may offer a sustainable and safe and effective future workforce solution to provision of medicines support for older people in the home care setting.

Exploring stakeholder perspectives on medication review services for older residents in retirement villages

Objective

To explore stakeholder perspectives on a government-subsidised Home Medicines Review (HMR) service and factors affecting the uptake of HMRs for older residents of retirement villages in Australia.

Methods

Thirty-two in-depth interviews and four focus groups were undertaken with a purposive sample of 32 residents of retirement villages, 10 pharmacists, nine general practitioners (GPs) and a general practice nurse. Data were transcribed verbatim and analysed using the framework approach.

Key findings

Three major themes were identified: participants' perceptions of the HMR service, barriers to the uptake of HMRs and strategies for increasing the uptake of HMR. Residents had positive, negative or mixed perceptions, whereas health professionals were generally positive about the benefits of the service. Barriers to the uptake of HMRs were related to GPs, pharmacists, patients and the healthcare system. A strategy recommended by multiple stakeholders for increasing the uptake of HMRs was to use a multi-faceted intervention targeting residents and their health professionals.

Conclusions

Multiple barriers to the uptake of HMRs and multiple strategies for increasing the uptake of HMRs were identified. These findings could inform the design of interventions to improve uptake of HMRs by residents and health professionals, in turn leading to better medicine use and safety.