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Medication Management Medication Management in Dementia: in Dementia: Key prioritiesKey priorities
Ian Maidment, Ian Maidment, Senior Lecturer in Clinical PharmacySenior Lecturer in Clinical Pharmacy
Background
• Qualified ’87 - industrial, acute, community pharmacy
• 20 years MH – 8 years senior level
• Chief Pharmacist - 2 NHS trusts
• Started academia – February 2012
• Long-term clinical & research interest medication safety Older People – successful publication
• Anti-psychotics in dementia
– Pharmacist-led medication reviews in Care Homes
• Wider medication management issues
– Exploratory stage
– Qualitative data – the carer perspective
Pharmacist-led medication review projects
• Three projects
– West Kent
– Essex
– Medway – supervisory level
• Original aim anti-psychotic prescribing
• UK objective - 2/3 anti-psychotic
• Political hot potato
Anti-psychotics & NDS
• Very ambitious target quoted by politicians
– 2/3 reduction anti-psychotic - unable find any evidence base
• The NDS vague with this target (DoH, 2009)
– “Proportion these prescriptions which would be unnecessary if appropriate support were available is unclear and will vary by setting, but may well be of the order of two-thirds overall.”
– “Explicit goals for the size & speed of this reduction, & improvement in the use of such drugs where needed, should be agreed & published locally following the completion of baseline audit.”
• International evidence – view from USA
International view
• 1987 Federal Nursing Home Reform Act (ORBA)
• Residents Medicare / Medicaid funded facilities achieve “highest practicable physical, mental, psychosocial well-being.”
• Enormous Changes
– Emphasis quality of life as well as quality of care;
– Expectation ability walk, bathe & perform other ADLs maintained or improved
– Free unnecessary & inappropriate physical & chemical restraints
• Set minimum standards for Medicare / Medicaid homes
Anti-psychotic • Limit use approved indications
Appropriate Indications
1. Schizophrenia, psychoses, delusional disorders
2. Dementia / delirium hallucinations, continuous crying, yelling, screaming functional impairment or behaviour danger patient / others / interfering care.
Inappropriate Indications
1. Undefined aggression/agitation
2. Agitation or wandering not danger others / individual
3. Uncooperativeness, unsociability, poor self-care, restlessness, nervousness or anxiety
4. Depression, indifference, insomnia, impaired memory
• Reduced antipsychotic use 28 & 36% (NLTCORC, 2011; Furniss, 2002).
• Reduced physical re-strain by 40%
Risks - rigid targets
• Need short-term method control behaviour danger to self or others
– Lavender oil unlikely to work
– Obvious alternative benzos
• In USA ORBA scripts anxiolytics (e.g. benzodiazepines)
48.6% regular
27.5% as required (Borson et al, 1997).
West Kent - outreach Project
• Experienced MH pharmacist reviewed medication collaboration GP & carer(ICAD, 2011)
– Included all psychotropics - not just anti-psychotics
• Nursing Home – London Suburb
• Appropriateness every medicine assessed as follows -
• Confirmation medication still indicated. USA guidelines anti-psychotics (OBRA, 1987).
• Appropriate alternative solutions were developed for every problem identified.
• Appropriate information about treatments supplied carer.
Results
• 26 reviews 25 patients (one patient reviewed twice)
– Three visits: 5.11.2010, 12.11.2010 & 10.12.2010.
• Agreed review medication next 6/12 medication review = 11
• Medication discontinued or dose reduced = 11
• Medication started = 2
• For 6 patients no action was taken.
Medication Discontinued / Reduced
• Details medicines discontinued or reduced
• No longitudinal falls record.
• No evidence ABC (Antecedents Behaviour Consequences) type system recording behaviour that challenges (KMPT, 2009).
Name / class medicine
N
Lorazepam 4
Anti-psychotics 1
Zopiclone 1
Anti-depressant 2
Non-pyschotropics 3
Examples
• Hypnotic polypharmacy - lorazepam & zopiclone at night.
– Reduce lorazepam from 1mg to 0.5mg night 1/52 & then reduce liquid (NB: history epilepsy)
• Patient end stage dementia e.g. bed bound.
– Discontinue treatments high BP - atenolol 50mg & lisinopril 20mg.
• Aggressive behaviour – danger others
– Re-start risperidone (previously worked) - lower dose 0.25mg BD. Review regularly.
Essex Project
• Pharmacist with liaison nurse reviewed medication
• Nursing home residents
• Prescribed psychotropics
• Primary focus anti-psychotics
– Need holistic approach
• Presented at 3 national / international conferences
Medication Stopped / to be Reviewed
Medicine N
Anti-psychotics 50
Anti-depressants 24
ACHIs 15
Zopiclone 10
Benzo’s 7
Others 53
• 86 residents
• 162 medicines identified for review or discontinuation
• On average 1.88 medicines per resident
Qualitative examples
• Anti-psychotic (aripiprazole) started mixed anxiety/depression/ personality disorder by secondary care: not reviewed since 2008. Resident suffering falls.
• Older person (without dementia) prescribed anti-psychotic for BPSD (care home queried script)
• Low-dose trazodone in morning rather than at night (and patient very drowsy).
• Anti-histamines prescribed in middle winter
Medway project
• 2 stages:
– GP IT systems includ dementia register searched identify people dementia anti-psychotics.
– Trained specialist pharmacist targeted clinical medication reviews.
• Data 59 / 60 practices (98.3%) across Primary Care Organisation (250,000).
• 1051 dementia reg: (n=462 residential care; n=589 own home).
• 161 people on reg low-dose anti-psychotics
– n=118 residential care; n=43 own home.
– People dementia residential homes nearly 3.5 times more likely receive anti-psychotic
– 25.5 % (118/462) vs. 7.3% (43/589) (p<0.0001; Fisher’s exact test)
Prevalence Anti-psychotic Prescribing
• Compared with national audit
– 15.3% people with dementia on anti-psychotics vs. 10.5%
– More complete dataset – 98.3% vs 17.5%
• Official DoH figures under-estimate anti-psychotic usage
• 2.77 (– 0 to 26; +/- SD 4.88) people dementia low-dose anti-psychotic per practice
• 26 (44.1%) practices no-one dementia on low-dose anti-psychotics.
– Expect 3 to 5 per practice
• Accuracy records: AS survey identified significant under diagnosis (AS, 2012)
– Medway only 43.8% expected numbers dementia received diagnosis.
Pharmacist-led Medication Review
• Commonly used anti-psychotic amisulpride (52 / 161; 32.3%)
– Licensed product risperidone (37 / 161; 23.0%)
• Care picture - anti-psychotics and dementia
– n=87 - local secondary care MH services
– n=4 - local Learning Disability Teams.
– n=70 – included pharmacy led review.
• Anti-psychotics withdrawn / dosage (n=43; 61.4%).
Summarise – Pharmacist Medication Review
• Significant issues – older people with dementia receiving inappropriate medication
– Much broader than anti-psychotics
• People with Dementia unable self-advocate (Maidment et al, 2008, Maidment et al, 2009)
• Reason’s model: error causation barrier removed
• ↑ cognitive impairment → carer-controlled med man (Cotrell et al, 2006; Arlt et al, 2008)
Reason 1997 – “Swiss Cheese”- Model of error theory
Carers & Medication Management
• Conduct up to 10 med man activities (Smith et al, 2003; Francis et al, 2002).
– Noticing & managing side-effects, deciding administer medication
• Key role safe medication use
• Family carers not equipped & responsibility significant burden (Francis 2002;
Smith 2003).
• Greater no. med related activities → ↓ social function & family carer stress & burden (Francis 2002, Gort 2007).
Impact of Carer Burden
• Carer burden linked collapse current care arrangement (Gort 2007).
• Polypharmacy → carer burden & use residential care (Gort 2007).
• Very little research in dementia (Maidment et al, 2010; Mountain et al, 2012;While et al, 2012)
• Explore medication management carer perspective
Qualitative Data
• Exploratory understand medication management user viewpoint
• Predominantly - carer (family) data
– Focus Group Alzheimer’s society
– Survey 20 members AS Research Volunteer’s Network
Focus Group• Focus Group Alzheimer’s society
• Participants experience caring family member dementia or have dementia.
• Group facilitated specialist mental health pharmacist (IM), qualitative researcher, GP.
• Also present members Alzheimer's Society staff & community pharmacist.
Aim of focus Group
• Understand key issues med. man. in dementia carer / patient viewpoint.
• Explored issues considered priority e.g.
– Benefits vs. side-effects
– Adherence/concordance issues
– Practical issues
– Medication review
– Communication healthcare professionals.
• Identify key ethical issues future research programme.
• Inform grant application develop systems improve med. man. dementia.
Results Focus Group
• Four key issues
– Medication administration practicalities and pressures
– Communication barriers and facilitators
– Bearing and sharing responsibility
– Weighing up medication risks and benefits
• Practical issues
• Numerous
– e.g. making up Fybogel / Metamcil
• Hidden:
– “something we don’t actually talk about. It’s a very difficult thing …..” Carer
• Healthcare professionals unaware
– Don’t forget that the clinician can have little or no understanding of practicalities.
• Communication barriers & facilitators
– Barriers embarrassment about disclosure both relatives’ loss dignity and own perceived lack knowledge, competence.
– Confidentiality –
• We felt really frustrated obviously GP trying keep private confidential information but it was extremely frustrating for us wanting to get some support.
– Simple check list improve communication
• Weighing risks vs. Benefits
• Carers decisions about whether benefits outweigh risks
– At one point I carried on giving my mother her diuretics actually she was dehydrated
• Particularly difficult situations – challenging behaviour
– Need for anti-psychotics certain cases
• Time to benefit difficult concept in reality
– I don’t think anyone wants to face it really
• Bearing & sharing responsibility
• Heavy burden responsibilities need share with people expert knowledge
– Knowing that you can go to the doctor or the District Nurse takes a great weight off your shoulders
• Failed role considerable self-blame
– So it would be neglect & carelessness carry on giving laxatives when they have diarrhoea or they are dehydrated
• Balance need safely empower people with dementia
– I could see her so it’s giving the autonomy to the patient as far as possible
Survey - Method
• AS Volunteer Network - March to May 2012
• Snowballing technique > 20 surveys returned
• Covered medication and possible medication-related problems.
• Focus group & carer feedback problems categorised
– Issues side-effects, packaging, admin, information, adherence & other
– Free text area carers write responses categories.
• Carers also asked highlight ways easier manage medication.
• Mainly qualitative data analysed modified-grounded theory approach.
Survey - Results
• Completed surveys (n=20).
• Cognitive impairment person dementia often lacked capacity self-admin meds:
– “My father would have been unable to manage his medication (P11).”
• Carers responsibility medication; make judgements whether meds necessary, or had been taken:
– “He was once prescribed Oramorph, as it was not sure if he was in pain, we did not like to give him this because it made him drowsy (P11).”
• Barriers difficult carers exercise responsibility role
Survey - Barriers
• Practical issues - clic-locks, blisters, compliance aids:
– “Even pharmacist prepared weekly dispensed blister packs can be difficult for the not-so-nimble or partially sighted (P 15).”
• Significant polypharmacy Med Man very challenging:
– “The whole regimen was so complex – several times a day, only made simpler when one consultant said the regime was not necessary (P2).”
• Support often lacking and systems not responsive:
– “Looking back as I try to consider the very real issue of medication, each day was a challenge and my memories of what we did and how we coped is very difficult to describe except that I know there was no support and advice (P8).
– “Individual doctors, GPs and others prescribe a tablet or change it apparently confident that they know best. It feels like lucky dip at times. There is no follow-up from hospital or home or vice versa - letters are written which no-one reads or actions (P20).
Survey – Impact
• Lack support risk medication related adverse events and worsen QoL:
– “The anti-depressant caused, within 3 days, very severe swelling of paratoid gland in neck probably because (he) wasn’t drinking enough and I wasn’t told that he should drink plenty of water – this was very distressing for both of us (P5).”
Summary
• Significant medication management issues in dementia
– Anti-psychotic issue - symptomatic
• Med man major issue significant numbers carers people dementia
• Impacting carer’s QoL, exposes PwD medication-related ADEs
• Urgent need further research:
– RfPB – feasibility combined psychosocial – 2ary care pharmacist intervention
– PRUK – qualy exploration role of community pharmacists support family carers PwD
References
• Alzheimer’s Society. PCT dementia prevalence and diagnosis rates. Available on http://www.alzheimers.org.uk/site/scripts/directory_home.php?directoryID=13 (accessed 24th March 2012)
• Arlt S, Lindner R, Rosler A et al. 2008. Adherence to medication in patients with dementia. Drugs Aging 25: 1033-1047.
• Cotrell V, Wild K, Bader T. 2006. Medication management and adherence among cognitively impaired older adults. J Gerontol Soc Work 47: 31-46.
• Department of Health. The use of anti-psychotic medication for people with dementia: Time for action Living well with dementia: A National Dementia Strategy. London, Stationary Office. 2009. Available on www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108303 (accessed 14th April)
• Francis SA, Smith F, Gray N et al. 2002. The roles of informal carers in the management of medication for older-care recipients. Int J Pharm Pract 3: 1-10.
• Gomez-Pavon J, Gonzalez Garcia P, Frances Roman I et al. 2010. Recommendations for the prevention of adverse drug reactions in older adults with dementia. Rev Esp Geriatr Gerontol 45: 89-96.
• Goodwin N, Curry N, Naylor C, Ross S, Duldig W. Managing people with long-term conditions – an inquiry into the quality of General Practice in England. The King’s Fund, London. 2010. Available on www.kingsfund.org.uk/document.rm?id=8757 (accessed 25th March 2012)
• Maidment ID, Boustani M, Rodriguez J, Brown R, Fox C, Katona C. 2008. A systematic review of the use of memantine in agitation associated with dementia. Annals of Pharmacotherapy, 42, 32-38
• Maidment ID, Elswood M. 2009. Mental Health Trust Chapter in Themed Review of Medication Safety Incidents (Safety in Doses; NPSA, 2009). Available on http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61626&type=full& (accessed 11 July)
• Mountain et al. 2012. What should be in a self-management programme for people with early dementia. Aging and Mental Health.
• Smith F, Francis SA, Gray N, Denham M, Graffy J. 2003. A multi-centre survey among informal carers who manage medication for older care recipients: problems experienced and development of services. Health Soc Care Community 11: 138-45.
• Thorpe JM et al. 2012. The Impact of Family Caregivers on PIM use in non-institutionalised older adults with dementia. Am J Geriatr Pharmacotherapy.
• While C, Duane F, Beanland C. 2012. Medication management; the perspectives of people with dementia and family carers. Dementia, doi:10.1177/147130121444056