• Introduction
• Principles of medical care of older persons in RACFs
• Medical assessment of residents
• Advance care planning
• Palliative and end-of-life care
• Medication management

Medication management

Prescribing medication
Dispensing, storage and disposal of medication
Administering medication

Residents' medication needs are complex. They are large users of medications due to the high prevalence of disease and comorbidity, and they are dependant on RACF staff for administering their medication.

Optimal medication management in RACFs involves a multidisciplinary and systematic approach with residents or their representative, GPs, pharmacists, aged care nurses, other RACF staff and health service providers. The APAC Guidelines for medication management in residential aged care facilities recommended that each facility has a Medication Advisory Committee with GPs, pharmacists (supplying pharmacists and if different, the pharmacist conducting medication reviews), RACF management and staff (including nurses), and resident advocate/s working together to facilitate the quality use of medicines.⁶⁷ Figure 2 summarises the organisational issues for medication management in RACFs that are addressed in the guidelines.

Particular aspects for GPs to consider include (also refer to the APAC guidelines mentioned above):

• an efficient and effective partnership between residents, prescribing GPs, dispensing and review pharmacists and administering RACF staff

• monitoring of risks of adverse medication reactions and interactions, particularly if polypharmacy is combined with over-the-counter medications, or alternative supplements

• regular reviews of prescribed medication following changes in comorbidity and progression of disease

• prescribing as required (PRN) and nurse initiated medication (NIM) to cover anticipated events

• use of alternative oral formulations

• requirements for end of life care.

Prescribing medication

All people have the right to give informed consent or to refuse any medical intervention including medication. It is therefore important to discuss treatment issues with residents and their relatives/carers or representatives using easily understood language. Treatment objectives from the perspective of residents may be affected by their experience of the ageing process, cognitive impairment, physical disability, chronic disease, pain, accumulated losses and social isolation.⁶⁸

General principles of prescribing medication for older people include⁶⁹:

• nonmedication treatments should be used wherever possible

• treat adequately to achieve goals of therapy

• new medications: start low, go slow and increase slowly checking for tolerability and response

• use the lowest effective maintenance dose

• generally prescribe from a limited range of medications and ensure familiarity with their effects in older people

• prescribe the least number of medications, with the simplest dose regimens

• consider the person's functional and cognitive ability when prescribing

• consider medication adverse effects if there is a decline in physical or cognitive functions or self care abilities

• prescribe suitable formulations of medications if a person experiences swallowing problems

• provide patient education, using Consumer Medicine Information (CMI) or simple verbal and written instructions for each medication to reinforce adherence

• regularly review treatment and the person's ability to manage the medications

• consider the medicines already being taken including prescription, nonprescription and complementary medicines.

Prescribing medications include routine medications, as well as pre-planning medications when required (PRN) for anticipated events from specific conditions (eg. allergic reaction, angina, asthma, behaviours of concern, constipation, diabetes, diarrhoea, pain).

Decisions to prescribe medication are optimally⁷⁰:

• evidence based

• made in the context of the patient's medical and psychosocial condition, prognosis, quality of life and wishes

• made in the context that overuse, underuse, and inappropriate use of medications are equally important quality of care concerns

• made with disclosure of confidential information, only as necessary for direct patient care.

General practitioners have access to several excellent sources of evidence based information on prescribing medication. The National Prescribing Service website (www.nps.org.au) includes the Therapeutic Advice and Information Service (TAIS) for health care professionals. TAIS provides immediate access to independent medication and therapeutics information for the cost of a local call (1300 138 677). Therapeutic guidelines for management of patients with common clinical conditions are available as pocket sized books, CDROMs for installation on personal computers, and versions for use on health department intranets, commercial prescribing software, and hand held computers. These are obtainable at www.tg.com.au/home/index.html or telephone 1800 061 260. The Australian medicines handbook (AMH) provides a comparative, practical formulary covering most of the medications marketed in Australia. It is available in annual book editions, CDROM, PDA, or online (via the Health Communications Network (www.amh.net.au). Also provided by the AMH is the Medication choice companion: aged care, which is particularly relevant for older people living in RACFs.⁷¹

In addition, best practice for medication management in older adults includes these steps⁷²:

• Identify the presence and nature of the resident's symptom, disease, condition, impairment, or risk

• Assess the resident to identify the cause of the problem, or document why an assessment was not performed

• Gather and assess information about the resident's current medications and treatments as well as responses and adverse reactions to previous medications and treatments

• Identify and document the reason(s) why the disease, condition, symptom, or impairment needs to be treated, or why treatment is not to be provided

• Choose an appropriate medication or modify an existing medication regimen

• Identify and document the objective(s) of treatment

• Consider and document the benefits and risks of treatment

• Consider and document possible medication interactions

• Order the selected agent

• Order appropriate precautions in administering the medication, including instructions for resident monitoring

• Assess and document the resident's status during or at the end of treatment

• Assess the resident for possible adverse medication reactions

• Modify the medication regimen as indicated by its effectiveness or by the presence of complications.

Medication orders are written on RACF medication charts by qualified prescribers taking into account the needs and views of residents (or representatives), policies of the RACF, legislative requirements and professional standards. The qualified prescriber is usually the resident's GP, but may also be a locum or hospital doctor, geriatrician or palliative care physician. In some situations, registered dental practitioners or registered nurse practitioners are able to prescribe medications.

It is considered best practice for GPs to work closely with RACF staff to regularly review and rewrite medication charts to maintain a continuum of medication for residents. The APAC National guidelines to achieve the continuum of quality use of medicines between hospital and community should be referred to when a resident moves between different health care settings (eg. hospital to RACF).⁷³ A residential medication management review, conducted by the GP and pharmacist, is recommended for each resident on admission and regularly thereafter (see Organisational aspects).

Dispensing, storage and disposal of medication

Pharmacists work closely with GPs to dispense medication as prescribed and conduct medication reviews. They work closely with RACF staff to supply the dispensed medications in a suitable form and ensure their safe handling at the facility. The Pharmaceutical Society of Australia has developed standards for pharmacy services to residents⁷⁴:

• Maintain appropriate systems for the supply of medicines to the facility

• Ensure that medicines are delivered to the RACF in a timely manner

• Ensure that medicines are stored within the RACF in accordance with legislative and manufacturers' storage requirements

• Monitor stock medicines used in the RACF

• Check medications brought into the RACF by new patients, as soon as practicable after admission, to ensure consistency with currently prescribed medications

• Conduct a comprehensive medication review of all residents at regular intervals and maintain appropriate records

• In consultation with medical practitioners identify residents who may require therapeutic medication monitoring

• Identify, monitor and document adverse medication events

• Provide information on medicines that adequately meet the needs of the RACF

• Provide an education program appropriate to the needs of the RACF

• RACFs must have a mechanism in place for the disposal of returned, expired and unwanted medicines.

Administering medication

Medications can be administered by a registered nurse who is qualified to administer medication, or self administered by the resident (who is assessed as competent to do so). Dose administration aids (DAAs) are used to provide medications where there is not a registered nurse qualified to administer medications, or to assist residents who are self administering medications. 'Blister' packaging systems or 'compartmentalised boxes' are packed and labelled by a pharmacist and the medications administered directly from the DAA to the resident. If the prescriber alters any medication order, the entire DAA must be returned to the supplying pharmacist for repackaging. Residential aged care facility staff should refer to relevant state/territory legislation for further information on DAAs.

It is recommended that RACFs have policies and procedures for the alteration of oral dose formulations (eg. crushing tablets or opening capsules) to make it easier to administer medication to residents with swallowing difficulties. In some cases, the practice of altering the form of medication may result in reduced effectiveness, a greater risk of toxicity, or unacceptable presentation to residents in terms of taste or texture. Controlled release medications should not be crushed or altered without consultation with the pharmacist. Residential aged care facility staff could refer to Appendix F of the APAC Guidelines for medication management in residential aged care facilities for more information on alteration of oral formulations (Figure 2).

Figure 2: Organisational issues for medication management in RACFs. (*See the Australian Pharmaceutical Advisory Council Guidelines for medication management in residential aged care facilities) ⁶⁷

© 2006 The Royal Australian College of General Practitioners. All rights reserved.
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