Australia’s Aboriginal population initially occupied the continent over 70,000 years ago. Since European colonization in 1788, there have been severe disruptions to the health and well-being of the original inhabitants (Flicker and Kerse, Reference Flicker, Kerse, Michel, Beattie, Martin and Walston2018). This has resulted in major disadavantage to the health of Aboriginal people with an almost 10 years difference in life expectancy when compared with non-Aboriginal Australians. The age-specific prevalence of dementia is fivefold greater in Aboriginal Australians (Smith et al., Reference Smith2008), and there is a greater prevalence of incontinence, pain, falls (LoGiudice et al., Reference LoGiudice2012), and frailty (Hyde et al., Reference Hyde2016).
On this backdrop, it is hardly a surprise that the use of medications has been suboptimal by the older section of the original inhabitants of Australia. Australia’s National Medicines Policy (2000) acknowledged that there has been “substantial access barriers and evidence of underuse of medicines by Aboriginal and Torres Strait Islander peoples” and committed partners to “collaborative agreements to address specific barriers to access for identified groups, including Aboriginal and Torres Strait Islander peoples”. There was then substantial investment, including the Indigenous Health Services Pharmacy Support and Indigenous Dose Administration Aids Programs, and recently through enhancements to the Closing the Gap program, to address financial and administrative barriers to Aboriginal people acquiring the medicines they need to manage their health conditions.
Notwithstanding the reality of historical barriers to Aboriginal people accessing required medicines, with resultant underspending of subsidies (Murray, Reference Murray2003), it is now apparent that polypharmacy and use of inappropriate medicines are also challenges facing older Aboriginal people. In six remote communities and the town of Derby in the Kimberley, Western Australia, we identified evidence of suboptimal prescribing among 166 of 273 participants aged 45 years or more (61%) (Page et al., Reference Page2019). This included polypharmacy for 145 (53%) and potentially inappropriate prescribing for 54 participants (20%). Potential underprescribing of at least one indicated medicine was present for 33 participants (12%).
One type of potentially inappropriate prescribing is the use of medicines with anticholinergic properties. This is of particular concern because of the observed associations with adverse clinical outcomes, particularly among vulnerable older people, such those with preexisting cognitive impairments (Wang et al., Reference Wang, Alan, Page, Dimopoulos and Etherton-Beer2021). Although there has been extensive interest in approaches to measure anticholinergic burden (ACB), the limitations of measurement of serum anticholinergic activity, and the problems besetting application of the published scales, are well described (Mayer et al., Reference Mayer, Kopitz, Plaschke, Weiss, Seidling and Haefeli2016).
In this context, Mate et al. examined medication histories of 312 Aboriginal and Torres Strait Islander people aged >60 years from two Aboriginal communities in metropolitan Sydney, and three communities in regional New South Wales, to determine the anticholinergic burden (ACB) of participants, and association of ACB with adverse health outcomes including cognitive impairment, falls, hospitalization and depressive symptoms (Mate et al., Reference Mate2020). The authors observed polypharmacy (use of >5 medicines) in more than 40% of participants. Around 1 in 8 people (12.2% of the sample) were exposed to cumulative ACB that is likely to be clinically important (ie ACB score >3). In multivariate modelling depressive symptoms remained associated with use of anticholinergic medicines, but not falls or hospitalizations in the past year, or cognitive impairment. The authors conclude that this was largely attributable to inappropriate use of tricyclic antidepressants. Although limited by the cross-sectional observational nature of the study, use of antidepressants was largely reported by participants to be used for the treatment of depression, supporting the authors’ interpretation and limiting the likelihood that factors such as reverse causality explain the observed association. Although the authors emphasize that medications with strong ACB (particularly tricyclic antidepressants) were a major driver of significant anticholinergic burden, medications with strong ACB were only being taken by 18 people (6% of the sample) suggesting an approximately equal contribution to significant ACB by combinations of medicines with lower anticholinergic potency that, when summed together, is likely to be clinically relevant.
Overall, 47% of participants were exposed to medications with ACB. As the authors suggest, the proportion of people exposed to ACB appears similar to previous studies of older people. Although median ACB scores were not reported, visual inspection of the figure suggests median ACB score was 0 for the entire sample and 1 among people exposed to anticholinergic medicines. As acknowledged by the authors, the cross-sectional nature of the data is a major limitation, particularly as it is known that medication use is not necessarily stable over time: Australian data show that only around one-third of older women exposed to anticholinergic medicines appeared to be using anticholinergic medicines in all six semesters of a 3-year observation period (Parkinson et al., Reference Parkinson2015).
It remains confronting that Aboriginal people, who may comprise some of the most vulnerable consumers of health services, appear to continue to be exposed to inappropriate medicines, such as those with anticholinergic properties in high numbers. We agree with Mate et al. that the reasons for this are likely to be multifactorial and may include socioeconomic disparities, persisting barriers to access to services (such as specialist psychiatric review), lack of culturally appropriate services and disparities in health literacy. Unfortunately, these assertions are largely speculative, given inadequate empiric evaluations of interventions that address these factors among Aboriginal people.
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Australia’s Aboriginal population initially occupied the continent over 70,000 years ago. Since European colonization in 1788, there have been severe disruptions to the health and well-being of the original inhabitants (Flicker and Kerse, Reference Flicker, Kerse, Michel, Beattie, Martin and Walston2018). This has resulted in major disadavantage to the health of Aboriginal people with an almost 10 years difference in life expectancy when compared with non-Aboriginal Australians. The age-specific prevalence of dementia is fivefold greater in Aboriginal Australians (Smith et al., Reference Smith2008), and there is a greater prevalence of incontinence, pain, falls (LoGiudice et al., Reference LoGiudice2012), and frailty (Hyde et al., Reference Hyde2016).
On this backdrop, it is hardly a surprise that the use of medications has been suboptimal by the older section of the original inhabitants of Australia. Australia’s National Medicines Policy (2000) acknowledged that there has been “substantial access barriers and evidence of underuse of medicines by Aboriginal and Torres Strait Islander peoples” and committed partners to “collaborative agreements to address specific barriers to access for identified groups, including Aboriginal and Torres Strait Islander peoples”. There was then substantial investment, including the Indigenous Health Services Pharmacy Support and Indigenous Dose Administration Aids Programs, and recently through enhancements to the Closing the Gap program, to address financial and administrative barriers to Aboriginal people acquiring the medicines they need to manage their health conditions.
Notwithstanding the reality of historical barriers to Aboriginal people accessing required medicines, with resultant underspending of subsidies (Murray, Reference Murray2003), it is now apparent that polypharmacy and use of inappropriate medicines are also challenges facing older Aboriginal people. In six remote communities and the town of Derby in the Kimberley, Western Australia, we identified evidence of suboptimal prescribing among 166 of 273 participants aged 45 years or more (61%) (Page et al., Reference Page2019). This included polypharmacy for 145 (53%) and potentially inappropriate prescribing for 54 participants (20%). Potential underprescribing of at least one indicated medicine was present for 33 participants (12%).
One type of potentially inappropriate prescribing is the use of medicines with anticholinergic properties. This is of particular concern because of the observed associations with adverse clinical outcomes, particularly among vulnerable older people, such those with preexisting cognitive impairments (Wang et al., Reference Wang, Alan, Page, Dimopoulos and Etherton-Beer2021). Although there has been extensive interest in approaches to measure anticholinergic burden (ACB), the limitations of measurement of serum anticholinergic activity, and the problems besetting application of the published scales, are well described (Mayer et al., Reference Mayer, Kopitz, Plaschke, Weiss, Seidling and Haefeli2016).
In this context, Mate et al. examined medication histories of 312 Aboriginal and Torres Strait Islander people aged >60 years from two Aboriginal communities in metropolitan Sydney, and three communities in regional New South Wales, to determine the anticholinergic burden (ACB) of participants, and association of ACB with adverse health outcomes including cognitive impairment, falls, hospitalization and depressive symptoms (Mate et al., Reference Mate2020). The authors observed polypharmacy (use of >5 medicines) in more than 40% of participants. Around 1 in 8 people (12.2% of the sample) were exposed to cumulative ACB that is likely to be clinically important (ie ACB score >3). In multivariate modelling depressive symptoms remained associated with use of anticholinergic medicines, but not falls or hospitalizations in the past year, or cognitive impairment. The authors conclude that this was largely attributable to inappropriate use of tricyclic antidepressants. Although limited by the cross-sectional observational nature of the study, use of antidepressants was largely reported by participants to be used for the treatment of depression, supporting the authors’ interpretation and limiting the likelihood that factors such as reverse causality explain the observed association. Although the authors emphasize that medications with strong ACB (particularly tricyclic antidepressants) were a major driver of significant anticholinergic burden, medications with strong ACB were only being taken by 18 people (6% of the sample) suggesting an approximately equal contribution to significant ACB by combinations of medicines with lower anticholinergic potency that, when summed together, is likely to be clinically relevant.
Overall, 47% of participants were exposed to medications with ACB. As the authors suggest, the proportion of people exposed to ACB appears similar to previous studies of older people. Although median ACB scores were not reported, visual inspection of the figure suggests median ACB score was 0 for the entire sample and 1 among people exposed to anticholinergic medicines. As acknowledged by the authors, the cross-sectional nature of the data is a major limitation, particularly as it is known that medication use is not necessarily stable over time: Australian data show that only around one-third of older women exposed to anticholinergic medicines appeared to be using anticholinergic medicines in all six semesters of a 3-year observation period (Parkinson et al., Reference Parkinson2015).
It remains confronting that Aboriginal people, who may comprise some of the most vulnerable consumers of health services, appear to continue to be exposed to inappropriate medicines, such as those with anticholinergic properties in high numbers. We agree with Mate et al. that the reasons for this are likely to be multifactorial and may include socioeconomic disparities, persisting barriers to access to services (such as specialist psychiatric review), lack of culturally appropriate services and disparities in health literacy. Unfortunately, these assertions are largely speculative, given inadequate empiric evaluations of interventions that address these factors among Aboriginal people.
Conflict of interest
None.