clinical focus
commission. We feel strongly that access to high-quality medical
care is a critical component to the overall wellbeing of complex
older people, especially people receiving coordinated community
care or in residential care.
On top of that, older people deserve better access to specialists
who are experts in managing their specific medical problems, as
well as better access to GPs and primary care services within their
place of residence.
What role do geriatricians have in monitoring the appropriate
use of medication in people as they age?
effects. Anything we take, we always have to balance the benefit
versus the potential risk of treatment. Some agents have more
risks than others. These are relatively high-risk medications.
A study in NSW found adequate consent in only about 6.5 per
cent of people. So, the benefit is only seen in about 10 per cent
of the people who use psychotropics, and the consent is only
found in about 6.5 per cent. So, it’s really about using non-drug
treatments first and tailoring those interventions to the individual.
It’s never going to be one size fits all.
Aside from the literature, have you noticed yourself people
Well, we’re good team players. We work with primary care
being put on these drugs sooner than they should be?
physicians and GPs, as well as nursing and allied health, and
I would be the first to admit that I do use these medications on
pharmacists as well – who are a key component in this – on
occasion. But I’d like to think that we use them as a last resort.
looking at quality use of medications, of which the use of
We sometimes see situations where, through issues with staffing
psychotropics is one. There are recommendations and guidelines
or funding, it can be difficult to provide non-pharmacological
available through the National Prescribing Service or the NHMRC
management strategies, and so reaching for the prescription
that can help prescribers look at quality use of medications.
pad becomes an earlier intervention and one based on a larger
Some of what I was talking to the royal commission about
number of people than we’d say would be ideal.
concerned the use of alternatives to medication. When we’re
As we said, there’s probably a small number, 10–20 per cent,
talking about the use of medications for dealing with behavioural
of people with these symptoms who will benefit, but that means
and psychological symptoms of dementia, it’s important to realise
80–90 per cent of them won’t. We are seeing those sorts of
that we should really be looking at this as a cognitive disability.
numbers in real life as well as in the literature.
When looking at these symptoms, we need to think
about them as an expression of unmet need.
There’s probably a generation of clinicians, nurses
Is this due to pain? Is this due to interactions
and doctors who’ve grown up on the way things
with the physical environment? Are these
are done now. So how do we turn that ship
due to psychosocial needs?
around?
We often talk about memory problems
That’s the big question I’m hoping the royal
You can tell
as being a proxy for dementia, but
commission will delve into in more detail. We’ve
the quality of a
dementia involves changes across
already heard some interventions that can
many cognitive domains, including the
be beneficial. We’ve already seen good work
society by the way
ability to recognise people, faces and
come out from Dementia Services Australia,
it treats its most
objects, the lack of which is agnosia, or
the Dementia Behaviour Management Advisory
vulnerable.
problems with apraxia or dyspraxia, where
Service, and the Severe Behaviour Response Team.
purposeful movement is difficult.
You can argue about some of the terminology,
You can see that what you’re dealing with
but the move towards looking at providing support,
when looking at a symptom is actually a sign
advocacy and consultancy for non-pharmacological
of changes within the brain. When we look at it that
interventions, training and education is key. The fact that, even
way, there are options there to look at non-pharmacological
within health organisations, you’ll often have to do a ton of
management first. Too often, what should be the last resort – that
mandatory training on fire evacuations, lifting and so on, yet we
is, medication – becomes the first resort. If we flip this issue on its
don’t mandate training in managing people living with dementia,
head, rather than looking at quality use of medications, we should
which, in the end, if you’re working in residential care, make up
be looking at quality use of not using medications.
more than 50 per cent of your workload. If you work in acute care
We do know that these agents are used a lot more than what we in a hospital, they still make up around 10–20 per cent of your
see as ideal. Studies outside of Australia but also within Australia
workload, if not closer to 40 per cent if you’re working in a hip
have shown that up to 80 per cent of people in residential care
fracture service or in an older person’s ward.
facilities with dementia are on at least one psychotropic. By
In mandating training and skills, and looking at supporting
that, we’re talking about antidepressants as well as antipsychotic
people with an interest in developing these skills, we need to
medications. But the reality is that only about 10 per cent of those
acknowledge the specialty as key for the benefit of both older
would benefit.
Australians and society. You can tell the quality of a society by the
An example that we use comes from a paper that was done
way it treats its most vulnerable.
on minimising the use of antipsychotics in dementia in the UK. It
It’s important to realise that medical conditions – often
concluded that, if we used antipsychotics on 1000 people with
multiple and interacting, and including cognitive decline – are
dementia for 12 weeks, we would see some benefit in 10–20 per
the main reason for older people moving into residential aged
cent; there would be some reduction in those target symptoms,
care. Adequate management of all these conditions requires
but at the cost of around 10 deaths, 18 strokes and an increased
the involvement of medical professionals, especially those with
risk of falls in about 10 per cent of those people. The use of these
expertise in caring for older people. It’s about interdisciplinary
medications is not without their side effects.
integrated care for complex older people. It’s not that everyone
The other thing we’re concerned about is adequate consent
needs every component, but everyone should have access to that
on their use, because any drug with an effect has potential side
care, be it to geriatricians, GPs, allied health or specialist nursing. ■
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