DR Juanita Breen describes herself as a “nowhere girl”, the product of a nomadic Air Force life.
Now working as a Senior Lecturer at the Wicking Dementia Research and Education Centre at the University of Tasmania, Dr Breen is a pharmacist and passionate advocate for the appropriate use of psychotropic medications in aged care.
“My father joined the Royal Australian Air Force when I was 2 years old,” Dr Breen tells the MJA. “I was born in Gippsland, but I don’t remember it at all, because we moved around a lot.”
Inevitably, her father ended up stationed in Canberra, just as Dr Breen was thinking about going to university.
“I very much enjoyed chemistry and physiology, anatomy and medicine-type things, but I never really wanted to be a doctor,” she says. “I like information, helping people, and educating. And I’m very interested in medicines and health.”
“I find a lot of people say to me, ‘oh so pharmacy was your second choice then’, but it never was – it was the subject that interested me the most.”
Pharmacy was not on offer in Canberra, so she moved to Sydney and graduated from the University of Sydney in 1985.
She worked for a while in community pharmacy but again her desire to be not so hands-on with patients saw her drawn to research and teaching.
“[Customers] would always say ‘do you want to have a look’. And I’d say ‘no, I really don’t’,” Dr Breen says. “I just would prefer not to look.”
It was also the time when her interest in psychotropic use in aged care was born.
“I was asked by a nurse from a nearby aged care home if she could order a pump pack, like the ones used to measure out methadone syrup,” she says.
“The nurse explained that she thought it would be a good way to prepare the multiple doses of antipsychotics that they gave to their residents. That request didn’t sit well with me.
“Risperidone solution, the specific medication being used, was developed to treat severe conditions like schizophrenia, but the nurse said it was needed by most of their residents with dementia to keep them calm and comfortable. They were totally oblivious to the adverse effects like increased rates of stroke, pneumonia, movement disorders and daytime sedation.”
About 15 years ago Dr Breen spent 4 years working as a primary care pharmacist in GP practices in the UK.
“A large part of the work we did then was about cost containment. We did audit and feedback, usually followed by an educational session. Then we targeted patients to review these medications. At that stage we were doing things like trying to reduce proton pump inhibitor use and making sure guidelines were followed about spirometry testing for people with chronic airways disease.
“I enjoyed that work because there's nothing like really tangible feedback. You could graphically see the use going down or the use becoming more appropriate.”
Back in Australia, she was asked by the National Prescribing Service to write a background paper about dementia.
“When I was writing this dementia material I came across the big problem of overuse of psychotropics that's been reported around the world, and I thought to myself ‘I bet that a similar sort of quality improvement initiative would work’."
Her doctorate on reducing the inappropriate use of psychotropics in aged care followed.
“It attracted me as a problem I thought was fixable, because it hasn't been fixed in well over 30 or 40 years. And I think the more I've worked in this area the more I realize how complex a problem it is.” No-one takes responsibility – the nurses blame the doctor, the doctor blames the nurses. Increasingly, staffing is blamed. So no one does anything because it’s always someone else’s fault.
A program called the Reducing Use of Sedation Program (ReDUSe) was developed over the course of her PhD.
According to her University of Tasmania profile page, this multi-component initiative included several strategies: an interactive training program for staff; the appointment of a champion nurse to promote good practice among peers; targeted review of all those residents taking sedatives by pharmacists, nurses and doctors; and the auditing of medications. Awareness raising and interdisciplinary practice is key.
The RedUSe project was trialled in 25 aged care homes in Tasmania in 2008 and was subsequently funded by the Australian Government to reach 150 homes in six states and the ACT. Between 2014 and 2016, the 6-month interventions reached more than 12 000 aged care residents. A total of 300 training sessions were delivered to around 2500 care staff, with nearly 400 doctors and nurse practitioners attending educational sessions. Over 40% of residents taking antipsychotics and benzodiazepines at the start of the project had their dose reduced, predominantly ceased.
RedUSe went on to win an international research award.
“And then I thought, ‘move on’,” says Dr Breen. “But then this subject keeps on coming up, and it keeps on becoming a political and human rights imperative.
“I'm really happy to see that the Aged Care Quality and Safety Commission have recently employed 11 pharmacists and those pharmacists are going now to rural and remote aged care facilities offering the RedUSe project and other initiatives, which is great.”
Dr Breen says it is the thought of being the aged care residents’ voice that keeps her passionate about this topic.
“It’s really about the resident,” she says. “They’re not getting a voice. They deserve better.”
“I don’t think pharmacists are taking advantage of the role we have in aged care – and have had for over 20 years – as much as we can. We’ve had this role called the QUM program - which funds strategies like staff education, audits and medication policy making but what have pharmacists done with it? Psychotropic use has remained high and medication management has been the top-rated complaint in aged care homes for the last 4 years. The RedUse project shows that quality improvement strategies can work and that interprofessional working with pharmacists can make a real difference. The QUM program could be hugely effective and could make a big difference [to residents], but it isn't taken advantage of as much as it could be.”
“And then you have the age-old question – who is responsible for ensuring that consent is gained before an aged care resident’s medications are changed? Is it the nurse? Is it the doctor? Sometimes the relative doesn’t even know that these changes are being made. They should be involved at the very first instance.
“When somebody doesn't have capacity, I don't think there's a strong awareness of the fact that you have to have consent – you can't just make the decision for them. Most of the time the relatives will agree to medical treatment if it’s explained to them. They trust the practitioner.”
For now, Dr Breen is more than content to continue her work at the Wicking Dementia Institute.
“I used to work just in pharmacy circles, but I just think it's much more useful if I'm working with other practitioners – better for me and better for them,” she says.
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