The Aged Care Quality Indicator Program: Medication Management (Polypharmacy and Antipsychotics)

A 2020 report from the Pharmaceutical Society of Australia found that 95% of aged care residents were experiencing at least one problem with their medicines. Furthermore, over half of all aged care residents were found to have been prescribed potentially inappropriate medicines.

Older people often need to take a variety of medicines due to age-related chronic illness, with about 80% of people over the age of 65 having at least one chronic condition (ACSQHC 2021). However, the physiological processes of ageing make older people more sensitive to the effects of medicines and cause their bodies to respond differently, increasing their risk of experiencing adverse events and interactions (PSA 2020).

Inappropriate medicine use has the potential to cause a variety of negative health outcomes including falls, admission to hospital, adverse drug reactions and even mortality, yet, inappropriate prescribing continues to be a widespread and complicated issue in residential aged care (ACQSC 2020).

In order to address this issue and improve the quality of care for older people, The National Aged Care Mandatory Quality Indicator Program (QI Program) requires all government-subsidised residential aged care providers to collect and report data on two significant aspects of medication management: polypharmacy and antipsychotics (DoHaAC 2023).

The Quality Indicator Program Under the Strengthened Aged Care Quality Standards

Standard 2: The Organisation - Outcome 2.3: Accountability and quality systems under the strengthened Aged Care Quality Standards (Action 2.3.1) requires aged care providers to establish a quality system that uses data from the QI program to assess the organisation’s performance in delivering quality care and services (ACQSC 2024a).

Polypharmacy

Polypharmacy is common among older people, with two-thirds of people aged over 75 taking five or more medicines simultaneously (ACSQHC 2021).

While polypharmacy is necessary in some cases, it carries significant risks and has been associated with serious consequences, including:

• Delirium
• Falls
• Reduced quality of life
• Adverse drug reactions
• Medicine interactions
• Medication errors
• Cognitive decline
• Admission to hospital
• Premature illness or death.

(ACSQHC 2021; DoHaAC 2023)

Polypharmacy in the Quality Indicator Program

Under the QI Program, polypharmacy is defined as the prescription of nine or more medicines to a single care recipient (DoHaAC 2023).

The medicines included in this count are all medicines (both prescription and non-prescription) with an active ingredient, except for:

• Lotions, creams and ointments used for skin and wound care
• Dietary supplements, including vitamins
• Short-term medicines (e.g. antibiotics, temporary eye drops)
• PRN medicines
• Different dosages of the same medicine.

(DoHaAC 2023)

Under the QI Program, residential aged care providers must collect and report data on the number of residents who have been prescribed nine or more medicines (DoHaAC 2023).

This data collection must take place on a single collection date every quarter (DoHaAC 2023).

Providers must review the medication charts and/or administration records of all care recipients and report the following information:

• The data collection date for the quarter
• The number of care recipients whose records were assessed for polypharmacy
• The number of care recipients excluded because they were admitted to hospital on the date of data collection
• The number of care recipients who have been prescribed nine or more medicines.

(DoHaAC 2023)

Polypharmacy Under the Strengthened Aged Care Quality Standards

Standard 5: Clinical Care - Outcome 5.3: Safe and quality use of medicines under the strengthened Aged Care Quality Standards (Action 5.3.2) requires aged care providers to conduct medication reviews for an older person when there is polypharmacy that can potentially be deprescribed (ACQSC 2024b).

Antipsychotics

Antipsychotics are a type of medicine intended to treat diagnosed psychosis (e.g. schizophrenia, bipolar disorder, Huntington’s chorea, delusions and hallucinations, psychosis while receiving end-of-life care) (DoHaAC 2023).

Despite this, many aged care residents are prescribed antipsychotics in order to manage behavioural and psychological symptoms of dementia (BPSD), despite this practice being contraindicated due to evidence of harm (ACQSC 2020).

About one in five aged care residents are taking antipsychotics. Many of these people are also taking high doses for a longer period of time than recommended (PSA 2021; ACQSC 2020).

As well as being potentially harmful, antipsychotics are also unlikely to result in significant benefits when used to manage BPSD (Welberry et al. 2021).

Even in cases where antipsychotics are indicated, most people benefit from short-term use only (PSA 2021).

The use of antipsychotics in older adults may be associated with adverse effects such as:

• Drowsiness or over-sedation
• Confusion
• Dizziness
• Falls
• Delirium
• Increased risk of being admitted to hospital for hip fracture or pneumonia
• Reduced quality of life
• Stroke
• Death.

(ACSQHC 2021; PSA 2021; ACQSC 2020)

Antipsychotics in the Quality Indicator Program

Under the QI Program, residential aged care providers must collect and report data on the number of residents who have received antipsychotics (DoHaAC 2023).

The provider must identify a data collection date every quarter. The collection date, and the six days prior to that date, form the seven-day assessment period during which the medication charts and administration records for all care recipients must be assessed for antipsychotics (DoHaAC 2023).

Providers must collect and report the following information:

• The data collection date for the quarter
• The number of care recipients whose records were assessed for antipsychotics
• The number of care recipients excluded because they were admitted to hospital for the entire seven-day assessment period
• The number of care recipients who received antipsychotics during the quarter
• The number of care recipients who received antipsychotics for medically diagnosed psychosis.

(DoHaAC 2023)

Antipsychotics Under the Strengthened Aged Care Quality Standards

Standard 5: Clinical Care - Outcome 5.3: Safe and quality use of medicines under the strengthened Aged Care Quality Standards (Action 5.3.4) requires aged care providers to establish processes for recognising, assessing and reducing risks to older people who are using high-risk medicines. This includes minimising inappropriate use of psychotropic medicines (ACQSC 2024b).