Sedative Load Before and After Entry to Residential Aged Care

Background: Older people are commonly prescribed multiple medications with sedative properties and the cumulative effect is termed sedative load. There is increasing concern regarding the inappropriate prescribing of sedative medications to individuals in residential aged care facilities (long-term care) and the association with poor health outcomes. Little is known regarding the extent to which prescribing of sedative medications changes after older people enter residential aged care in Australia.

Objectives: The aim of this study was to examine the sedative load before and after older people enter residential aged care in Australia.

Methods: A retrospective cohort study of individuals (>= 65 yrs) entering residential aged care in Australia between 1 July 2017 and 30 June 2018 was conducted using data from the Registry of Senior Australians (ROSA), a national cohort of all Australians receiving government subsidised aged care services. Using a previously published model, sedative load was calculated by summing sedative ratings of medications dispensed during the year preceding and the year after entry to residential aged care, by quarter. Prevalence estimates of high sedative load (>= 3) and 95% CI adjusted for age, sex and comorbidity using logistic regression models were calculated and analyses were stratified by the presence of dementia.

Results: A total of 52,620 individuals entered residential aged care during the study period, median age 86 years (IQR 80-90), 61% were female, with a median of 5 (IQR 3-7) comorbid conditions and 48.5% had dementia. In the 9-12 months prior to entry to residential aged care, 20.2% (95% CI 19.5-21.3) of individuals without dementia had high sedative load (>=3), increasing to 27.8% (95% CI 26.3-28.1) in the 3 months prior to entry. In the 3 months immediately following entry to care, 38.6% (95% CI 38.0-39.3) had high sedative load and remained high 12 months after entry (35.1% 9-12 months post). Similar results were observed for residents with dementia. Of the 20,141 residents who were not dispensed any sedative medications in the 12 months prior to entry to residential care almost a third (30%, N=6,035) had a high sedative load within 3 months. Combinations of medications contributing to high sedative load included opioids and anti-depressants (12.9%), multiple opioids (9%), benzodiazepines and anti-depressants (8.9%) and anti-psychotic and anti-depressants (7.2%).

Conclusions: Dispensing of sedative medications in older Australians is high before they enter residential aged care and increases markedly after entry into care. Given the potential risks associated with high sedative load, prescribing of these medications should be reduced through targeted prescribing interventions and non-pharmacological strategies.