More guidance from Choosing Wisely Australia developed by the Royal Australasian College of Physicians (RACP) focussed on the use of medicines for older Australians.
Choosing Wisely Australia was launched in April 2015, led by representative groups of the health profession and facilitated by NPS MedicineWise. To date, 98 recommendations have been released from 21 colleges, societies and associations.
In its latest list of recommendations, Choosing Wisely says older Australians may not realise they are on a ‘prescribing cascade’, where they take one medicine and have an adverse reaction, so are put on another medicine.
"One common example is when a patient is prescribed a non-steroidal drug for pain, and is then prescribed a proton pump inhibitor (PPI) to reduce the risk of stomach side effects caused by the first prescribed medicine," it says.
Amongst the new recommendations, Choosing Wisely says prescribers should reduce the use of multiple medicines, not prescribe medicines without conducting a drug review, to avoid adverse outcomes for people on 5 to 20 medications, and stop medicines when no further benefit will be achieved.
The Australian and New Zealand Society for Geriatric Medicine recommends against the use of antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.
It also recommends against the prescribing of benzodiazepines or other sedative-hypnotics as first choice for insomnia, agitation or delirium, not to prescribe antibiotics for asymptomatic bacteriuria in older adults, medication without conducting a drug regimen review and do not use physical restraints to manage older adults with delirium.
According to RACP President and The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) member, Dr Catherine Yelland, “Care principles need to reflect the latest evidence and science, so that unnecessary tests, treatments and procedures are avoided. Equally important is the doctor-patient conversation to support informed and sound decision making to support high-quality care for older Australians.
“One of our recommendations is to not use antipsychotics as the first choice in treating behavioural and psychological symptoms of dementia, including aggression, resistance to care and disruptive behaviour. The use of antipsychotics is of dubious benefit and can lead to serious side effects that can be life-threatening. We recommend trying non-drug interventions first as they are an effective option. Ensuring a workforce is trained to be able to deliver non-pharmacological interventions is critical to being able to provide high quality care.”
PBAC's Drug Utilisation Sub-Committee (DUSC) has previously identified the utilisation of antipsychotics as a safety issue, particularly in the elderly as a sedative. In an analysis, it found PBS prescribing data revealed "high and inappropriate utilisation of antipsychotics in the elderly."
Changes were subsequently made to the PBS prescribing criteria for antipsychotic quetiapine, limiting the number of repeats for the 25 mg dose. DUSC confirmed a review of antipsychotic medicines at its most recent meeting, including a review of quetiapine.
“Many of our recommendations today will help patients avoid unnecessary tests and procedures and lead to discussions on reducing waste and overuse of medicines," said Professor Jennifer Martin from the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT).
“One of our recommendations is to reduce the use of multiple medicines, common in older patients. Hyper-polypharmacy is where people may be on as many as 15 to 20 medicines at a time. Research has confirmed a significant association between polypharmacy and adverse outcomes among older people and an association with decreased physical and social functioning; increased risk of falls, delirium, hospital admissions and death. With an ageing population, use of many medicines at the same time is something we need to be having conversations about to avoid potentially harmful implications.”
CEO of NPS MedicineWise, Dr Lynn Weekes, said: “We are delighted to launch two more lists of Choosing Wisely Australia recommendations today. Choosing Wisely Australia is all about kick starting conversations about unnecessary tests, treatments and procedures, and that more is not always better. The adoption of these recommendations by health professionals will improve care.
“With the focus on medicines and older Australians in these lists, we urge people to consider if they are on the right medicine, or whether they could be taking too many medicines and if you are due for a review. It’s always timely to check with your doctor or pharmacist to see if any medicines are unnecessary and if they could cause harm if taken together.”
