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Roles for pharmacists in improving the quality use of psychotropic medicines in Residential Care facilities


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Westbury, JL 2011 , 'Roles for pharmacists in improving the quality use of psychotropic medicines in Residential Care facilities', PhD thesis, University of Tasmania.

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The major psychotropic drug classes are antipsychotics, antidepressants and anxiolytic/hypnotics.
Professional guidelines advise that these agents should only be prescribed to manage behavioural
and psychological symptoms of dementia (BPSD), anxiety and insomnia in older people after
non-drug measures have proved ineffective. Psychotropic medications, particularly antipsychotics
and benzodiazepines, are associated with significant risks, yet they only offer modest benefits to
treat these conditions. Consequently, these medications should be initiated at the lowest effective
dose, monitored regularly and administered for time-limited periods. Despite this advice, many
researchers have reported high rates of psychotropic drug use in Residential Aged Care Facilities
(RACFs) both in Australia and internationally over the last three decades. Moreover, rates of
psychotropic use in RACFs appear to be increasing, a trend which most likely reflects the
growing proportion of residents with mental health conditions.
The main focus of this thesis was on antipsychotic and benzodiazepine use as the prescribing
of these particular psychotropic agents is widespread, there are doubts over their effectiveness and
they are strongly associated with significant risks in older people. There has also been considerable
attention from both professional and regulatory authorities directed at rationalising the use of these
medications. Although antidepressants are also associated with risks, there is strong evidence for
their effectiveness in this population and many experts in the psychogeriatric field feel they are
underutilised in the RACF setting. For this reason, the research was targeted at promoting
guideline-based use of antipsychotics and benzodiazepines.
Aside from their traditional supply role, pharmacists are increasingly becoming involved in
promoting Quality Use of Medicines or ‘QUM’. In Australia, at the time of this research,
community pharmacies were funded to provide Residential Medication Management Reviews
(RMMRs) and associated QUM strategies to each facility, such as medication audit, formulary
development and nurse education. Although RMMRs were shown to improve medication use in
one large controlled trial, the effect of pharmacist-led QUM strategies on RACF psychotropic
prescribing has not been evaluated. Therefore, the key objective of this thesis was to assess if
pharmacists could positively influence RACF psychotropic utilisation through the use of a series of
facility-focused QUM strategies delivered in a dedicated intervention project.
However, before the intervention project could be developed, some vital background
research was required. This is why the research for this thesis was conducted in three chronological
stages. An evaluation of current psychotropic usage was initially needed to identify the main areas
of concern and gauge the overall pattern of prescribing; thus, the first stage involved a retrospective
cross-sectional study of prescribing data in a large representative sample of 40 RACFs throughout Tasmania. As professional guidelines recommend that psychotropic medications are reviewed on a
regular basis and dose reductions attempted routinely, the cross-sectional measure was repeated 12
months later to evaluate the extent of review in the RACFs.
Previous studies had shown a high rate of psychotropic use in Tasmanian RACFs. This trend
was also evident in this study, with an average of 42% of residents taking regular doses of
benzodiazepines and 20% of residents taking antipsychotics during 2006. Although the rate of
antipsychotic prescribing was similar to rates reported in Sydney and New Zealand in the same
time frame, the rate of benzodiazepine use in Tasmania was three times that reported in these other
studies. Further, when the RACFs were re-audited a year later, over 60% of antipsychotic and
benzodiazepine medications and doses were unchanged; a finding which strongly implies a lack of
review of these psychotropic agents, contrary to current professional guidance.
After obtaining an overall picture of prevalence, inappropriateness and the extent of review
of antipsychotics and benzodiazepines, the second stage of this research thesis sought to gain a
greater understanding of the determinants underlying their use in RACFs. A qualitative approach
involving thematic analysis of semi-structured interviews with health professionals and relatives
was chosen to answer the key research questions of this second stage, including why these
medications are used and who is influencing their initiation and review? As there is a paucity of
qualitative research related to psychotropic use in the residential aged care setting, this study not
only provided valuable insight but also strongly informed the methodology of the subsequent
intervention project.
It became evident that many health professionals had limited knowledge about the risks
associated with psychotropic use in older people, and that reviews were conducted infrequently, if
at all. Of all health professionals, nursing staff were the most influential when psychotropic
medications were initiated and utilised. As a consequence of this qualitative research, the key
strategies of the intervention project were primarily targeted at nursing staff and designed to offer
feedback on psychotropic use to individual RACFs, provide education about the risks associated
with these agents, promote professional guidelines and encourage regular review and dose
The main objective of the thesis was to design, conduct and evaluate an intervention project,
trialling QUM strategies provided by community pharmacists, to facilitate the quality use of
antipsychotic and benzodiazepine medications in RACFs. This third and final stage involved a
large controlled trial run in 25 RACFs in the two major cities of Tasmania and was termed the
‘Reducing Use of Sedatives’ (RedUSe) project. Thirteen Hobart RACFs were recruited as the
intervention group, with 12 Launceston RACFs acting as the control group.
The RedUSe intervention was run over six months during 2008 to 2009. A series of QUM
strategies were offered in the intervention RACFs, including two dedicated psychotropic
medication audits, nurse education and feedback, and an interdisciplinary sedative review process.At the conclusion of the project, the prevalence of benzodiazepines was significantly reduced in
intervention facilities (31.8% to 26.9%, p < 0.005), whereas a small non-significant increase in use
was found in control homes. Likewise, antipsychotic use was significantly reduced in intervention
facilities when compared to control facilities, although to a lesser extent than benzodiazepines
(20.3% to 18.6%, p < 0.05). Over the six months of the intervention project, the proportion of dose
reductions of both benzodiazepines and antipsychotics in intervention facilities was almost double
the proportion recorded in control facilities.
Although several intervention projects aimed at improving RACF psychotropic use have
been published, few research teams have reported cost effectiveness data, clinical outcomes for
residents or evaluated the sustainability of the intervention project over the long term.
Consequently, various post-analyses of intervention data were conducted to evaluate the clinical
impact of the project on residents in terms of falls and behaviour, and assess cost effectiveness. In
order to determine the sustainability of the intervention, a final follow-up audit measure was
performed 12 months after the project was completed.
The post analyses indicated that the reduction in sedative use had limited impact on falls;
however, there was a significant decrease in challenging behaviours in those facilities recording a
significant reduction in antipsychotic use. Some cost savings were achieved resulting from the
reduction in benzodiazepine prescribing, but savings were not observed in antipsychotic costing.
Finally, the repeat 12- month audit measure demonstrated that the reduction in benzodiazepine use
in the intervention RACFs was sustained, with the mean daily dose of benzodiazepines continuing
to reduce even further. In contrast, RACF antipsychotic use returned to pre-trial levels and doses
remained static.
The RedUSe intervention led to a statistically significant reduction in the proportion of
residents in RACFs receiving benzodiazepines and antipsychotics, and the number of dosage
reductions of these agents in intervention facilities was double that reported in the control facilities.
These findings suggest that QUM strategies coordinated through community pharmacies, and
incorporating the dissemination of local data on medication use, offer an effective approach to
reduce antipsychotic and benzodiazepine use in RACFs.

Item Type: Thesis - PhD
Authors/Creators:Westbury, JL
Keywords: pharmacists,psychotropic, nursing homes, antipyychotics, benzodiazepines, aged care
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