eHealth solution to RedUSe the use of sedatives in aged care

Research has consistently shown unnecessarily high usage of benzodiazepine and antipsychotic medications in the aged care sector, both within Australia and internationally, leading international experts to dub residential aged care facilities (RACFs) “modern mental institutions for the elderly”.

Most recently in Australia this was highlighted by the Senate Committee on Community Affairs, in late March. This report (pdf) refers to an “over-reliance on medication to manage the behaviour of residents”.

This was not the first government inquiry to look into the issue. A Senate committee reported on the topic in 1995, and in 1997 a NSW ministerial taskforce looked into psychotropic use in nursing homes. Both reports recommended measures such as pharmacists reviewing psychotropic medication and staff education on the problems associated with giving psychotropic medication to older frail residents.

Promotion of alternate non-drug ways to manage behavioural problems, anxiety and sleep disturbance was strongly endorsed. Despite these reports, little substantive change has occurred within the sector.

Residents of RACFs are prescribed antipsychotics and benzodiazepines (collectively known as sedative medications) to manage behavioural problems in dementia, including aggression, agitation, calling out and wandering. However, it is well established that antipsychotics only work to reduce agitation in about one in five residents who take them.

In recent years the use of antipsychotics in people with dementia has been linked to stroke, kidney disease, increased risk of pneumonia, heart conditions and death. There is no evidence to support the use of benzodiazepines for dementia; in fact, recently published research indicates that these medications actually worsen Alzheimer’s disease.

Benzodiazepines are also used to combat sleep disturbance and anxiety, conditions very common in RACF residents. Yet, many residents become tolerant to benzodiazepines effects and these medications cause falls, day time sedation, increase pneumonia rates, cause confusion and impair resident engagement.

Research has shown that the most effective interventions to reduce psychotropic medication use in RACFs involve audit, benchmarking and feedback; staff education and interdisciplinary review.

With this in mind, a team of researchers at the University of Tasmania resolved to automate the process of auditing benzodiazepine and antipsychotic usage rates within RACFs. This process had to be quick, easy, and reliable. The most effective way to determine psychotropic usage levels within a given RACF was to extract the data from the medication packing software system used by the pharmacy that serviced the RACF.

In 2007, Juanita Westbury initiated a pilot study called Reducing the Use of Sedatives: RedUSe, which trialled this approach in 15 facilities in Tasmania. This automated audit, coupled with education and training sessions, was aimed at promoting appropriate use of sedative medicines and equipping carers with alternative strategies to manage behavioural problems.

In these training sessions nurses and carers were confronted with their RACFs sedative and antipsychotic usage levels, extracted from the medicine packing software, and challenged to explore ways of improving them.

The results of this pilot study were very encouraging. Benzodiazepines and antipsychotic medicines were significantly reduced in all participating RACFs, with little to no ill effects being reported. This study inspired a similar successful recent trial conducted by NPS MedicineWise and Webstercare that was recently reported on by Pulse+IT.

More significantly, based on the results of the pilot study, the Australian government awarded a $3 million grant to the University of Tasmania to expand this program to 150 RACFs as a nationwide implementation trial.

This implementation project commenced in 2013, and is now well underway. It is supported by Bupa Care, Southern Cross Care and a broad range of independent RACFs.

The RedUSe data extraction software can automatically extract all packed medicines for a given RACF from a range of common medicine packing systems, including FredPak, Webstercare, MPS and Minfos.

This extracted data is securely uploaded to the RedUSe web server, where each resident taking sedatives is reviewed by a RedUSe project pharmacist, a nurse from the given RACF, and the Quality Use of Medicines pharmacist that works at the facility. The data is then benchmarked against national sedative use and presented to the participating RACF, coupled with a customised training session.

The process is repeated at three months, re-iterating the message of the project, and giving the RACF an opportunity to see how their usage levels are tracking over time. A final benchmarked eHealth audit report is presented to the RACF and participating health professionals at six months.

The RedUSe project was rolled out to 27 RACFs in March this year and interim results look promising. Facilities have typically reduced benzodiazepine and antipsychotic doses at the three-month mark in somewhere between 30 and 70 per cent of their patients who were originally taking them.

Another 40 RACFs will start “RedUSing” from October 2014, followed by two more similarly sized waves in 2015.

For more information about the RedUSe project, see the RedUSe website.

Dr Ivan Bindoff is a research fellow at the School of Medicine's unit for medication outcomes research and education, and Dr Juanita Westbury is a research fellow and lecturer in pharmacy practice, both at the University of Tasmania.

Posted in Aged Care

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