in Frail Older People

In Australia, almost 1 in 4 older adults aged 65 years and over suffer from chronic pain

Chronic non-cancer pain is a common problem among older people and has a significant impact on their quality of life. Medical comorbidities and polypharmacy are often additional challenges in managing these patients. Appropriate assessment of chronic non-cancer pain is important for the development of a patient-centered, goal-directed management plan.
When assessing patients with cognitive impairment, modified communication strategies and validated pain assessment tools can be useful. The quantity and quality of the evidence supporting individual drugs in the management of chronic non-cancer pain varies and studies focused on frail older people are limited. Caution is generally advised when introducing drugs and escalating the doses. Drugs that are not effective should be stopped. A shared decision-making approach is advised for deprescribing analgesics used for chronic non-cancer pain

Let’s define Chronic Non-Cancer Pain

Chronic non-cancer pain is defined as pain lasting beyond the time of tissue healing or for over three months. It is a significant problem among older people, due to the high prevalence of conditions, such as osteoarthritis, in which pain is a predominant symptom.
Older people living with chronic pain are more likely to report significant limitation in their daily
activities as compared to those without chronic pain. Chronic non-cancer pain can have a negative impact on a person’s psychological well-being, and vice versa.
However, it is under-recognised, undertreated, and often challenging to manage. The presence of
frailty in older people adds an extra layer of complexity, given these patients often have several
comorbidities treated with multiple medicines and are prone to falls and adverse effects.

Assessment

The first step in the successful management of chronic non-cancer pain is recognising the presence of pain and accurately assessing its severity and impact on function, in conjunction with history and examination.
Stoicism, and the expectation that pain is part of aging, have been implicated in the under-reporting of
pain in older people.
Cognitive and sensory impairments that affect communication can also limit the accurate identification of
pain. The initial assessment needs to identify or exclude serious and treatable causes of pain, before
embarking on a symptom management approach.
In a holistic assessment, it is important to address the psychological and functional impact of chronic
non-cancer pain.
Multiple functional assessment tools are validated and practical for use in older people. Understanding
the impact of the pain can facilitate negotiating realistic and meaningful treatment goals. For example, in
some cases improving self-care or mobility to enable the person to participate in certain life activities will
be more achievable than complete pain relief.

Pain assessment in older people

• Provide adequate time to discuss their pain, process the question, and to formulate a response.
• Use open-ended questions when discussing pain, rephrase the questions to elicit the presence of pain,
for example:
Do you hurt anywhere?
Do you have any aches, soreness, or discomfort?
What is stopping you from doing what you want to do?
• Use a self-reported pain measurement tool to assist in evaluation e.g. brief pain inventory.
• Arrange for someone who knows the patient well to do the pain assessment and use the same tool and standardised wording during each discussion.

It is important to include insights and observations from family members and familiar carers about behaviour that may be pain related. When reassessing the efficacy of pain management, the same scale should be used each time.

Drug treatment

Drugs only form part of a multidimensional management plan for chronic non-cancer pain, in conjunction with other strategies, such as physical exercise and cognitive behavioural therapy.
When a decision is made to prescribe, careful
consideration should be taken off the age-related
physiological changes and the impact of polypharmacy in older people.

Current guidelines recommend the following general principles when prescribing for older people:

• Start one drug at a time, at a low dose, with slow-dose titration.
• Allow an adequate time interval to enable the drug to take effect, before introducing additional drugs.
• Constantly monitor efficacy and adverse effects and adjust or cease the drug if required.
• Consider deprescribing at regular intervals once self-management of pain is achieved.
• Review all analgesia, including over-the-counter products, for potential interactions.

Analgesic dosing considerations in frail older people with chronic non-cancer pain

DOSING CONSIDERATIONS

Decreased volume of distribution (20%) and clearance (37%) in frail older people, hence guidelines recommend reduced doses:

• 0.5–1 g every four to six hours, up to a maximum of 3 g in 24 hours, if weight >50 kg

• 15 mg/kg/dose every four to six hours up to a maximum of four doses in 24 hours, if weight <50 kg.

DOSING CONSIDERATIONS

Increased prevalence of chronic renal disease and co-prescription of
anticoagulation and antiplatelet therapies in frail older people makes this class of analgesics discouraged.
Consider dose reduction and co-administration of proton pump inhibitors if indicated.

Deprescribing

Regular review of the drug treatment of chronic non-cancer pain is recommended. Assess the effectiveness of analgesia using the ‘5As’ principle:

• Analgesia
• Activity
• Affect
• Adverse Effects
• Aberrant behaviours, such as unapproved increase of dose or use of the drug to treat other symptoms.
  Consider deprescribing if there has been no meaningful improvement in function or pain, when the risk of harm (side effects) outweighs the benefit, and/or if the resident reports no pain for more than 3 months.
  Doses should be reduced slowly to avoid rebound side effects and possible signs of dependence.

General Approach For Weaning Opioids And Gabapentinoids

Conclusion

Managing chronic non-cancer pain, especially in frail older people, remains challenging. The altered harm versus benefit profiles of drugs in this group of patients needs to be carefully considered and regularly reviewed when prescribing. If pain remains troublesome despite standard therapies, consideration should be given to seeking support from a geriatrician, pain specialist, or pain service.

Opiod Conversion Guide

These conversions are a guide only. Patients may vary in their response to different opioids. After changing opioids, close assessment should follow and the dose altered as necessary.

Equianalgesic doses of oral opioids

• GREEN shaded opioids are those STRONGER than morphine mg for mg
• PURPLE shaded opioids are those WEAKER than morphine mg for mg

Subcutaneous route conversions

Transdermal preparation conversions

Methadone and medicinal cannabis conversions are complicated and prescribing should be restricted to medical specialists for pain management.
• Reduce Opioid dose by 30-50% to accommodate for unknown cross-tolerance and titrate to goal
• Short acting PRN opioid doses are approximately 10-20% of total 24hr scheduled opioid dose.
online Opioid Calculator – http://www.opioidcalculator.com.au/opioidsource.html

Pain Management – Summary of Medications

High-Risk Medicines are those that have a high risk of causing injury or harm if they are misused or used in error. Error rates with these medications are not necessarily higher than with any other medicines, but when problems occur, the consequences can be more significant.

The National Safety and Quality Health Service (NSQHS) Standard on Medication Safety requires health services to identify High-Risk Medications used within the organisation and take appropriate action to ensure they are stored, prescribed, dispensed, and administered safely. As a minimum, facility policy on High-Risk Medicines should include Hydromorphone, Oral Methotrexate, Paracetamol dosing, and Anticoagulants.

High-Risk Medicines can also include

• Medicines with a narrow therapeutic index such as Digoxin, Lithium, and Warfarin.
• Medicines that present a high risk when administered via the wrong route.
• Have similar names.o
• Administered as variable dose daily, weekly or monthly.

There is no standard list ofhigh-risk medicines for aged care homes in Australia, however, lists have been created largely based on incident reporting systems in different health services, jurisdictions and countries.

Some Recommended requirements when discussing High-Risk Medicines –

1. Establish a policy within your organisation for the management of High Risk Medicines including a list of medicines you consider as high risk.

a. Assess and determine the medicines to be included in the register.
b. Maintaining regular updates and reviews of the register.
c. Establish protocols for each category of High Risk Medicine.
d. Incident reports on policy compliance and corrective action needed for High-Risk Medicines.

2. Protocols for managing residents on High Risk Medicines should include:

a. Responsibilities for the prescribing and administration of high-risk medicines.
b. Additional considerations for patients with conditions that may affect drug excretion such as renal function and weight.
c. Patient monitoring parameters, for example, clinical observations, are required to ensure a timely response to adverse events such as sedation and breathing rate side-effects associated with the treatment.
d. Therapeutic drug monitoring requirements, including laboratory tests and dose amendment.
e. Specific storage requirements to minimise selection error.
f. Timeframe for review of parameters and person responsible.
g. Potential risk of inappropriate use of these medicines

3. Establish strategies to minimise the risk with High-risk Medicines using measures such as:

a. Pre-measured medicine doses in a form that requires minimal manipulation prior to administration (blister packs or sachets).
b. Use of shelf reminders, Checklists, and alerts placed within the treatment room and/or electronic system in use.
c. Review of incidents or near-misses to reassess systems in place.

It is important to note that a single risk-reduction strategy for a High-Risk Medicine is rarely capable of preventing patient harm. When seeking to reduce the likelihood of harm in healthcare settings, a range of strategies need to be considered to promote safer use or decrease the opportunity for misuse or error. Risk-reduction strategies can be based on a review of how High-Risk Medicines are managed within the organisation using audits, incident analysis, risk assessment tools, and benchmarking activities.

In the acute sector, the ‘APINCH’ acronym and classification are widely used to assist clinicians to focus on a group of medicines known to be associated with a high potential for medication-related harm. The ‘APINCH’ classification is not an exhaustive list and other medicines or classes of medicines may also present a high risk and may be included alongside the APINCH list within your organisation, examples include Digoxin, Paracetamol, and oral
hypoglycaemics.

Possible reporting systems from Ezymed that can assist in such activities may include:
• Automated list of residents on High Risk Medicines using the
‘APINCH’ criteria.
• Assist in protocols for prescribing and administering
High Risk Medicines.
• Review of incidents and near-misses during MAC and adopting
strategies to minimise risk with High-Risk Medicines

Other High-Risk Medications to Consider in Residential Aged Care Homes

Next time you are doing a medication round and have to crush medicines, administer Warfarin, Insulin, Oxycodone and/or a patch prescribed for your resident, consider the potential danger that even ‘APINCH’ can do.

Falls are one of the major causes of injury amongst older people and stand as the second leading cause of death worldwide.

Did you know

Falls are a major health issue in the community, with around 30% of adults over 65 experiencing at least one fall per year

Falls account for 40% of injury-related deaths and one percent of total
deaths in the over 85ʼs

Between 22-60% of older people suffer injuries from falls
10-15% suffer serious injuries
2-6% suffer fractures
0.2-1.5% suffer hip fractures

Definition of a Fall

A fall is when a person unintentionally goes from a higher to a lower point, or from a standing position onto a chair. It doesn’t include intentional changes in position such as intentionally sitting on a chair or if the person collapses from a medical episode such as a stroke.
The impact of falls can be very serious
● Physical injuries such as bruises, skin tears, fractures, and head trauma
● Can often lead to hospitalization, surgery, and even death
● Psychological strain and loss of confidence to maintain quality of life

• Altered medical conditions such as – Incontinence – Parkinson’s disease – Dementia – UTIs • Malnutrition • The type and number of medications used • Psychosocial changes such as anxiety and depression • Problems with sensory-motor functions such as balance, muscle weakness, vision and hearing impairment. • Environmental factors such as unsafe footwear, poor lighting, cluttered rooms etc

Hearing • Not wearing hearing aids • Wax buildup or ear infections affecting their balance Vision • Bifocal glasses • Wearing the wrong glasses Inactivity • Leading to muscle wasting and impaired balance. Walking aids • Incorrect walking aids • Inappropriately fitted walking aids

Medication associated with increased risk of falls

Some medications or combinations of medications may increase the risk of falling. Certain classes of medication as well as the overall number of medicines prescribed simultaneously have shown a similar effect on fall risk.

How Medications Increase Risk of Falls :

• Antihypertensives, by reducing blood pressure and/or slowing the heart rate • Sedatives, antipsychotics, and anticonvulsants act on the brain causing increased sedation and gait disturbance. • Antidepressants, particularly sedating antidepressants can cause drowsiness and slow reaction times • Cardiovascular medications can exacerbate dizziness or light-headedness from their effect on BP. • Anticholinergic agents affect vision making it blurry and causing double vision • Diuretics such as Frusemide and Hydrochlorothiazide have a diuretic effect, making people rush to urinate more frequently

Some medications may also impact the severity of falls e.g. if someone is on anticoagulants, they are at greater risk of bleeding. Regular medication reviews are important to assess the number, time, and dosage of medications that can be reduced

Postural/Orthostatic Hypotension

Determining Medication Falls Risk

The Agency for Healthcare Research and Quality developed the medication fall risk score to evaluate patients’ fall risk related to the use of certain high-risk medications. Each medication included in the tool is given a score from 1 to3 based on its contribution to fall risk. A combined score of more than 6 points means that a person is considered to be at higher risk of falls and may signal the need for an in-depth evaluation by the prescriber and pharmacist to further evaluate the person’s medication regimen. How do your residents score?

Hydration & Nutrition

It is important to support people to maintain a well-balanced diet, to ensure they get the necessary hydration and nutrition. A low body weight due to malnutrition can increase falls risk, due to the effects on strength and bone density. Vitamin D is a vitamin that helps improve muscle function, and in conjunction with calcium helps minimize bone loss. Evidence-based research suggests that if older people take Calcium and Vitamin D supplements, it can lead to a reduced risk of falls and reduced fracture rates. At least three serves of calcium-rich foods are recommended each day. Although Vitamin D is found in some food sources (eggs, margarine, oily fish), the best source is the sun.

Other important vitamins associated with mobility include Vitamins A, C and E. All are important for eye health and a deficiency can cause vision impairment that can lead to confusion, disorientation and poor balance, increasing the risk of a fall. Folic Acid and Vitamin B12 deficiency can also cause confusion and affect perception or awareness of the position and movement of the body, again affecting mobility

Strategies to Minimize the risk of Falls

• Encourage and enable residents to stay as active as possible. • Review BP and BGL levels if possible • Assess their medication use and refer for RMMR • Remove any clutter from their room and other common areas around the home • Assess walking aids and footwear • Keep a night light for bathroom use, • For residents with cognitive decline – Allow assisted toileting rounds after administering medications such as Frusemide. Apply Hip protectors, making sure they are worn correctly

Behaviour Management and BPSD
(Behavioural and Psychological Symptoms of Dementia)

Challenging behaviours are a common symptom of dementia and remain to be one of the biggest challenges to care, staff.

When poorly managed, these behaviours can have far-reaching effects, including distress for the client, disruptions to the lives and comfort of other clients, and added stress and workloads to healthcare workers. Research has shown that antipsychotic medicines (which may cause significant side effects) continue to be used ‘too often’ to manage
behavioural and psychological symptoms of dementia.

Appropriate behavioural management is not only essential to maintaining a high quality of life and comfort for all clients, but it is also directly tied to Standard 1, 7 and 8 of the Aged Care Quality Standards.

So, how can nurses use non-pharmacological interventions to prevent antipsychotic use for people with dementia?

Non-Pharmacological Treatment in Dementia Care

There have been a number of systematic reviews that showed Psychosocial Interventions for aged care residents with dementia can prevent the use of antipsychotic medicine. Often, behavioural and psychological symptoms of dementia such as agitation are treated with prescribed antipsychotic medicines. However, this can lead to frequent side effects including falls, sedation and cardiovascular issues.

Additionally, antipsychotic medicines have been associated with an increased risk of stroke, increased risk of mortality and confusion (Alzheimer’s Australia 2014).
Antipsychotic medications should also be time-limited as most BPSD symptoms show an intermittent course which does not support long-term treatment with antipsychotics.

Managing Behaviours: Person-Centred Approach

There are countless ways to handle challenging behaviours, however, approaching the situation methodically with an assessment tool like the ABC approach examines the behaviour from a person-centred perspective.
The aim of this type of approach is to help us understand the etiology of the behaviour and develop a suitable, consistent response for ongoing support.

ABC Approach to Behaviour Management

• A: Antecedents / Activating Event – What led to or caused the behaviour?
• B: Behaviour – What is the behaviour?
• C: Consequences – What is the result of the behaviour?
• D: Decide and Debrief – What will be done differently to disrupt the behaviour?

A. Antecedent or Activating Event

The antecedent or activating event looks at direct or indirect triggers of the behaviour; the why, what, when, where and who. These stimuli could include:
• Organic causes – e.g. health conditions, pain, fatigue, effects of medicine etc.
• Emotional state – e.g. happiness, anger etc.
• Cognitions – e.g. what the person may be thinking.
• Environmental factors – e.g. a noisy or unfamiliar environment.
• Social relationships – e.g. interactions with other people

Common Triggers directly associated with an unmet need

B. Behaviour

The challenging behaviour should be defined clearly. Types of BPSD commonly seen include:

• Wandering or absconding;
• Depression;
• Sundowning;
• Anxiety or agitation;
• Aggression;
• Disruptive or intrusive behaviour;
• Hallucinations or delusions;
• Socially inappropriate or disinhibited behaviour.

Note, that simply labelling the behaviour is not sufficient. You must be able to describe what was
observed. For example, did the client yell, cry, punch or use particular words?

C. Consequences

The consequences of the behaviour are the responses from everyone involved. These could include those of the staff, family members or other residents who were witnesses to the behaviours.
• Were they emotional and panicked in their response?
• Did they simply ignore the behaviour?
• Did they reprimand the client?
• Were their actions calm and respectful?

D. Decide and Debrief

The final and additional step to the ABC approach is to decide and debrief. Before jumping to the option of pharmacological therapy, this step allows the care team to come together, consider their findings and collaborate on the best way to manage the situation. Remember that in true client-directed care, the client themselves is part of the care team and should be involved in this process, or alternatively the client’s family or designated decisionmakers.
Decisions on what actions to take could involve:
• Using a calm, gentle manner when communicating with the person;
• Reducing the number of staff who interact with the person;
• Have a consistent routine;
• Offering more stimulating or distracting activities or exercises;
• Use short, clear statements;
• Stronger, more effective means of communication between staff about potential triggers;
• Removing certain stimuli from the environment, such as overly-bright lights or loud noises;
• Closely monitoring interactions between particular people;
• Addressing underlying emotions and referring to other healthcare services when necessary

In Conclusion

The ABC approach to behavioural management works best when the challenging behaviour is
clearly documented and understood. The first approach should always be non-pharmacological and should involve tweaking the personal and environmental elements that contributed to the event. The client’s regular medical prescriber may consider a medications review if the behaviours are still ongoing however please keep in mind many milder challenging behaviours tend to run a course and can resolve with time, so patience and support are often the best response in these cases

For Additional Resources
• The Dementia Behaviour Management Advisory Service (DBMAS)
• Communicating with Someone Who Has Dementia
• Purposeful Engagement and Activities for People with Dementia

Overview of the “Mandatory Quality Indicator Program Manual 2.0 –Part B” (Program Manual B)

Program Manual B’s is designed to help providers understand how they can support continuous quality improvement for each of the quality indicators. It explains what “quality improvement” is and how to undertake it by,
• reintroducing the five quality indicators found in Program Manual A
• describes the adverse impacts of each of the quality indicators on recipients
• details the causes and risk factors for each of the quality indicators
• provides checklists for the prevention and management of the quality indicators

What is “quality improvement”?

“Quality” is described as care that is “effective and safe, and provides a positive experience by being caring, responsive and person-centered.” (Program Manual B, p. 3). An important part of providing “quality” care is quality improvement which is “a systematic, coordinated and ongoing effort to improve the quality of care and services.” (Program Manual B, p. 3).

Overall quality improvement is about identifying what systems are working well, the quality of care and services being provided, and understanding where we could do better and improve outcomes for consumers. Throughout the quality improvement process, three key areas need to be considered with respect to change:

• Being open to change and exploring ways that will improve the way we deliver care and services – what changes that we can make that will result in improvement.
• The goal or the purpose – why is change needed and what we hope to achieve
• The way you will be able to measure or show the change is an improvement – how we
well know that a change is an improvement

How do you make quality improvement possible?

There are six steps to enabling quality improvement:

1. Collecting and submitting data in line with your Quality Indicator Program obligations
2. Reviewing quality indicator data reports through the My Aged Care provider portal
3. Comparing your performance to data available on the Australian Institute of Health and Wellbeing GEN Aged Care Data Website
4. Identifying how your performance compares to the national benchmark, previous performance, and/or other similar services
5. Recording performance and noting that a quality issue exists
6. Taking action to improve quality of care through initiating a quality improvement activity (Program Manual B, p.5)

How do you undertake quality improvement?

The Program Manual proposes a “Plan-Do-Check-Act” tool that can be used across each quality indicator (Program Manual B, p. 6). This method allows you to identify a “quality issue” and then trial a “quality improvement activity” to gauge whether the activity should be implemented more broadly.

A summary of the tool and its four steps is set out in the table below

PLAN-DO-CHECK-ACT

STEP 1: PLAN:

Involves developing a plan by gathering information about what is causing the quality issue, establishing goals for your quality improvement activity, and making a plan for how the activity will be carried out

STEP 2: D :

This is where you carry out the activity by allocating resources, testing the activity on a small scale, and documenting observations

STEP 3: CHECK :

Involves collecting data and analysing information from the QI program to understand if your current systems and related processes are achieving the desired outcomes.

STEP 4: ACT :

This step involves deciding whether the current systems and related processes are successful in achieving quality of care and services. Depending on the outcome you will:
• if successful, embed the activity into business-as-usual processes and continue to monitor outcomes
• if the activity was unsuccessful, determine what you may need to do differently next time – this is a quality improvement opportunity
• repeat the process to continue to increase the quality of care and services for consumers

When do you undertake quality improvement?

Quality improvement is an ongoing process. This means that you should regularly repeat the quality improvement process to continually improve the care and services you deliver (Program Manual B, p. 5)

What are some benefits of quality improvement?

By regularly undertaking quality improvement, you will:
• improve the delivery of your care and services
• identify quality issues promptly
• be more responsive to the changing needs of recipients
• improve outcomes for recipients
• improve systems to monitor and track change
• create long-term sustainable improvement across your organisation
• increase collaboration amongst staff
• enhance professional development across the workforce (Program Manual B, p. 4).

The National Aged Care Mandatory Quality Indicator Program started in 2019. From July 2021, there will be two new quality indicators (QIs) that Aged Care Providers will have to report on:

• Falls and major injury
• Medication management

What is required within the Quality Indicators on Medication Management?

The Medication Management QI covers two issues:

• Polypharmacy – defined as the prescription of nine or more medications to a care recipient
• Antipsychotic medications – Care recipients assessed for antipsychotic medications and care recipients who received an antipsychotic medication for a diagnosed condition of
psychosis

What is not counted in Polypharmacy Reports?

Any medication with an active ingredient is counted in the polypharmacy quality indicator, except
for those listed below which should not be included in the count of medications as per the QI program:

“Different dosages of the same medicine is also NOT to be counted as different medications.”

Is Polypharmacy an issue in aged care?

We know that 2 out of 3 Australians aged over 75 take 5 or more medicines and in residential aged care homes, residents are taking on average 9 to 10 medicines each day. Polypharmacy has demonstrated a major impact on the health and financials of an older person. It can affect how they feel, their ability to enjoy daily activities and how they interact with their family, other residents, and carers. The elderly taking 5+ medicines have a higher risk of

• Side effects: Interactions with medicines
• Adverse outcomes include: falls, increased frailty, hospitalisation, and overall mortality.
Polypharmacy can also lead to additional nursing and administrative time; time they would often prefer to spend doing more enjoyable activities with the older person.

What are the causes of Polypharmacy?
There are many factors that may contribute to the development of polypharmacy:

• More medicines on the market • The use of medicines to alleviate symptoms • Multiple chronic conditions
• Longer lifespans • Multiple prescribers • Complex care needs • Reluctance to trial ceasing medicines
• Use of regular rather than PRN dosing

Polypharmacy can also increase the risk of the Drug Burden Index, but what is a Drug Burden Index? It is defined as the functional burden of medications in older people.

Older people carry a high burden of illness for which medications are indicated, along with an increased
risk of adverse drug reactions. The drug burden index was developed to determine the drug burden based on
pharmacological principles in relation to physical and cognitive performance apart from the underlying disease
indication.
Examples of medications that contribute to the Drug Burden Index –

Other resources recommended when reviewing medication in the elderly include –
• Beers criteria – Potentially Inappropriate Medicines (PIMs) –
• STOPP/START criteria – looking at the Potential Prescribing Omission (PPO) when starting ANY new medicine.
• MATCH-D criteria – Medication Appropriateness for comorbid health conditions in Dementia patients

What happens during a Residential Medication Management Review?

What happens during a Residential Medication Management Review?

Our Ezymed pharmacists have been clinically trained and certified to conduct Residential Medication Management Reviews.
The Clinical pharmacist reviews typically focus on –
• Why is the medicine being taken? Is it for preventative or symptomatic treatment?
• Is the medicine appropriate for the consumer?
• Is it still needed?
• Can the dose be reduced or discontinued?
• How many medicines are being taken overall?
• What is their drug burden?
• Would the consumer benefit from the reduction of any of them?

Deprescribing, is it possible in aged clients?

Deprescribing has been defined as, “the process of withdrawal of an inappropriate medication, supervised by a health care professional
with the goal of managing polypharmacy and improving outcomes”.
Br J Clin Pharmacol. 2015 Dec;80(6):1254-68
Deprescribing should always be part of the holistic medication review
for all patients, particularly the vulnerable elderly.
Structured deprescribing can successfully reduce the number of medicines by 1-3 medicines per person

Clinical trials on Deprescribing

Medication Withdrawal Trials in people aged 65 years and older: A systematic review of 31 clinical trials in older people
concluded that specific classes of medications like Antihypertensives, Benzodiazepines, and Psychotropic drugs could be withdrawn successfully without causing harm in people aged 65 years and older.

The War against Polypharmacy: a new Cost-effective geriatric approach to improving drug therapy in disabled elderly
people: Evaluations of the use of medications in 190 geriatric patients led to discontinuation of 322 drugs in 119 patients with no significant adverse effects after 12 months. Drugs discontinued no adverse effects including NSAIDs, analgesics, statins, oral hypoglycemics, carbamazepine, and digoxin.

Did you know that consumer reluctance/refusal to take medicines should be considered as a prompt to consider deprescribing, rather than changing dosage forms or finding alternate ways to administer the medicines?

A Patient-Centred Medication Review is the answer to effective deprescribing The CEASE Framework was developed to assist in the development of an effective care plan when deprescribing –

Antibiotic use in Australian services (RACS) continues to increase! BUT WHY ? …. COMMON ISSUES

The use of urine dipstick testing as a first step in diagnosing UTIs  Prolonged duration of antimicrobial use – The majority of infections should not exceed 7 days of treatment. High rates of topical antimicrobial use, particularly for PRN administration without adequate indication.

Prolonged prophylaxis for conditions not recommended by guidelines, including the use of Methenamine hippurate (Hiprex)  Poor documentation of indication, review and stop dates for antimicrobial prescriptions.
Barriers adhering to AMS included

•   difficulties in diagnosis of infections (sample collection, cognitively impaired residents),

•   staffing issues (off-site general practitioners and pharmacists, nursing staffing levels and workload),

•   delayed laboratory services

•   family expectations.

Australian Guidelines advise that Urine Dipstick Testing is not the first step for older people. Instead, RACFs are encouraged to use  Clinical Pathway.

•   A campaign to increase education around Asymptomatic Bacteriuria

•   Improve awareness and diagnosis of UTIs in aged care facilities

•   To reduce unnecessary antibiotic use

•   To support non-pharmacological management in the prevention of UTIs by managing hydration and providing good basic hygiene care

Antibiotics – too much of a good thing?

•   Antibiotics are powerful and precious drugs.

•   Bacteria can develop antibiotic resistance. This means that antibiotics may not work when a person really does need them and these resistant bacteria can spread very easily in an aged care home setting.

•   Side effects such as nausea, stomach upset, and skin rashes are common in older people receiving antibiotics and can cause significant harm.

•   Everyone has a responsibility to protect antibiotics and they should only be used when there is strong evidence of a bacterial infection.

Antimicrobial Stewardship (AMS)

The term antimicrobial stewardship provides a systematic approach to optimising the use of antimicrobials.
The goal is to promote in order to maximize the effectiveness of treatment and minimize the potential for risk (including drug resistance and toxicity). This means patients are offered the

✓ right antibiotic
✓ to treat their condition,
✓ the right dose,
✓ the right route,
✓ at the right time and
✓ for the right duration.

The process should be based on an accurate assessment and timely review so as to improve patient outcomes, ensure cost-effective therapy, reduce the risk of adverse effects and emergence of antibiotic resistance

Principles of Antimicrobial Management in RACF

● Therapy should be based on clinical assessment by the GP, ensuring the benefits of the antimicrobial
outweighs the risk of harm.
● The antimicrobial agent used is based on the best available evidence. (Therapeutic Guidelines).
● Clear documentation for all antimicrobial prescriptions including an indication to therapy.
● Resident or Carer awareness of the treatment and potential side effects (informed Consent).
● Regular review and refinement of the antimicrobial therapy should occur based on the resident’s clinical
progress (improvement or deterioration) and available clinical information (investigation results).
● Diagnostic test results to be reviewed in a timely way.
● All key prescribing elements are clearly documented with set policies surrounding fixed-length courses of
treatment and mandatory review dates, particularly for prn prescriptions.
● Infection prevention and control with AMS education offered to nurses, prescribers, and family members of
residents to raise awareness and skill levels in relation to recommended practice,
● Education for non-nursing staff who provide care to residents on the importance of infection prevention
and control and basic personal and hygiene care
● Clear treatment plan with 3-6 monthly review dates for all long-term antibiotic prescribing

ANTIMICROBIAL STEWARDSHIP – AGED CARE HOMES

What can NURSES do to help?

• Take samples for microbiology testing preferably before starting antimicrobials and ensure timely transfer of samples to laboratories.
• Check that the resident is not allergic to the antimicrobial prescribed.
• Administer antimicrobials according to evidence-based guidelines and medication safety principles, such as the nine ‘rights’*.
• Support good documentation; generic name, dose time, route, indication and plan (review and/or stop date).
• Monitor residents to assess clinical response and identify side effects.
• Recognise when treatment is not in line with microbiological results and prompt review of antimicrobial therapy.
• Education residents and carers about antimicrobial therapy.
  

  Getting to Know Your Antibiotics

  Aminoglycosides: Gentamicin, Neomycin, and Tobramycin are commonly used in hospitals for surgical prophylaxis. There is an increased risk of renal toxicity and ototoxicity. The dose in the elderly is always calculated based on Creatinine C

  Lincosamides: Clindamycin and Lincomycin – Clindamycin is the more commonly used oral Lincosamide recommended as second-line therapy for those who can’t tolerate Penicillins and Cephalosporins. Therapy
  is associated with more side effects, particularly diarrhea.

  Beta Lactams: Cephalosporins and Penicillins Most used oral antibiotics are given can be well absorbed orally, show a g

  Macrolides: Azithromycin, Clarithromycin, Erythromycin, and Roxithromycin – They have a relatively broad spectrum of activity with effective treatment in most respiratory tract infections. Erythromycin and Clarithromycin are both potent inhibitors of CYP3A4 and therefore associated with significant drug interactions.

  Cephalosporins: – Cefalexin – Moderate Spectrum, orally.– Cefuroime and Cefaclor – are also moderate spectrum with an anti-Haemophilus activity making it more active for respiratory infections. Widespread use of cephalosporins, particularly the broad spectrum ones has been linked with the increasing prevalence of
  infections caused by methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE),, multiresistant Gram-negative organisms, and Clostridium difficile

  Nitrofurantoin: Active against most organisms that commonly cause UTIs, however activity is dependent on adequate urine concentrations and kidney function. Even mild renal impairment can reduce urine concentration and hence reduce the efficacy of the antibiotic.

  Penicillins: Narrow Spectrum Penicillins – Benzylpenicillin – remains the treatment of choice for
  susceptible infections (such as pneumococcal pneumonia) – Procaine Penicillin – intramuscular preparation that is often used as an alternative to benzylpenicillin when intravenous therapy cannot be administered.
  – Dicloxacillin and Flucloxacillin – Narrow Spectrum Penicillins with antistaphylococcal activity. Absorption is affected by food and has a short half-life, hence given before food four times a day. – Amoxycillin and Ampicillin – Moderate Spectrum Penicillins – Amoxycillin with the Clavulanic acid– Broad Spectrum Penicillins

  Nitroimidazoles: Metronidazole – Has a significantly broad spectrum of activity as well as an effect on Helicobacter pylori and Protozoa. (commonly used for bacterial Vaginosis, fungal wounds, dental infections, etc. Interacts with alcohol causing significant nausea and CNS effects.

  Quinolones: Ciprofloxacin, Moxifloxacin and Norfloxacin – They have very limited use in general practice, except in the treatment of UTIs caused by resistant organisms, prostatitis or resistant bone/joint infection.
  Resistance to Quinolones in now wide spread and judicious use is recommended to extend their clinical life. Superinfections with enterococci or Candida species may occur with all Quinolones

  Chloramphenicol: Broad spectrum antibiotic most commonly found in topical
  preparations for eyes and ears

  Rifamycins: Rifampicin – A broad spectrum antibiotic reserved for treatment of MRSA and Mycobaterial infections, as well as Prophylactic therapy in Meningitis and epiglottitis

  Folic Acid Antagonists: Trimethoprim and Trimethoprim + Sulfamethoxazole. For the treatment or prophylaxis of uncomplicated urinary tract infections, trimethoprim alone is considered as effective as
  trimethoprim+sulfamethoxazole. The combination is restricted to evidence the Trimethoprim alone
  not work ing or in MRSA patients

  Tetracyclines: Doxycycline, Minocycline and Tetracycline – A broad spectrum commonly used for bronchitis, acne and community acquired pneumonia

  Fusidate Sodium: Fusidic Acid – it has a narrow therapeutic index but active against Staph aureus, resistance develops readily and hence always used with another antibiotics such as Rifampicin

  Glycopeptides: Vancomycin and Teicoplanin – Vancomycin is the more commonly used oral Glycopeptide. Recommended for treatment and prophylaxis in patients with hypersensitivity to Penicillin. Also used for treating some MRSA infections as well as Clostridium difficile, however high risk of developing of Vancomycin-Resistant Enterococci (VRE)

  Recommended Antibiotics for Common Infections in Racs

  Urinary Infections : (E.coli, Staphylococcus, Proteus, Klebsiella and Enterococcuss). Acute Cystitis
  First line therapy – Trimethoprim 300mg orally, daily for 3 days, or Nitrofurantoin 100mg orally, 6 – hourly for 5 days.
  Second line therapy – Cefalexin 500mg orally, 12 – hourly for 5 days. Recurrent UTIs
  Prophylactic Antibiotic – Trimethoprim 150mg orally, at night or Cefalexin 250mg orally, at night.
  Prophylactic therapy is usually recommended at night for 3 – 6 months, then stopped

  Skin and Soft Tissue Infections

  Erysipelas Cellulitis (unbroken skin)
  First line therapy – Phenoxymethylpenicillin 500mg orally, 6 – hourly for 5 days or Cefalexin 500mg orally, 6 – hourly for 5 days.

  Purulent Cellulitis (associated abscess) First line therapy – Dicloxacillin 500mg orally, 6 – hourly for 5 days orFlucloxacillin 500mg orally, 6 – hourly for 5 days.

  Cefalexin is often preferred to Dicloxacillin or Flucloxacillin in patients who have swallowing difficulties,
  because the liquid formulation is better tolerated. In most cases, it can also be used for patients with delayed
  non-severe hypersensitivity to penicillins.

  Cutaneous Candidiasis – Diagnosis should be confirmed by microscopy and culture. Removing or modifying
  predisposing factors when possible (eg modify personal hygiene, apply emollients to skin folds for prevention,
  cease oral antibiotics unless essential) should also be in place alongside antimicrobial therapy.
  First line therapy – Clotrimazole 1% cream topically, twice daily for 2 weeks or
  Mmiconazole 2% cream topically, twice daily for 2 weeks.

  Respiratory Infection

  Bronchiolitis and Bronchitis usually viral but can develop secondary bacterial infections in some patients.
  Antibiotics therapy is not recommended in ALL cases.For non-severe exacerbations of Bacterial Bronchiectasis

  First line treatment – Amoxicillin 1g orally, 8 – hourly; 7 – 14 days (depending patient review) or
  Doxycycline 100mg orally, 12 – hourly; 7 – 14 days (depending patient review).
  In exacerbations of COPD,antibiotics such as amoxicillin+clavulanate, macrolides and cephalosporins are not
  recommended for initial therapy because they are not more effective than amoxicillin or doxycycline, and
  they expose the patient to harms from unnecessary broader-spectrum treatment.

  Community-Acquired Pneumonia (CAP)

  CAP in aged care facilities – First line therapy – Amoxicillin 1g orally, 8 – hourly; 7 – 14 days or
  Doxycycline 100mg orally, 12 – hourly; 7 – 14 days (depending patient review) For patients initially treated with amoxicillin who are not improving after 48 hours (more likely in patients with comorbid lung disease),
  Amoxicillin+clavulanate 875+125mg orally, 12 – hourly; 7 – 14 days can be used.