Discussion
cognitive impairment, constipation
This is the first randomised controlled trial conducted to assess the effects of an on-site pharmacist in residential aged care model on medication appropriateness. The study found a statistically significant reduction in the number of residents using PIMs, residents’ mean anticholinergic burden scale, and chlorpromazine equivalent dose of antipsychotic medications per resident in the intervention group compared to the control. There were no significant changes identified in other outcomes, including number of regular medications, ADR documentation status, the proportion of residents taking one or more benzodiazepine or antipsychotic, and the dose of benzodiazepines between control and intervention groups.In this study, pharmacists were included as part of each facility’s multi-disciplinary care team to perform resident-level clinical activities, including comprehensive medication reviews, and facility-level activities such as clinical audits and contributing to policies and procedures. This holistic approach to medication management allowed pharmacists to prioritise and resolve medication-related problems as they occurred and mitigate risks through improving organisational systems within the RACFThe study found a significant decrease in the proportion of residents taking at least one PIM in the intervention group compared to the control group over the study period. According to the adjusted model presented, the odds of having at least one prescribed PIM in the intervention group had halved over the period of the study, when compared to the control group. The use of PIMs has been considered as an indicator for the QUM in healthcare settingsThe study observed a statistically significant reduction of residents’ anticholinergic drug load in the intervention group. Older residents are particularly vulnerable from the detrimental effects of anticholinergic medications, such as cognitive impairment, constipation, and behavioural disturbancesThe proportion of residents taking psychotropics, defined as one or more benzodiazepines or antipsychotics, had a reduction in the intervention arm when compared to the control but the difference was not statistically significant. While the dose of benzodiazepines didn’t show a reduction, notably, the dose of antipsychotics after adjusting for potential confounders, showed a statistically significant reduction in the intervention arm. This finding suggests the pharmacists were able to initiate reduction in dose of antipsychotics but may have not been able to achieve cessation over the period of the intervention, as the process requires dose tapering and monitoringPolypharmacy is prevalent amongst residents in residential age care. In the RACF setting polypharmacy is often defined as the use of nine or more regular medicationsThe study had the following limitations. Due to COVID-19 we could not assess the effect of the on-site pharmacist in RACF model on medication round time and inappropriate administration of dosage forms, as was initially planned. The Beers criteria tool was used as the primary outcome of the study to identify the use of potentially inappropriate medications amongst residents in RACFs. While the Beers Criteria tool is a useful proxy for QUM, it does not assess the underuse of helpful medications. All participating facilities in the study were in the Australian Capital Territory (ACT) Australia which is a metropolitan area. A careful analysis of the contextual differences should be considered when generalising to other regions in Australia and beyond, such as regional and rural areas. Future studies could assess the longer-term impact of OSP in RACF model on resident health outcomes and include economical analysis for the wider roll out of this model.