RACGP aged care clinical guide (Silver Book)

Silver Book - Part A

Medication management

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Last revised: 30 Oct 2019

  • As the population ages, more people are living with multiple chronic diseases with an associated increase in polypharmacy (multiple medicines use).
  • Medication use in older people is a complex balance between managing disease and avoiding medication-related problems.
  • Supervised withdrawal of unnecessary medicines (deprescribing) is safe and may improve quality of life in older people.
  • Optimal medication management in older people requires a multidisciplinary approach to ensure the best quality of life.

Older people’s medication needs may be complex because of the high prevalence of disease and comorbidities (refer to Part A. Multimorbidity). Optimal medication management for older people in residential aged care facilities (RACFs) and the community involves a multidisciplinary and systematic approach with patients and/or their representative, general practitioners (GPs), pharmacists, aged-care nurses, other RACF staff, health service providers and allied health practitioners.

The Australian Pharmaceutical Advisory Council’s (APAC’s) Guiding principles for medication management in residential aged care facilities (the Principles) builds on previous editions of guidelines developed under Australia’s National Medicines Policy. It promotes safe, quality use of medicines and medication management in RACFs.1 The Principles is intended to assist RACFs to:

  • develop, implement and evaluate locally specific policies and procedures
  • support those involved in assisting residents
  • support residents in the medication management process.

It is essential that GPs working in RACFs are familiar with the 17 Guiding principles as listed in Table 1.

Table 1. APAC’s guiding principles

Table 1.

APAC’s guiding principles 1

Particular aspects of medication management for GPs to consider when working in RACF include:1

  • efficient and effective partnership between patients, prescribing GPs, dispensing and accredited consultant pharmacists and support staff (eg nursing staff, RACF staff, clinical care coordinator)
  • assessing risks of adverse medication events and drug interactions, particularly if polypharmacy is combined with over-the-counter medications, or complementary and alternative medicines (refer to Part A. Polypharmacy)
  • regular reviews of prescribed medication following changes in comorbidity and progression of disease to optimise medication use
  • prescribing as required to cover anticipated events
  • using appropriate dose forms and devices for administrating medicines
  • requirements for end-of-life care (refer to Part A. Palliative and end-of-life care).

Medication management differs between residents in RACFs and older people in the community as, for the former group, medications are administered by staff at the optimal times with few issues in compliance. In addition, regular observation of residents in RACFs enables early recognition of medical conditions and monitoring of treatment goals.

All people have the right to give informed consent or refuse any medical intervention, including medication. It is important to discuss treatment issues and ongoing care plans with patients and their relatives/carers or representatives using language that can be easily understood.2 Prescribing principles for older people include the following:1,2,3,4,5,6

  • Consider medication being taken by the patient on admission, including prescription, non-prescription and complementary and alternative medication, and effect of prior adherence or non-adherence.
  • Wherever possible, use non-drug treatments either alone or as an adjunct to medication in preference to medication.
  • New medications should follow a ‘start low, go slow’ approach; increase slowly according to tolerability and response.
  • Use the lowest effective maintenance dose.
  • Select medications that are suitable for use in older people with minimal adverse effects.
  • Be aware of changing pharmacokinetics in older people that can affect drug absorption, distribution, metabolism and excretion, and adjust doses as appropriate.
  • Check drug–drug, drug–disease and drug–food interactions using evidence-based references.
  • Set monitoring protocols when appropriate.
  • Prescribe the least number of medications, with the simplest dose regimens.
  • Consider the patient’s functional and cognitive ability when prescribing.
  • Consider medication adverse effects if there is a decline in physical or cognitive function.
  • Prescribe suitable formulation of medications if a person experiences problems with swallowing.
  • Involve patient and family regarding any significant changes in medication (eg deprescribing; refer to Part A. Deprescribing).
  • Regularly review treatment and cease medications if they are no longer appropriate or goals of management change.
  • If the patient is self-administering, regularly assess their ability to continue to manage their medication administration and storage.

Prescribing medications include routine medications, as well as pre-planning medications when required for anticipated events from specific conditions (eg allergic reaction, angina, asthma, chronic obstructive pulmonary disease [COPD], constipation, diabetes, diarrhoea, dry eyes, nausea, pain, skin rashes).

The decision to prescribe medications should optimally be:

  • 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.

The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) has released a position statement on Prescribing in older people that provides further details.7

In the RACF setting, medication orders are written on the RACF medication chart 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, Hospital in the Home (HITH) prescriber, geriatrician or palliative care team member. In some situations, registered dental practitioners or registered nurse practitioners may be able to prescribe medications.

It is necessary for GPs to work closely with RACF staff to regularly review and rewrite medication charts and prescriptions to maintain a continuum of medication for residents. There is currently a transition from medication charts to the national standard medication chart, and also to electronic chart prescribing in accordance with mandatory legislative requirements.8

APAC’s National guidelines to achieve continuity in medication management should be referenced when a resident moves between different healthcare settings (eg hospital to RACF).7 The World Health Organization’s (WHO’s) Medication safety in transitions of care provides further detailed information to improve safety in transition from hospital to home or RACF.9

Residential medication management review

Under the sixth Community Pharmacy Agreement, Medicare requires contracts in order for accredited pharmacists to undertake a Residential Medication Management Review (RMMR; Medicare Benefits Schedule [MBS] item number 903) in a particular RACF.10

RMMRs are services provided to permanent residents of Commonwealth-funded RACFs. The RMMR is conducted by an accredited pharmacist when requested by a resident’s GP, and undertaken in collaboration with the resident’s GP and appropriate members of the resident’s healthcare team. A comprehensive assessment is undertaken to identify, resolve and prevent medication-related problems, and this assessment is provided to the resident’s GP. The RMMR is recommended for each resident on admission and regularly reviewed thereafter when there is a therapeutic need.

Quality Use of Medicines

The Quality Use of Medicines (QUM) program is a separate service provided by a registered or accredited pharmacist, and focuses on improving practices and procedures as they relate to QUM in an RACF.10

Home Medicines Review

In the community, medication should be reviewed regularly to identify discrepancies between medicines being taken and those prescribed. The Home Medicines Review (HMR; MBS item number 900) is available for the GP and pharmacists to assess optimal medication management.

Dispensing, storage and disposal

Pharmacists work closely with GPs to dispense and supply medication safely, and accredited consultant pharmacists conduct medication reviews only on referral from a GP. All three can work closely as a team with the 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 residents, outlining the following recommendations:11 

  • Maintain appropriate systems for the supply of medicines to the facility.
  • Ensure medicines are delivered to the RACF in a timely manner.
  • Ensure 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

Medication can be administered by a registered nurse (RN), an endorsed enrolled nurse (EN) or a personal care assistant (PCA) who is qualified to administer medication, or can be self-administered by the resident if they are assessed to be competent to do so.1,2

Dose administration aids can be used to provide medications where an RN who is qualified to administer medications is unavailable, and can be used to assist residents to self-administer. ‘Blister’ packaging systems or medication sachets are packed and labelled by a pharmacist, and the medication is administered directly from the dose administration aid to the resident. If the prescriber alters any medication order, the entire dose administration aid must be returned to the supplying pharmacist for repackaging. RACF staff should refer to relevant state/territory legislation for further information on dose administration aids. Older people in the community may administer from original containers or use dose administration aids either packed by themselves, family members or the supply pharmacy.

Modifying oral products

Many older people have difficulty swallowing tablets and capsules. Wherever possible, oral dose forms of medicines should not be altered.1,2

Medications must not be crushed or altered without consultation with the pharmacist or drug information centre. Altering the form of medication by crushing, cutting or dispersing may result in the risk of toxicity, reduced effectiveness, gastrointestinal irritation, unacceptable presentation to residents in terms of taste or texture, or an occupational health and safety issue to nursing staff.1,2

Details about the suitability for dispersion, crushing or cutting for people with difficulties swallowing or with enteral feeding tubes are provided in The Society of Hospital Pharmacists Australia’s Don’t rush to crush.12 This resource is available as a text or as part of Monthly Index of Medical Specialities (MIMS) or Australian Drug Information (AusDI) as an additional subscription and should be used in conjunction with advice from a pharmacist.

Alterations in drug delivery should be recorded on the patient’s medication chart with the date reviewed, so that all members of the healthcare team are aware of the new procedures. Each RACF is required to have a policy for the administration of altered medications, and suitable techniques if the drug is approved for crushing.12

Review medication regimen

Difficulty in swallowing provides an opportunity to review the medication profile; before trying to cut, crush and/or dissolve a tablet or capsule, consider:2

  • stopping medicines that are no longer necessary
  • using an oral liquid
  • using other available routes (eg rectal, topical, transdermal, parenteral) that may be appropriate
  • changing to an alternative drug that is easier to give or has a liquid or dispersible preparation available.

If a resident has difficulties swallowing medicines, it can be assumed that they will also encounter difficulties with food. Referral to a speech pathologist and dietitian may also be considered.

GPs should have access to evidence-based information on prescribing medication, including the following:

Production information and consumer medicines information guides are available from MIMS, AusDI, the Australian Register of Therapeutic Goods (ARTG), and are included in most prescribing software. Prescribers should ensure they are registered to receive regular Therapeutic Goods Administration (TGA) alerts (including any adverse event reporting) and alerts on the monthly changes to the Pharmaceutical Benefits Scheme (PBS).

Prescribing guidelines and position statements are also available from many chronic disease organisations, including:

  1. Rossi S. Australian medicines handbook. Adelaide: Australian Medicines Handbook Pty Ltd, 2019 [Accessed 8 August 2019].
  2. NPS MedicineWise. Medical info. Canberra: NPS MedicineWise, 2019 [Accessed 8 August 2019].
  3. Department of Veterans’ Affairs. Publications. Canberra: DVA, 2019 [Accessed 8 August 2019].
  4. Basger BJ, Chen TF, Moles RJ. Validation of prescribing appropriateness criteria for older Australians using the RAND/UCLA appropriateness method. BMJ Open 2012;2:e001431. [Accessed 8 August 2019].
  5. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;1:1–16. [Accessed 8 August 2019].
  6. Australian and New Zealand Society for Geriatric Medicine. Prescribing in older people. Sydney: ANZSGM, 2018 [Accessed 8 August 2019].
  7. Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity in medication management. Canberra: APAC, 2005. [Accessed 8 August 2019].
  8. Australian Commission on Safety and Quality in Health Care. National residential medication chart. Sydney: ACSQHC, 2018 [Accessed 8 August 2019].
  9. World Health Organization. Medication safety in transitions of care. Geneva: WHO, 2019 [Accessed 8 August 2019].
  10. 6th Community Pharmacy Agreement. Residential medication management review and QUM. Canberra: 6CPA, 2018 [Accessed 8 August 2019].
  11. Pharmaceutical Society of Australia. Professional practice standards. Canberra: PSA, 2017 [Accessed 8 August 2019].
  12. Burridge N, Symons K (eds). Don’t rush to crush. Melbourne: The Society of Hospital Pharmacists of Australia, 2019 [Accessed 8 August 2019].