Objective: To investigate administration of pro re nata (PRN) medications and nurse-initiated medications (NIMs) in Australian aged care services over a 12-month period. Design: Twelve-month longitudinal audit of medication administrations. Setting and participants: Three hundred ninety-two residents of 10 aged care services in regional Victoria, Australia. Methods: Records of PRN and NIM administration were extracted from electronic and hard copy medication charts. Descriptive statistics were used to calculate medication administration per person-month. Poisson regression was used to estimate predictors of PRN administration. Results: Over a median follow-up of 12 months (interquartile range 10e12 months), 93% of residents were administered a PRN medication and 41% of residents an NIM on 21,147 and 552 occasions, respectively. The mean number of any PRN administration was 5.85 per person-month. The most frequently administered PRN medications per person-month were opioids 1.54, laxatives 0.96, benzodiazepines 0.72, antipsychotics 0.48, paracetamol 0.46, and topical preparations 0.42. Three-quarters of residents prescribed a PRN opioid or PRN benzodiazepine and two-thirds of residents prescribed a PRN antipsychotic had the medication administered on 1 or more occasions over the follow-up. Conclusions and Implications: Most residents were administered PRN medications. Administration was in line with Australian regulations and institutional protocols. However, the high frequency of PRN analgesic, laxative, and psychotropic medication administration highlights the need for regular clinical review to ensure ongoing safe and appropriate use.Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine.Medication management is an increasingly complex and important component of quality care in residential aged care services (RACS). 1 Australian RACS are synonymous with long-term care facilities and nursing homes in other countries and provide permanent and respite accommodation for people who require access to 24-hour care that can no longer be provided in their own homes. 1 A review of the international literature suggests that up to 74% of residents take 9 or more regular medications, 2 with most residents dependent on staff for medication administration. Up to 94% of residents are prescribed pro re nata (PRN) or "as-needed" medications. 3 PRN medications are prescribed by the resident's physician and administered by nurses, or in some situations by care workers, on an as-needed basis. 4 Previous Australian and German research suggests residents are prescribed up to 4 PRN medications, 5e7 with analgesics and laxatives most frequently administered. 3 In addition to administering PRN medications, Australian guidelines permit registered nurses to initiate specific over-the-counter BA and LMC are employed by health services overseen by the Department of Health and Human Services.

BackgroundResidents of aged care facilities use increasingly complex medication regimens. Reducing unnecessary medication regimen complexity (eg, by consolidating the number of administration times or using alternative formulations) may benefit residents and staff.ObjectiveTo develop and validate an implicit tool to facilitate medication regimen simplification in aged care facilities.MethodA purposively selected multidisciplinary expert panel used modified nominal group technique to identify and prioritize factors important in determining whether a medication regimen can be simplified. The five prioritized factors were formulated as questions, pilot-tested using non-identifiable medication charts and refined by panel members. The final tool was validated by two clinical pharmacists who independently applied the tool to a random sample of 50 residents of aged care facilities to identify opportunities for medication regimen simplification. Inter-rater agreement was calculated using Cohen’s kappa.ResultsThe Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) was developed as an implicit tool comprising of five questions about 1) the resident; 2) regulatory and safety requirements; 3) drug interactions; 4) formulation; and 5) facility and follow-up considerations. Using MRS GRACE, two pharmacists independently simplified medication regimens for 29/50 and 30/50 residents (Cohen’s kappa=0.38, 95% CI 0.12–0.64), respectively. Simplification was possible for all residents with five or more administration times. Changing an administration time comprised 75% of the two pharmacists’ recommendations.ConclusionsUsing MRS GRACE, two clinical pharmacists independently simplified over half of residents’ medication regimens with fair agreement. MRS GRACE is a promising new tool to guide medication regimen simplification in aged care.

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Background Diagnosis of dementia may change peoples' goals of care. In people with diabetes, this may lead to relaxing treatment targets and reducing the use of diabetes medications. The aim of this study was to examine changes in diabetes medication use before and after initiating medication for dementia. Methods A national cohort of people aged 65–97 years, living with dementia and diabetes, and a general population cohort with diabetes matched for age, sex, and index date were extracted from the Australian national medication claims database. Trajectories of diabetes medication use, expressed as mean defined daily dose (DDD) each month for each individual from 24 months before to 24 months after the index date, were estimated using group‐based trajectory modeling (GBTM). Cohorts were analyzed separately. Results People with dementia (N = 1884) and the matched general population (N = 7067) had a median age of 80 years (interquartile range 76–84) and 55% were female. In both models, people exhibited one of five diabetes medication trajectories, with 16.5% of people with dementia and 24.0% of the general population assigned to trajectories that represented deintensification. In the general population model, those on deintensifying trajectories were older than those on stable trajectories (median 83 vs. 79 years). In the dementia cohort model, those on high or low deintensifying trajectories were slightly older (median age 81 or 82, respectively, vs. 80 years) and had at least 1 more comorbidity (median 8 or 7, respectively, vs. 6) than those on stable trajectories. Conclusions Initiating medication for dementia does not appear to be a trigger for deintensification of diabetes treatment regimens. Deintensification was more common in the general population; people living with dementia are potentially overtreated for diabetes.