Prescribing and medication management

INTRODUCTION: Our QIP was conducted in the Geriatric wards at Royal Gwent Hospital by doctors working in Geriatrics. Delirium, falls, confusion and urinary retention are common reasons for hospital admission in the elderly. Anticholinergic burden (ACB) is the cumulative effect of taking multiple medicines with anticholinergic properties contributing to frequent admissions. The aim of our QIP was to increase doctor’s awareness of ACB and encourage the review and deprescribing of regular medications in elderly patients to decrease ACB.

METHODS: ACB was measured on admission and discharge using the AEC tool by doctors and pharmacists. Baseline data was collected. Awareness of ACB among doctors was improved through education email and posters on the ward followed by another data collection. An oral presentation on ACB and stickers on patients drug charts and medical notes prompting medication review was done, followed by final data collection. A questionnaire was distributed to all doctors working in the Geriatric unit before the first cycle and after the third cycle to evaluate their knowledge on ACB.

RESULTS: Baseline data shows the percentage of patients admitted with an AEC ≥ 3 on admission and discharge was 12.7% and 10.9% respectively. In the 3rd data collection, these figures were 17.3% and 11.5% respectively. The questionnaire before and after intervention indicated that clinician confidence in identifying anticholinergic medications improved from 44% to 83.8% and awareness of tools to calculate ACB increased from 8% to 88.9%. Utilization of the AEC tool grew from 4% pre-intervention to 73.7% post-intervention. The percentage of patients with reduced AEC scores due to the interventions rose from 16.4% (baseline) to 30.7% (3rd data).

CONCLUSION: The project demonstrated significant enhancements in clinician awareness and utilization of tools to assess anticholinergic burden (AEC) in elderly patients and reduced ACB significantly, which is vital in reducing admissions in elderly.

Introduction  Converting oral Parksinon’s disease (PD) medications to transdermal Rotigotine is sometimes required when patients have swallowing difficulties. Correct dosing is important to avoid under-treatment and deterioration of PD symptoms. Conversely, excessive dopamine agonist can cause hallucinations and confusion. In the UK, 2 main dose conversion calculators exist: PD Med Calc1 and OPTIMAL2, both utilising different formulae. We compared both to identify any dose discrepancies in their recommendations, and select one for use within revised trust guidelines.  Methods  We conducted a retrospective analysis of 22 cases from pharmacy data of 1400 prescriptions issued between January 2021 - July 2022 for patients switched from oral PD medications to a Rotigotine Patch whilst admitted to a UK teaching hospital. We calculated the recommended Rotigotine patch dose from each patient’s usual oral medication regimen using both the PD Med Calc1 and OPTIMAL2 calculators to identify discrepancies.  Results  In 86% of cases (19/22) there was a difference between doses suggested by both calculators. Of these, 95% (18/19) showed OPTIMAL recommended doses 20-200% higher than PD Med Calc. In 5% (1/19) OPTIMAL recommended a marginally lower dose than PD Med Calc.   Conclusions  In dopamine agonist naive patients, PD Med Calc recommended a lower starting Rotigotine dose than OPTIMAL. Most admitted PD patients on patch conversion were older adults, and this population is particularly vulnerable to the side effects of excessive dopamine agonist exposure. The authors recommended using PD Med Calc within revised trust guidelines to minimise negative sequelae and ensure dosing consistency.  1 PD 'Nil by Mouth' Medication Dose Calculator http://pdmedcalc.co.uk/ 2 OPTIMAL Calculator - A Guideline for the OPTIMAL management of inpatients with Parkinson's Disease. http://www.parkinsonscalculator.com/index.html  

Introduction:

Care home residents are increasingly presenting to hospitals. In October 2022, a frailty team was formed in our district general hospital, consisting of two SHOs, one SpR and one consultant, with support from pre-existing care home ANP and community resource team (CRT). Focusing on patients presenting to the Emergency Department, their aims were early identification of care home residents in order to optimise their care by facilitating discharge, tackling polypharmacy and seizing opportunities for advanced care planning.

Method:

Care home residents were highlighted on the ED clinical system, using a unique icon, and reviewed by the frailty team. Anonymised patient statistics were logged into a bespoke e-database. This generated a dashboard of graphs showing trends in outcomes. The statistics from the first 8 months (3/10/22 to 5/6/23) were utilised to show patient demographics, number of reviews and rates of discharge.

Results:

297 care home residents were reviewed. 83.8% of these patients had a Rockwood Clinical Frailty Score of ≥ 7. Delirium was present in 91 (30.6%) patients. 121 (40.7%) had at least 1 medication stopped. 165 (55.6%) were discharged after frailty review. Do not resuscitate forms were completed for 208 (70.0%) patients. Advanced Care Planning was discussed with 138 (46.5%) patients and 6 (2.0%) patients were not for re-admission. End of life care was commenced for 17 (5.7%) patients.

Conclusion:

It is clear that patients attending the Emergency Department would benefit from an early comprehensive geriatric assessment. The benefits this has provided in one North Wales DGH are significant and have made strides in reducing unnecessary admissions, reducing polypharmacy and providing holistic, interdisciplinary and patient centred care including advanced care planning. Whilst the Emergency Department is not an ideal environment for this, the team have demonstrated the benefits to this model.

Introduction: The Acute Frailty Team (AFT) review all acute admissions referred to Medicine for the Elderly within our organisation. Our team is comprised of a consultant, AHPs and a specialist clinical pharmacist. The Clinical Frailty Scale Score (CFS) was used to quantify frailty within our patient population. Recognising that older patients are at increased risk of medicine related harm, medication reviews are undertaken as part of the comprehensive geriatric assessment. The aim of this project was to determine the number of documented Level 3 medication reviews on discharge including number of medication interventions and determine any correlation with CFS. 

Methods: For a 5 month period, all patients reviewed by AFT (Monday to Friday) had a documented CFS score on admission. A retrospective review was then undertaken with data collected on CFS score, patient demographics and number of Level 3 medication reviews documented on discharge. Data was then collated to indicate medication interventions and the most common medication changes.

Results:  212 patients were reviewed during the study period. Range of CFS score was 2 to 8 and 81.2% were classified as CFS ≥5. 101 patients had a documented Level 3 medication review accounting for 380 medication interventions; 210 medications were stopped and 82 medications were started. 36.6% of the patient group were deceased within 1 year of review.

Conclusion(s):

In order to optimise effective prescribing and minimise harm in older, frail people, this data will be used locally to promote the importance of medication reviews during an acute admission and ensure this is reliably communicated on discharge. Deprescribing accounted for 55.3% of changes. Since 1/3 of patients are deceased within one year, a targeted medication review is essential and should influence our prescribing practice going forward.

Improving the assessment and management of blood pressure in older populations

Introduction
Managing blood pressure in patients above 65 years old remains controversial with limited evidence in relation to balancing cardiovascular benefit and risks of postural hypotension. National guidelines highlight appropriate medications and contraindicated drugs. An initial audit identified a large proportion of elderly Wigan borough residents being on inappropriate medication alongside poor compliance in assessing and managing abnormal blood pressure. This quality improvement project aims to increase clinician knowledge and improve assessment and management of antihypertensives and blood pressure in older populations. 

Methods
We retrospectively analysed summary care records of 54 patients over the age of 65, admitted under the care of the Ageing and Complex Medicine team, with diagnoses related to postural hypotension, hypertension and falls. Metrics interrogated included documentation of LSBP on admission and appropriateness of blood pressure medication on admission and subsequently on discharge 3 PDSA cycles were undertaken. These targeted senior clinicians within the trust, the Care of the Elderly MDT and new junior doctors.

Results

There was no improvement on measurement of LSBP on admission (Baseline 67%, Implementation 1: 55%, Implementation 2: 27%, Implementation 3: 50%). There was some improvement in percentage of patients discharged on appropriate medications as compared to admission (Baseline 12%, Implementation 1: 5%, Implementation 2: 0%, Implementation 3: 10%). Average confidence rating in junior doctors managing anti-hypertensives and postural hypotension. significantly improved from 2.5/5 to 4/5 pre vs. post teaching session. 

Conclusion
Although teaching sessions were delivered to clinicians all all levels and this improved doctor's confidence in blood pressure management, this did not translate to any tangible improvements in LSBP monitoring on admission/ discharge nor the selection of appropriate medications. Further interventions to improve LSBP monitoring and documentation, medication reviews and MDT education are ongoing. 

Introduction

Older patients admitted to the emergency department (ED) do not have a pharmacist-led medication review within the comprehensive geriatric assessment (CGA), yet the presenting complaint can be attributed to overprescribing and problematic polypharmacy. Taking ten or more medications increases the risk of hospital admission by 300% due to adverse drug reactions (ADRs)1, therefore a medication review can reduce this outcome by optimising current therapy2. Responsibility of safely transferring this medication information between care settings is a healthcare professional's duty, as the rate of error is 30 - 70%3.

Method

Patients were identified by the ED Frailty Team according to local frailty criteria, including patients > 65 years presenting with delirium, a fall and/or multi-morbidities. Medicines reconciliation was carried out by the frailty pharmacist, and medications optimised to reduce future harm with investigations prompted where needed. Interventions were categorised. A summary plan was written to the General Practitioner (GP) and each patient was followed up after 4 weeks to assess if received and actioned appropriately.

Results

73 medication reviews were conducted for patients (mean age 84.4 years) from June to September 2022, majority presenting with fall (69%). High-risk medication review was most common intervention (90%), followed by counselling (50%). 92% patients required a pharmaceutical intervention (n=208). GP plans were actioned for 65% patients in Primary Care.

Conclusion

ED frailty pharmacist's input reduced inappropriate polypharmacy and optimised medication for this patient cohort, with majority of care plans carried out appropriately following discharge. A future study could examine re-admission rates of patients in comparison to those without a frailty pharmacist's input.

References

1. Payne RA et al. British Journal of Clinical Pharmacology 2014; 77: 1073 – 1082.

2. Department of Health and Social Care, 2021. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf. Accessed 19/1/23.

3. Department of Health, 2011/2012. Available at: www.wp.dh.gov.uk/healthandcare/files/ 2011/01/outcomesglance.pdf. Accessed 19/1/23.

Introduction

Prior stroke is one of the biggest risk factors for future stroke events. Secondary prevention medications are key to reducing subsequent vascular events, and guidelines recommend use of antithrombotics, antihypertensives and lipid lowering drugs. We carried out a retrospective study of adherence to these medications in a post stroke population.

Methods

Consecutive patients admitted with acute stroke to a Dublin hospital between July 2022 and November 2023 were invited to participate. Participant interviews were carried out at 1 year post stroke, including demographic and clinical information and care needs. Functional ability was graded using the Modified Rankin Scale (mRS). Adherence to three key categories of secondary preventative drugs was assessed using the 4-item Morisky Medication Adherence Scale, and participants were asked to show all current medications, which were compared to the discharge prescription.

Results

Interviews were conducted with 197 participants at 1 year post stroke. Mean age was 68.8 years, 66% were male and 79% were of white Irish ethnicity. Twelve (6%) were living in nursing homes while 68% were functionally independent with mRS 0-2. High adherence to all prescribed medicines was reported by 79% and was higher for antihypertensives and antithrombotics (87%) than for lipid-lowering drugs (78%). There was no statistically significant difference in self-reported adherence between gender or race subgroups. Adherence was better in participants who were functionally dependent by mRS (71% vs 97%, p<0.0001) and those who had an involved caregiver (69% vs 89%, p<0.0001).

Discussion

Self-reported adherence to medication was high in this cohort but a significant proportion were not adherent to important secondary prevention medications 1 year after a stroke. Adherence was higher for those who had more disabling strokes and an involved caregiver. We did not find any difference between race or gender groups. 

Introduction

The UK population is ageing quickly, with the number of individuals over 65 rising from 9.2 million to 11 million in the last decade. This increase has led to more comorbidities and complex treatment regimens, often referred to as polypharmacy, which can cause adverse effects, increase admissions, mortality and high healthcare costs. To address these issues, the NHS is adopting a patient-centred approach to optimise medication use and improve outcomes. This includes evaluating patients, setting shared goals, and identifying unnecessary or harmful medications. Data was gathered from community patients referred to the Early Intervention Team (EIT), which aims to ensure safe discharges and prevent hospital admissions related to falls, frailty, and cognitive or functional decline in Suffolk.

Method

Data were collected from March to May 2024 for fifty-one patients aged 65 and older who received home visits from EIT and were on five or more medications. Medical records were reviewed to identify medications associated with health deterioration and to assess the frequency of medication reviews, along with related costs. A survey was also conducted to evaluate the impact of their medication regimens on quality of life and gauge interest in reviewing and potentially reducing their medication burden.

Results

Out of fifty-one patients, 90.2% adhered to their medication regimen, but over half (54.9%) did not understand its purpose and reported side effects, including falls (82.4%), memory problems (64.7%), and constipation (54.9%). Additionally, 72.5% wanted their medications reviewed. Twenty-two patients GP were promptly contacted. Notably, one patient's annual medication cost was calculated as £5,256.96.

Conclusion

Polypharmacy leads to high financial and health costs, yet medication reviews are often inadequate or unavailable. The authors suggest conducting regular reviews in outpatient falls or frailty clinics to monitor adherence and tolerance. Further research is needed to ascertain the benefits of this practice.

Introduction

Metformin has pleiotropic biological effects which might improve muscle function in older people. The MET-PREVENT trial tested the efficacy and safety of metformin as a therapy for sarcopenia and frailty in older people.

Methods

Double blind, randomised, parallel-group, placebo-controlled trial. Participants aged ≥65 with walk speed <.8m />s and low muscle strength (handgrip <16kg for women, <27kg for men, or 5x sit to stand >15s) were recruited from primary care and hospital clinics. Participants were randomised 1:1 using a web-based interactive system to receive 4 months of 500mg metformin or matching placebo 3x/day. The primary outcome, analysed by intention to treat, was the between-group difference in 4m walk speed at 4 months, adjusted for baseline values. Secondary outcomes included grip strength, short physical performance battery, six-minute walk distance, muscle mass by bioimpedance, quality of life and activities of daily living. All adverse events were recorded.

Results

Seventy-two participants were randomised, mean age 80 (SD 6) years. 42 (58%) were women, 42 (58%) were frail (Fried score ≥3); mean baseline 4m walk speed was 0.59 m/s (SD 0.22). 70 (97%) completed the trial (metformin 34/36, placebo 36/36). 14 (40%) discontinued metformin and 5 (14%) discontinued placebo. There was no difference in the primary outcome between the metformin (0.57 m/s [SD 0.19] m/s) and placebo group (0.58 m/s [SD 0.24]); adjusted treatment effect was 0.001 m/s (95%CI -0.06, 0.06); p=0.96. There was no significant effect on measures of muscle mass, physical performance, quality of life or activities of daily living. The metformin group had more adverse events (110 vs 77) and more hospital admissions (12 vs 3)

Conclusions

MET-PREVENT achieved successful recruitment with high retention rates, however metformin did not improve physical performance and was poorly tolerated with high rates of adverse events in older people with sarcopenia.

Background: Clinical pharmacists are increasingly working as part of primary care teams in UK. Many people living with dementia live at home with the support of primary care. Given the complexity of their health problems and their use of several medications, clinical pharmacists may potentially play a crucial role in their support Aims: To explore clinical pharmacists’ experiences of working in primary care with people living with dementia and identify any specific training needs to provide effective support for this patient group.

Methods: An online survey sent via email in 2023 through professional organisations, social media, and utilising research team contacts. The survey covered topics including clinical pharmacists’ background, experience of working with people with dementia, and training needs.

Results: 57 clinical pharmacists responded to the survey; the meantime working as a clinical pharmacist was 9.6 years (standard deviation 8.6) and within a primary care setting was 6.1 years (standard deviation 6.1). Just over three-quarters of respondents (n=31, 77%) work with people living with dementia. While almost two thirds (n=35, 61%) had undertaken training for dementia care, such training often lasted a few hours (less than a day) (n=17, 49%). Most respondents (n=39, 89%) wanted further information or training; including non-pharmacological interventions to improve quality of life in dementia and how to support carers and relatives. Practice challenges reported included a lack of face-to-face consultations and getting assurance that the patient could safely take medications.

Conclusions: These findings indicate an interest in dementia care, a willingness to undertake further training but practice uncertainties that suggest a system approach might be beneficial.