Issue 3 / 4 February 2013

GERIATRIC medicine has lost its way in Australia, according to a geriatrician who says it is time specialists were more actively involved in treating residents of aged care facilities.

Dr Ludomyr Mykyta, a geriatrician in private practice in South Australia, said that when he visits his patients in residential aged care facilities “I’m not meeting any of my colleagues”.

He was responding to a Perspectives article in this week’s MJA on the rate of psychotropics prescribing for patients in residential aged care facilities. (1)

Geriatrician Dr Sarah Hilmer, from Royal North Shore Hospital, Sydney, and Dr Danijela Gnjidic, of the University of Sydney’s Faculty of Pharmacy and Centre for Education and Research on Ageing, wrote that psychotropics were being prescribed to residential aged care residents “too often, for too long, at doses that are too high, in dangerous combinations with other medications and without adequate consent”.

“There is growing evidence on the risks associated with psychotropics in [residential aged care facility] residents, including falls, pneumonia, hospitalisation and mortality”, they wrote.

The authors called for high-quality economic evaluations of non-pharmacological and pharmacological management options for residents with a range of conditions, to determine the effects and total costs of each approach.

“Non-pharmacological management options have some evidence of efficacy … and do not carry the risks of psychotropic medications”, they wrote.

“However, non-pharmacological management is constrained by requirements for more intensive, skilled nursing and allied health staff — limited resources in the aged care sector.”

Dr Mykyta told MJA InSight the problems in residential aged care were exacerbated because the facilities were outside the mainstream health system.

“Residential care facilities are seen as accommodation, even though 80% of the residents have dementia, many of them with advanced dementia”, Dr Mykyta said.

“These patients are at the nth stage of the disease and this is where the expertise is desperately needed, but the expertise doesn’t show up”, Dr Mykyta said.

“Where are the geriatricians? Where are the psychogeriatricians?

“The system should follow the patients wherever they are.

“Geriatric medicine in this country has lost its way — we think we’re too important and too busy. The whole system is sick.”

Professor Gerard Byrne, head of psychiatry at the University of Queensland and of the older persons’ mental health service at the Royal Brisbane and Women’s Hospital, agreed that the aged care system was in dire need of a “fix”.

“The proper solution is a reorganisation of the care of the elderly, particularly those with dementia”, Professor Byrne said.

“GPs are very busy and they don’t need this sort of work unless it is funded adequately, which it’s not. It’s not the fault of the aged care facilities or the GPs. It’s the structural reality of the current funding system”, he said.

“This is about how we feel about the elderly. We love the care of children, and that’s appropriate, but when it comes to [funding] the elderly, we hit trouble.”

The authors of the MJA article wrote that appropriate use of psychotropics in aged care facilities relied on adequate education and training, but cost pressures within facilities often favoured inappropriate use of the drugs, which required more complex policy solutions.

“Appropriate psychotropic use could be achieved through carefully considered financial incentives to equalise the costs of different management strategies. Investment could be made in recruiting and training staff to provide non-pharmacological therapies, and in research to develop better pharmacological and non-pharmacological management strategies.”

Dr Mykyta said he didn’t care whether psychotropics “worked” in dementia patients.

“Even if they do nothing, they make a huge contribution because in order to be prescribed, the patient must be assessed and that leads to more positive outcomes for these people”, he said.

“Management is more than treatment.”

– Cate Swannell

1. MJA 2013; 198: 77

Posted 4 February 2013

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4 thoughts on “Geriatric medicine loses its way

  1. Dr Harry Haber says:

    I spent forty years in general practice with a large nursing home practice, my belief being that the nursing homes should have direct contact with the local or regional hospital and that the GP should be part of the team. In the 1990s as a chairperson of the area health I established an agreement that with a patient of mine or the patient of a GP, his or her name would be included at the patient’s bed head and the GP was included in the care. A few years ago when a patient was dying I found I no longer had that right to care involvement of the patient. This matter of health department policy needs to be investigated

  2. L says:

    Over the last six months I have spent time working as part of an aged care mental health service that provides psychosocial interventions and medication advice to assist behavioural symptoms of dementia. Our team predominantly attended aged facilities.

    A few observations from my experiences:
    More than half the patients had an issue with pain or unrecognised delirium which when investigated and treated resolved the majority of symptoms. Facilities appear quick to call on public services to fix a “psychiatric issue” when an organic cause is the problem. Often, staff have had a negative experience with hospitals and are at a loss. I recall one patient who after having major surgery became extremely confused on return to their nursing home. The duty manager stated that she “couldn’t send a patient to hospital because they did it before and they would only get sent back.”

    Non pharmacological recommendations were often related to safe approach strategies and training, which members of our multidisciplinary team provided. Unfortunately, facility managers were often reluctant to let their staff attend. Facility managers are often keen to have “difficult” patients transferred elsewhere and pressure family and outside providers to do so. Sadly, aging in place facilities who receive funding to manage high level care patients were particularly notorious at having insufficient staff levels (pocket the change syndrome). As nursing homes are completely deregulated, most only have one RN per shift and may have a Nurse: Patient ratio of anywhere from 1:30-1:50. “Nurse” is used generally, as these figures would often include PSAs. As such, providing non pharmacological interventions was often too hard to implement for a number of facilities.

    On the other side of the coin, patients discharged from hospitals on antipsychotics prescribed for delirium are often left on these medications long after the delirium has been resolved highlighting a lack of communication.
    Finally, dementia is neither sexy nor glamorous work. The work is undervalued and reimbursement is relatively poor. Medical students dream of being trauma surgeons or orthopods, not managing fronto-temporal lobe dementias. I recall one GP who admitted that after failing his physician exams ended up earning double the public consultant wage as a locum GP.

    So what is going to make aged medicine more attractive?
    Should pay structures be reviewed? It seems that making the “Cognitive” vs “procedural” funding arrangements more equitable has been placed in the too hard basket, but with the baby boomer demographic aging, there will be even more demand for services with increased pressure placed on the public system. Either way, more money will be required as this issue will not go away.

  3. Sue Ieraci says:

    This is such an important area. Nursing Homes (RACFs) tend to be staffed as residential facilities, but with expectations to perform as health care facilities. Patients discharged from acute care hospitals go immediately from 24 hour RN care and daily medical rounds to largely lay care with occasional GP visits. There has been a lot of talk about step-down facilities, but these don’t seem to have materialised in any way that might meet the need. I agree with L that there needs to be some reward in medicine for cognitive skills – not just procedural skills. The RVS had a go – but little changed. How about some Aged Care policy for the next term of government? Let’s start with a new RVS and many more transition aged care beds – funded from a combination of hospital and NH fuding. And that would require…..a single funder!

  4. Anonymous says:

    With the item numbers 141-147 which only geriatricians can claim for a comprehensive geriatric assessment, geriatricians get comparatively very well remunerated-$427.00 for an initial consultation compared to $253.00 for an initial consultation by other physicians. Sadly, it seems that geriatricians are city beasts who rarely show their faces outside the safety of the big cities, except on a “telehealth” screen, when they can then charge over $600 for a “virtual” consultation which we all know is a second rate alternative to face to face consultations. Hence the 40% of Australia’s elderly population who live outside metropolitan areas will not have access to this rebate.
    How about we actually start providing that rebate to the physicians who are in the rural areas, looking after the elderly and doing comprehensive geriatric assessment and management as part of their work. There needs to be more incentive for other medical practitioners, rehab physicians, general physicians etc to take on their responsibilities for our ageing population, and not be financially penalised for doing so.

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