A Hospital Pharmacist’s view: Balancing complexities for better patient care

Kamaldeep Sahota is the Lead Pharmacist for Frailty and Elderly Medicine at Medway NHS Foundation Trust. Kamaldeep has worked extensively in hospital in various roles supporting older people and has also worked in a primary care network helping to establish the role of the pharmacy team. Her interests include bone health, person-centred care, and managing medicines in frailty. 

I started my career in community pharmacy but quickly realised that hospital pharmacy was the area I wanted to work in. The ability to be involved in the acute stage of care is both challenging and deeply rewarding. Working with frail older adults, I help navigate the intricacies of polypharmacy, multimorbidity and the delicate balance required to optimise medication regimes while ensuring safety and quality of life. The pharmacy team are usually involved in the last step before a person can go home and it is likely that we would have been involved in the person’s care throughout their admission.   

Working in hospital provides the unique opportunity to work within a multidisciplinary team and fully embrace the complexity of older people medicine. I have worked as part of different ward teams and, on the whole, I have always felt that my input is valued, and I am able to contribute to the overall care of the patient. On admission, we are already looking at the support our patient will need at discharge with their medicines. We are finding out about what they think about taking their medicines, if they have any problems or concerns, if they take them as the prescriber intended, if someone helps them and if they know why they have been prescribed in the first place. Asking these somewhat simple questions, can unearth many interesting answers, but most critically it guides the person to highlight what matters to them. Understanding medicine-taking behaviours is important because, despite every good intention during the inpatient stay, the key question I always have is: will the person take it when they go home?   

Drug-handling changes as you age and understanding the nuances around this are essential for the frailty pharmacist. A lot of time is spent reviewing patients with poor renal function, swallowing difficulties and managing drugs where older, people living with frailty are likely to be more sensitive, such as with opioid analgesics or where age-related organ decline may mean an increased risk of side effects such as antihypertensives or NSAIDs. The necessity to balance clinical need and the risk of adverse events is a regular consideration with any new medicine that is prescribed and also in some cases where evidence is lacking. We reconcile pre-admission medicines with the current clinical admission and ensure medicines are prescribed safely and any potential drug interactions are appropriately managed. Joining consultant-led ward rounds offers the opportunity to discuss deprescribing options to review long term medicines that are no longer beneficial or might even cause harm. The process of deprescribing is carefully managed with the patient or carer so they are aware of how the medicine will be tapered and stopped. 

During a hospital stay, there can be significant changes to medicines and the aim is always to make patients and carers aware of these changes at discharge.  The link with pharmacy colleagues in primary care should not be underestimated and ensuring information relating to medicines is documented and communicated effectively is critical for managing care. 

There are other aspects to my role, but my motivating factor is being able to support older and frail people with their medicines and driving the agenda for safer medication management. Pharmacists can make a difference in patient care, and I think as a profession we need to get better at showcasing all the good work we do.