Residential aged care facilities in Australia have long faced criticism – inadequate medical supervision, insufficient numbers of nursing and care staff, poorly trained and lowly paid workers… no one talks of an easy fix, but few argue that changes aren’t needed.
Although the number of elderly residents exceeds 200,000 (in 2672 ‘nursing homes’, as they were once called) the volume of concerns made public seemed relatively low… until recently when mounting complaints and media coverage prompted the Federal Government to call a Royal Commission into Aged Care Quality and Safety.
Hearings are well under way, as most Australians would know, and often harrowing evidence is being tendered. The Royal Commissioners are required to provide an interim report by 31 October this year, and a final report by 30 April 2020.
Among the key topics raised in the Royal Commission has been the inappropriate use of psychotropic or sedative medications, particularly in residents with dementia. From 2013-17 an innovative project known as Reducing Use of Sedatives – ‘RedUSe’ for short – was funded by the Department of Health through the ‘Dementia and Aged Care Service Fund’.
Program Research Lead Dr Juanita Breen (previously Westbury), Wicking Dementia Research and Education Centre, and Distinguished Professor Gregory Peterson Pharmacy, School of Medicine, University of Tasmania discuss the background and the significant outcomes…
One of the topics of discussion at the current hearings of the Royal Commission into Aged Care Quality and Safety has been the appropriate use of psychotropic or sedative medications, particularly in aged care residents with dementia. While there are no individual or quick fixes to the high use of these medications in aged care, a national interdisciplinary program, recently published in the Medical Journal of Australia,1 was very successful.
Antipsychotics were developed to treat serious mental health conditions, such as schizophrenia. We know that in older people these medications are prescribed mostly to manage behavioural and psychological symptoms of dementia (BPSD), a term that describes symptoms of disturbed perception, thought content, mood, and behaviour that frequently occur in patients with dementia. While their effectiveness to treat these symptoms is modest, the risks associated with use can be severe, ranging from confusion and falls, to stroke and death.
Similarly, benzodiazepines are prescribed in older people to treat sleep disturbance, anxiety and agitation. These can be effective in the short-term but in time tolerance develops, and their continued use is frequently associated with over-sedation and confusion, falls, and the risk of dependency.
Given the modest benefits and the attendant risks, which are not insignificant, national and international guidelines recommend that both medication classes should be prescribed carefully when anxiety, sleep disturbance and/or behavioural symptoms cause significant distress, or pose a safety risk. When prescribed, they should be monitored regularly for effect and adverse effects, whilst using the lowest effective dose for the shortest period of time.
Inappropriate use of antipsychotic and benzodiazepine agents has been recognised as an issue in Residential Aged Care Facilities (RACFs) in Australia for several decades, resulting in Federal and State government inquiries, media attention and the release of a succession of professional guidelines. However, antipsychotic and benzodiazepine use continues to be high in this setting, with many residents often taking these medications inappropriately, for extended periods.
The RedUSe (Reducing Use of Sedatives) project expansion was funded in 2013 by the Department of Health through the ‘Dementia and Aged Care Service Fund’. The overarching aim of RedUSe is to promote the appropriate use of antipsychotics and benzodiazepines (collectively termed ‘sedatives’) in RACFs. The project was first trialled successfully in a 2008 study involving 25 Tasmanian RACFs. The federally-funded expansion involved 150 RACFs across Australia during 2014-16.
RedUSe is a multi-strategic, interdisciplinary, structured initiative, which employs several approaches targeted to improve sedative use. During the 6-month project, each RACF’s sedative medication use is audited at baseline, 3 months and 6 months, using a customised computer program. The audit results are then presented to nursing staff and carers during two educational sessions. Following this education, all residents taking sedative medication are reviewed in an interdisciplinary process involving a pharmacist, a ‘champion nurse’ at each facility and the resident’s GP or nurse prescriber. The diagram below illustrates the main RedUSe strategies:
The RedUSe project was enhanced before expansion by developing an interactive training program for nursing staff, which was designed to challenge their positive beliefs around sedative use. Training was also delivered on the risks and benefits associated with sedative use in older people, and concise guidelines provided. The sedative review process was refined and automated. Nurse input was crucial and professional roles clearly defined. The ‘champion nurse’ role was created for an expert peer to promote and model ‘good practice’. Finally, academic detailing was delivered externally, by trained detailers, to inform and engage GPs.
Strong demand to participate in RedUSe was generated after the two Australian peak aged care organisations, LASA and ACSA, promoted the project in their newsletters (print and on-line), resulting in expression of interest forms from over 300 RACFs.
“Reducing benzodiazepine use was shown to increase the residents’ ability to perform activities of daily living… [while] participating in the RedUSe project… did not adversely affect job satisfaction of nursing staff”.
Throughout the RedUSe intervention, antipsychotic and benzodiazepine use in each of the 150 RACFs was measured at baseline and then re-measured at 3 and 6 months, with 12,165 residents, on average, included at each time point. At baseline we found that over one-third of residents (37%) were taking a daily sedative medication. Specifically, 22% of residents were taking an antipsychotic and 22% were taking a benzodiazepine. With ‘prn’ or ‘as required’ prescriptions included, over half of all RACF residents (54%) were prescribed a sedative.2
Overall, a significant reduction was found in antipsychotic and benzodiazepine use. A 13% relative reduction was observed in the use of antipsychotics from baseline to 6 months (The reduction in benzodiazepine prevalence from baseline to 6 months was higher, at 21%). Almost 40% of residents taking these agents at baseline had their psychotropics ceased completely or their dosage reduced. The reduction was also sustained over time.
The education provided to the aged care sector as a result of this project was substantial. Over 2500 nursing staff and carers attended RACF RedUSe educational sessions. Using a validated quiz, we found that the psychotropic knowledge of all levels of nursing and care staff significantly improved. Participants reported particularly valuing the opportunity to discuss the use of sedative medications for their residents and many wanted to learn more about medications and their side effects, along with non-pharmacological approaches.
Although several interventions have been designed and trialled to reduce sedative medication use in RACFs, few have evaluated the clinical impact of such a program on the residents themselves. The expansion of the RedUSe project offered an ideal opportunity to do this and also establish if the project impacted upon staff satisfaction.
Using a sample of over 200 sedative users from 27 participant RACFs, we found there were no significant increases in behavioural symptoms for sedative reducers, contrary to expectations. In fact, antipsychotic reducers saw improvements in some behaviours, specifically agitation, whilst the non-reducers had worsening behaviour. Reducing benzodiazepine use was shown to increase the residents’ ability to perform activities of daily living. Finally, participating in the RedUSe project, with ensuing sedative reduction, did not adversely affect job satisfaction of nursing staff.
In conclusion, the national expansion of RedUSe proved an effective intervention to significantly reduce RACF antipsychotic and benzodiazepine use, with high degrees of staff, pharmacist and GP satisfaction. A multi-strategic, interdisciplinary intervention can significantly reduce potentially inappropriate psychotropic use.
- The RedUSe project and researchers involved have been recognised by two international research awards, the 2018 Tasmanian Community outstanding achievement award and a 2018 Mental Health Services award. It has also received over $3.4M worth of research funding to date.
- Westbury JL, Gee P, Ling T, Brown DT, Franks KH, Bindoff I, Bindoff A, Peterson GM. RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities. Med J Aust 2018;208(9):398-403.
- Westbury J, Gee P, Ling T, Kitsos A, Peterson G. More action needed: Psychotropic prescribing in Australian residential aged care. Aust NZ J Psychiatry 2019;53(2):136-47.
Correspondence: Dr Juanita Breen, Senior Lecturer Dementia Studies, Wicking Dementia Research and Education Centre, Private Bag 143, Hobart, Tasmania, Australia 7001.
