Researchers from UNSW Sydney have conducted an observational study showing dementia patients are likely to receive a prescription for higher doses of antipsychotics, benzodiazepines and antidepressants when they enter aged care, and change doctors.
The study found that residents with a new general practitioner (GP) were dispensed more medicines (20% increase) — almost twice as much as those who retained their usual (9%) or known GP (10%).
Study author Dr Heidi Welberry from UNSW Sydney’s centre for big data research in health said the study showed why it was important to facilitate GP continuity of care and support the handover process when an aged care resident changes doctors. She acknowledged that GPs experienced pressure caring for so many people in aged care settings and that time constraints may exacerbate better handover processes.
“The takeaway message is the importance of looking at the continuity of care for residents as they enter residential aged care,” Welberry said.
“Anything that can provide a GP with greater support to spend more time in that transition period – and to really understand a new patient’s situation – will assist in establishing a higher level of care. This includes better organisation of GP care handover, including the medical history of the new patient.”
The study analysed the data of 2,250 people who were diagnosed with dementia prior to joining residential care between 2010 and 2014. Within this group, the researchers said there was a wide range of socio-demographic and health factors.
Previously, little was known about how often new aged care residents in Australia switched their treating GP.
The study identified that 44% of new aged care residents of the sample group they followed changed GPs. Another 28% of residents retained their ordinary GP, and another 29% changed to another known GP (who the patient had seen before but was not their usual doctor).
One of the study’s authors, Professor Henry Brodaty, added that the risk of regular use of five different medications or more – referred to as polypharmacy – in older people could lead to an increase in risk of medication errors and hazardous medicine interactions. With medicines such as antipsychotics and benzodiazepines, he said the benefits for people with dementia were small. But the risk of adverse effects such as stroke and death were high.
“Generally, the recommendation is to try other strategies first to help manage changed behaviours and psychological symptoms associated with dementia,” Brodaty said of alternative treatments to an antipsychotic prescription.
“This could include diversion therapy and music therapy.”
The study also endorsed findings of the Australian Royal Commission into the Quality and Safety of Aged Care, which scrutinised the practice of inappropriate medication (especially antipsychotics and use of sedatives as chemical restraints). The commission further identified that pharmacologically restraining patients could arise from a “lack of knowing the person as an individual person”.
The researchers suggested that for people with dementia, the sudden change in environment could add to feelings of distress which new GPs, unfamiliar with their personal circumstances, were treating with medication.
Welberry said more research was needed on this issue to understand why new care residents with dementia were being medicated in this way. This included how GPs approached care for a new patient they had not met before.
“New GPs who already see many patients in the residential care facility may possibly be influenced a bit more by the residential aged care staff as opposed to those who know their patients and families better. But this is something we don’t know,” Welberry said.
“This study has raised a lot of questions about what may drive changes in prescribing patterns.”
Welberry also noted 2018 research coming from the Australian Medical Association that examined barriers GPs faced in providing care in nursing homes.
“These [barriers] included geographical relocation and financial barriers,” Welberry said.
“As it can be difficult and inefficient for GPs to just visit a single patient in a particular nursing home, especially one they don’t regularly visit, they may transfer care to another GP.”
The study, ‘Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners’, was published in the Medical Journal of Australia in July.