Review of psychotropic medication in Tasmanian residential aged care facilities

Aim: To examine psychotropic medication review practices in residential aged care facilities. Methods: Psychotropic medicine use data were collected from residents from 40 residential aged care facilities throughout Tasmania. As an indication of review practices, the measure was repeated at 33 of the original facilities a year later. Results: A total of 2389 residents' medication records were examined in 2006. Regular doses of antipsychotics and benzodiazepines were taken by 42% and 21% of residents, respectively. Medication data were available for 1307 of the residents in 2007. Over 60% were taking the same antipsychotic or benzodiazepine agent, at the same dose in 2007, as they were in 2006. Dosage reduction or cessation occurred in less than a quarter of the residents. Conclusion: The utilisation of psychotropic medication is high in Tasmanian residential aged care facilities. Attempts to reduce psychotropic doses happen infrequently. Further research is required to establish the barriers to appropriate psychotropic medication review in this setting.     

Serum vitamin D and falls in older women in residential care in Australia

OBJECTIVES: To determine the prevalence of vitamin D deficiency in older people in residential care and the influence that the level of vitamin D may have on their incidence of falls. DESIGN: Prospective cohort. SETTING: Residential care facilities for older people in several states of Australia. PARTICIPANTS: Six hundred sixty-seven women in low-level care and 952 women in high-level care, mean age 83.7 years. MEASUREMENTS: Serum 25-hydroxyvitamin D (25D) levels and recognized risk factors for falls including current medication use, a history of previous fractures, weight, tibial length (as a surrogate for height), cognitive function, walking ability, and frequency of going outdoors were determined. The women in low-level care and high-level care were followed for an average of 145 and 168 days, respectively. Falls were recorded prospectively in diaries completed monthly by residential care staff. RESULTS: Vitamin D deficiency (defined as a serum 25D level below 25 nmol/L) was present in 144 (22%) women in low-level care and 428 (45%) in high-level care. After excluding 358 bed-bound residents and adjusting for weight, cognitive status, psychotropic drug use, previous Colles fracture, and the presence of wandering behavior, log serum 25D level remained independently associated with time to first fall. The adjusted hazards ratio was 0.74 (95% confidence interval=0.59-0.94; P=.01), implying a 20% reduction in the risk of falling with a doubling of the vitamin D level. CONCLUSION: Vitamin D deficiency is common in residential care in Australia. A low level of serum vitamin D is an independent predictor of incident falls.     

Prescribing for older people discharged from the acute sector to residential aged‐care facilities

For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper‐polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk–benefit ratio.     

Epidemiology of falls in elderly semi‐independent residents in residential care

Objectives: To determine the incidence and consequences of falls in elderly people living in hostels, and the role of comorbidity, orthostatic hypotension and medications as risk factors for falls. Methods: Cross‐sectional prevalence and event association was studied in eight aged‐care hostels (Canberra, ACT, 1999) of 179 residents aged 65 years and older (83 ± 7 years (mean ± standard deviation), 80% women) independent in activities of daily living. History of falls and injuries on falling, comorbidity, medications and mobility data were obtained. Measurements of blood pressure and heart rate were made supine after waking from overnight sleep and after standing for 1 and 3 min. Results: Forty‐three per cent of subjects had fallen in the last year (1.3 ± 2.6 falls per person per year) and 29% of these had sustained a fracture, 53% of fallers had recurrent falls. In multivariate analysis, four factors were associated independently with falling within a year: using a walking device, history of cancer, taking selective serotonin reuptake inhibitors (SSRI) and cigarette smoking. For recurrent falls, cerebrovascular disease and using nitrates were also independent risk factors. In univariate analysis, reversible inhibitors of monoamine oxidase and potassium‐sparing diuretics were negatively associated with falls. There were no differences between fallers and non‐fallers in blood pressure in supine and standing positions, although one‐third of residents had orthostatic hypotension. Conclusions: Falls in elderly hostel residents are common and often have serious consequences. Living in an institution is associated with an increased risk of fractures. The study identified several novel potential risk factors for falls in this population: using a walking device, history of falls, presence of cancer, presence of cerebrovascular disease, taking SSRIs, taking nitrates and cigarette smoking. These can be used to identify hostel residents at high risk of falling who can then be targeted for monitoring, specific treatment and prevention strategies.     

Applying workability in the Australian residential aged care context

The study is based on an innovative demonstration project which trialled the implementation of the Finnish ‘workability’ framework and research measures. It aimed, firstly, to test the applicability of the Workability Index (WAI) to the Australian residential aged care workforce, focusing on personal care assistants (PCAs), and secondly, to assess the effectiveness of actions aimed at improving workability. The facility manager implemented multidimensional ‘actions’ according to the workability framework. The Workability Survey (WAS) and WAI and intervention instruments were administered (n = 64). Completed responses to ‘pre’ and ‘post’ instruments formed matched pairs (n = 15). WAI scores increased significantly, by 3 points on average, after all ‘actions’ were implemented. The only significant ‘action’ was increasing the number of PCAs in high care. Workability provides a useful research workforce development instrument measuring interactions between aged care workers and organisational demands and the outcomes of ‘actions’.     

Southcare Geriatric Flying Squad: an innovative Australian model providing acute care in residential aged care facilities

This study reviews the outcomes of a model developed to improve the quality of care of residents living within residential aged care facilities (RACF). The Southcare Geriatric Flying Squad saw a total of 640 acutely unwell RACF residents over an 18‐month period. Of these, 578 (90.3%) were managed in the RACF avoiding emergency department. Only 35 (5.5%) patients required emergency department transfer and 27 (4.2%) were directly admitted to a medical ward. The service may have reduced emergency presentations by offering rapid assessment and management, choice in place of treatment and level of interventions.     

Atypical antipsychotic medications and risk of falls in residents of aged care facilities

OBJECTIVES: To determine whether use of atypical antipsychotics (olanzapine and risperidone) is associated with lower risk of falls than use of typical antipsychotics. DESIGN: Prospective cohort study with 1-month follow-up. SETTING: Residential aged care facilities in Sydney, Australia. PARTICIPANTS: Two thousand five people aged 65 to 104 (mean age 86). MEASUREMENTS: Medication use at baseline was collected from medical records. Data on potential confounders were collected at interview and physical examination and from medical records. The outcome was accidental falls (one or more). RESULTS: One thousand one hundred seven subjects (55%) used at least one type of psychotropic medication, with 289 (14%) using an antipsychotic. There were 82 olanzapine users, 38 risperidone users, and 181 users of typical antipsychotics. Eleven percent of subjects (n=226) had at least one fall during follow-up. After adjusting for a comprehensive range of falls risk factors, hazard ratios (HRs) for falls were 1.35 (95% confidence interval (CI)=0.87-2.09) for typical antipsychotics, 1.32 (95% CI=0.57-3.06) for risperidone, and 1.74 (95% CI=1.04-2.90) for olanzapine. Antidepressants were also associated with falls (adjusted HR=1.45, 95% CI=1.09-1.93). CONCLUSION: Despite fewer extrapyramidal side effects, atypical antipsychotic medications are not associated with fewer falls than the older, more-established antipsychotics.     

Interprofessional student teams augmenting service provision in residential aged care

The aim of this study was to determine the usefulness of student‐led interprofessional consultations within residential aged care in augmenting patient care and enhancing student education. Volunteer fourth and final year health‐care students conducted interprofessional consultations. In a mixed methods design, residents' health‐care changes and perspectives were collected prospectively, and student and educator perceptions were measured by survey and interview. Sixteen aged care residents were consulted by interprofessional teams. Students identified two new health issues and proposed 17 recommendations for referrals and five changes to medication management. At six‐weeks follow‐up, two recommendations had been acted upon clinically, and two medication changes had been implemented. Reasons for the low uptake of recommendations were determined. Residents, students and educators reported high levels of satisfaction. Residential care facilities offer a useful interprofessional learning environment. Student consultations are positively regarded by patients, students and educators and may augment existing health services.     

Risk factors for fracture following a fall among older people in residential care facilities in Australia

OBJECTIVES: To investigate which factors best predict whether a fall will result in a fracture. DESIGN: Prospective cohort. SETTING: Residential care facilities. PARTICIPANTS: One thousand three hundred forty‐two older men and women (mean age 86.0) who had a fall. MEASUREMENTS: Clinical risk factors and bone fragility by calcaneus broadband ultrasound attenuation (BUA) were assessed at baseline, and falls and fall‐related fractures were recorded for up to 2 years. All fractures were validated using X‐ray reports. RESULTS: During a median follow‐up of 1.97 years, 6,646 falls resulted in 308 fractures. Fracture rates were 6.7, 4.8, and 3.1 per 100 falls for BUA in the lowest (10.5–39.7 dB/MHz), middle (39.8–58.9 dB/MHz), and highest (≥58.9dB/MHz) tertiles, respectively. In multivariate analysis, the odds ratio for any fracture was 1.17 (95% confidence interval=1.08–1.27; P<.001) for every 10‐dB/MHz reduction in BUA. Other significant risk factors in the model were lower weight, longer leg length, better balance, no severe cognitive impairment, intermediate care residence, lack of a history of falls in the previous year, and a history of fracture since age 50. For hip fracture, the only significant risk factors were lower weight, longer leg length, intermediate care residence, and lack of falls history. CONCLUSION: Important risk factors for whether a fracture occurs immediately after a fall include direct measures of bone fragility and a number of anthropometric and clinical factors that may increase or attenuate the mechanical impact of a fall. By identifying those at highest risk of fracture after a fall, these findings should have important implications for fracture prevention strategies.