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FEATURE
ACCREDITED PHARMACIST SPECIAL INTEREST GROUP
Overcoming barriers to reducing sedative use
BY KOMAL THAKKAR
and about the development of tolerance with benzodiazepines. However, it is not uncommon to see staff request GPs to prescribe antipsychotics and benzodiazepines.
Insomnia misunderstood
Studies have shown that sleep requirements reduce with ageing. On average elderly people need four to six hours of sleep daily, including daytime naps. So it is not realistic to expect residents to sleep through the night. I have seen benzodiazepines prescribed on feedback from nurses and carers that ‘the resident doesn’t sleep.’ In fact, when this is followed by a sleep assessment, the resident is receiving adequate sleep in the 24-hour period.
Changing ‘as necessary’ to regular
dose
Another issue I have observed is that patients who are taking an ‘as necessary’ dose of temazepam
a few times a week have the dose changed to
a regular nightly dose. The staff may see this as meeting accreditation requirements. In the case of paracetamol being used frequently, it may be good management to change to regular analgesia. It is certainly the opposite for benzodiazepine use, as residents can develop tolerance and dependence. A solution we have found in some of my ACFs is
a note from the GP emphasising that despite the often frequent use of this medication, it is only appropriate to use it ‘as necessary.’
Staffing pressures
Staffing pressures in ACFs may contribute to the decision to change a benzodiazepine from ‘as necessary’ to a regular medication. There may
only be one registered nurse (RN) on the floor at night and the enrolled nurse must get permission from the RN to administer an ‘as necessary’ benzodiazepine. So having these medicines as ‘as necessary’ would significantly increase the workload for the staff.
If a few residents are up at night it can be difficult for the staff member to pay attention to individual requirements. This may lead to an increase in sedative use. A practical solution could be a wanderer’s lounge with a staff member dedicated to those residents needing assistance.
Individual assessment
To reduce sedative use, it is necessary to understand each resident’s individual story. There may be
Komal Thakkar is a consultant pharmacist in Melbourne, Victoria, and provides RMMR and QUM services to Aged Care Homes. She is also a certified GTD (Getting Things Done) trainer.
During the years that I have provided RMMR and QUM services to aged care facilities (ACFs) in Victoria it has been my passion to reduce the use of sedatives. This article will examine the barriers to reducing sedative use (both antipsychotics and benzodiazepines).
Unclear communication
Hospitals often commence patients on sedatives for the duration of their hospital stay but sometimes fail to cease them on discharge. Similarly, a patient who has had a medication commenced for short term use in the community may have this medication continued on admission to an ACF.
Prescribing pressure on GPs
Working closely with GPs, I see a lot of pressure to ‘fix’ the behaviour exhibited by ACF residents. These behaviours include aggression, wandering, intrusion due to confusion, and staying up at night. There is no evidence of benefit from using medication to alter some of the behaviours. As pharmacists we provide staff education about behaviours which may respond to antipsychotics,
20 Australian Pharmacist January 2017 I ©Pharmaceutical Society of Australia Ltd.