clinical focus
A nudge in the right direction?
Government ‘nudge’ letters
not the answer to drug
problem in aged care.
By Conor Burke
T
he overuse of antipsychotic
medication as a chemical restraint
has been, for some, a startling
revelation uncovered by the aged care
royal commission.
It has been estimated that 80 per cent
of people in residential care with dementia
are on one form of psychotropic – be that
antipsychotics, antidepressants or sedatives
– but experts believe that only about
10 per cent of those might benefit.
There are many reasons for over-
prescription in aged care, but one study
found that GPs reported feeling pressured
to prescribe psychotropics by aged care
staff. They said they often prescribed these
drugs due to of a lack of staff and training
on other ways to deal with these types
of symptoms.
Aged care pharmacist Dr Juanita Breen,
writing in Aged Care Insite, said that “when
these medications are given to older
people with less serious symptoms such as
calling out, agitation and wandering, the
risks associated with use often outweigh
any benefit they may offer”.
“To give an example, about one in five
residents with dementia experiencing
30 agedcareinsite.com.au
agitation will benefit from taking
antipsychotics, yet taking these
medications increases the risk of stroke,
pneumonia, death from all causes, cardiac
problems, falls, tremor and confusion.”
Breen wrote that many staff will request
psychotropic medication from prescribers
with the aim of ‘providing comfort’ to
residents, not for the benefit of the staff.
However, when given a psychiatric drug
knowledge quiz, Breen found that most
care staff and health practitioners were
unaware of the adverse effects.
The royal commission interim report
identifies three areas that need “urgent”
attention, one of which is “to respond to
the significant over-reliance on chemical
restraint in aged care, including through
the seventh Community Pharmacy
Agreement”.
This prompted the Morrison government
to announce funding for medication
management programs to the tune of
$25.5 million to reduce the use of chemical
restraints in aged care.
UNWELCOMED PROD
In December last year, the Department
of Health took the first steps to further
combat this problem by sending GPs
a letter outlining the adverse effects of
overusing these drugs and devising new
protocols for problem prescribers.
More than 28,000 health practitioners –
mostly GPs – who prescribe in residential
aged care facilities (RACFs) were sent the
letter with a follow-up “nudge” letter to
be sent to a smaller group to “assist them
to reflect on their prescribing patterns of
antipsychotics and benzodiazepines”.
The idea of a “nudge” is a tool of
behavioural science and is used to change
behaviour; in this case, it aimed to highlight
the prescriber’s rate of prescription in
relation to the average rate of their peers
in the hope that this would correct any
oversights in prescription.
However, GPs did not react well to the
advice, with RACGP president Dr Harry
Nespolon commenting that GPs are fully
aware of the correct way to prescribe
the drugs.
“GPs know that chemical restraints in
aged care facilities are the last resort.
Those aren’t my words, they’re what GPs
who work in these facilities every day have
told me,” he said.
“While there has been significant
attention [given to] this practice in the wake
of the royal commission, it’s important to
note that chemical restraint is not the norm
– it is rare.”
Nudges have been used in trials that
aim to reduce antibiotic prescribing in
Australian primary care, and GPs who
were high prescribers of antibiotics were
notified via letter that they prescribed
antibiotics at rates higher than their peers.
The trial showed a subsequent reduction in
antibiotic prescribing.