Prescribing and medication management

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

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. Pharmacists have traditionally worked in primary care, in the community, and with GPs. However, the role of the clinical pharmacist in primary care is evolving and there are plans to employ more clinical pharmacists in the NHS. With an ageing UK population, there is an increase in the number of people living with multiple long-term conditions, accompanied by polypharmacy, posing numerous challenges to healthcare systems. This review investigates the evidence about the varied roles and services delivered by clinical pharmacists in primary care, capturing the perspectives of health and care professionals, older adults, and their carers.

Method. Our scoping review followed the framework for scoping reviews in accordance with the Joanna Briggs Institute (JBI) methodology. A broad search was conducted in 2023 in CINAHL, Cochrane, Medline, SCOPUS, and Web of Science. We included articles that explored the landscape of clinical pharmacy services for older people in the UK, focusing on roles and services delivered, perceptions, and experiences.

Results. A total of 23 articles was included. These shed light on the multifaceted responsibilities of clinical pharmacists for older people. Stakeholder perspectives, including healthcare professionals and care home staff, emphasise the positive outcomes of clinical pharmacist involvement, from reducing other practitioners’ workloads to improving patient safety. However, communication gaps amongst the primary care team and those living with dementia, concerns about competence, and the need for clear role definitions of clinical pharmacists emerge as challenges.

Conclusions and implications. The review enhances our understanding of the clinical pharmacist service in the UK and identifies gaps in research evidence, emphasising the need for empirical studies on the experiences of older people with cognitive impairment and those from minority ethnic backgrounds. The findings can be used for policymaking, workforce planning, and healthcare provision to improve the services for older people in the UK.

Introduction At Wrightington, Wigan and Leigh we admitted over 400 patients with hip fracture diagnosis in 2023. As part of ortho-geriatric review, denosumab treatment would be utilised in a cohort of patients where this is appropriate, in line with NOGG guidelines. Traditional model of delivering first dose after outpatient appointment led to delays in treatment initiation and did not address the significant risk of “imminent fracture” which was recognised in the latest NOGG guidelines. The aim of this project was to reduce delays in denosumab treatment initiation by introducing consenting process during hospital stay led by ortho-geriatric Advanced Clinical Practitioner.

Method Utilising hospital electronic records, a sample of patients was selected from patients admitted in 2022 (19 patients), 2023 (19 patients) and 2024 (6 patients). Time of decision to treat with denosumab to time of first dose administered was used as the outcome measure. Alongside this, analysis of time to outpatient appointment was completed which was where the pre-intervention consent was taken. Intervention of inpatient consent being taken was implemented in September 2023.

Results The average length of time from clinical decision being made to first dose of denosumab being administered was 187 days in 2022 sample, 76 days in 2023 sample and 27 days in 2024 sample. The governance around consent process was established and adopted by the whole ortho-geriatric team. Waiting times for outpatient bone health clinic were on average 240 days in 2022, 164 days in 2023 and unknown in 2024 cohort.

Conclusion(s). Introduction of ward-based consent process for patients who are suitable for denosumab led to significant decrease in delays in time to first dose. This ensures that patients benefit from bone protection in a timely manner, as their risk of refracture is greatest in the first 6 months post index fracture.

This service evaluation reviewed the impact of the Perioperative Care of Older People Clinic (POPS) on Anticholinergic Burden (ACB) in older surgical patients and identified areas for improvement. The study assessed 75 patients aged ≥65 years, revealing widespread anticholinergic use. Among patients on anticholinergics, 34% experienced a reduction in ACB post-POPS review. However, maintaining these changes at ≥6 months was challenging, with 50% of patients experiencing a change in their ACB score due to new prescriptions or the re-initiation of old medications. The study identified communication gaps at the POPS-primary care interface affecting de-prescribing efforts, underscoring the need for improved discharge letters, systems to flag high ACB patients and a universal ACB tool.

Introduction

The UK's ageing population is increasingly undergoing surgery, and older adults are at higher surgical risk partly due to anticholinergic use. POPS is a relatively new initiative aimed at reducing ACB in this demographic, but the sustainability of these reductions is not well understood. This service evaluation aims to fill this gap and suggest solutions for maintaining reduced ACB levels.

Methods

Retrospective data from 75 patients from 2022-2023 who met the criteria for ACB evaluation pre- and post-POPS review, with follow-up at ≥6 months, were included. Results Post-POPS, ACB was reduced in 34% of patients, with a median decrease of -2. However, ACB increased again in 50% of patients at ≥6 months, with re-initiation of amitriptyline and furosemide contributing to the rise in 67% of these cases.

Conclusions

CGA effectively reduces ACB in older surgical patients, but sustaining these reductions poses significant challenges. Communication difficulties at the POPS-primary care interface likely contribute to the re-initiation of medications, indicating a need for standardised discharge summaries and a universal system for evaluating and flagging high ACB patients to maintain improvements.

Introduction Serum procalcitonin levels increase in response to bacterial infections and decrease with successful treatment. Procalcitonin can, therefore, inform decisions around antibiotic use. For adults with suspected infection, using procalcitonin to start antimicrobials is not advocated but serial testing is suggested to aid with the decision to discontinue therapy. Methods A retrospective study was performed of adults over the age of 80 years admitted on a medical ward whom had a serum procalcitonin completed between November 2022 and April 2023. Their electronic patient records were reviewed, with data collated and analysed using Microsoft Excel. Results Of 160 patients studied, median age was 85 with a median clinical frailty score of 6. The suspected sources of infection for the patients were chest (65%), unknown source (22.5%), urine (5%), cellulitis (3%), biliary (1.3%), osteomyelitis (1.25%), abdomen (0.63%) and infected haematoma (0.63%). Confirmed viral respiratory infection was present in 76 (47.5%) patients. Of all patients, only 62% were taking antibiotics at the time the procalcitonin was taken. Only 4 patients (2.5%) had serial procalcitonin testing (24-48 hours apart). Conclusion Procalcitonin was more likely to be used for suspected respiratory tract infection than other suspected infections. The majority of patient were taking antibiotics at the time the test was performed, which would indicate the tests being used to support a diagnosis of bacterial infection. Only a minority of patients (2.5%) had more than one procalcitonin result indicating that the clinical utility of this blood test to aid decision making in altering antimicrobial therapy was not occurring. Therefore, procalcitonin testing within an older adult population is being used in an inappropriate manner in the context of infection. Given a cost of £39.50 per test we anticipate that in its current use procalcitonin testing is not being used in a cost effective or clinically effective manner.

Introduction

Residents of care homes for older people experience multi-factorial problems when being given oral medication. A systematic integrated mixed-methods review of the literature revealed that practices of modifying tablets, crushing and mixing with food, in attempts to administer medication, remain widespread internationally. There is a high prevalence of swallowing problems. Care home routines are time pressured, and there are incidences of disempowering practices and language associated with processes of medication administration. The literature presented very little from the residents' experience, largely representing them as passive recipients in the activity.

Objective

The aim of this study was to explore the experience of residents of care homes for older people who need help from care staff to take their medication. Its purpose was to answer a single research question, 'What is the experience of residents of care homes when oral medication is administered?'

Methods

Observation of an episode of medication administration and semi-structured interviewing were conducted with eight residents between the ages of 84 and 95 from care homes in Scotland. Data was analysed in accordance with a Gadamerian philosophy of hermeneutics, with a commitment to understanding and representing the participants' experience.

Results

Four themes emerged from the data, 'Being in control/relinquishing control', 'Being comfortable in routine', 'Trusting', and 'Swallowing'. Interpretive exploration of these themes revealed the importance of facilitating individual routines when taking medication, and that a trusting relationship with staff and with the medication can be an indicator of vulnerability. The risks to autonomy in relation to taking medication, and an imbalance of power for care home residents who are given medication to take, emerged as an overarching concept.

Conclusion

Recommendations focus on the potential for empowering practices in relation to taking medication, both for those who provide care, and for those who prescribe medication.

Introduction:

Older adults are at increased risks of drug-related problems, contributed by increasing incidence of multimorbidity with age, and the consequent polypharmacy. We aim to investigate the drug classes associated with 30-day readmissions in hospitalised older adults.

Method:

We prospectively studied patients aged 65 years and above admitted to a general medical department in Sengkang General Hospital, Singapore, between October 2018 and January 2020. Medication lists were obtained from electronic medical records at admission. Unplanned readmission within 30 days of discharge was tracked through the hospital’s electronic health records. Medications were classified according to the World Health Organisation’s Anatomical Therapeutic Chemical classification system. Univariate logistic regression was performed for the association of drug classes with 30-day readmission.

Results:

We recruited 1507 consecutive admissions with follow-up data. 30-day readmission occurred in 331 patients (22.0%). Greater length of stay, higher comorbidity burden, hospitalisation in the one year preceding index admission, frailty and polypharmacy were more commonly observed among patients who were readmitted within 30 days of discharge. Admission diagnoses associated with 30-day readmission include infections, fluid overload, acute coronary events and constipation. Drug classes associated with a higher risk of 30-day readmission include drugs for acid-related disorder (OR=1.62, 95%CI 1.27-2.07), drugs for constipation (OR=1.96, 95%CI 1.41-2.73), antithrombotic agents (OR=1.40, 95%CI 1.09-1.79), antianaemic preparations (OR=2.22, 95%CI 1.68-2.91), cardiac therapy (OR=1.70, 95%CI 1.23-2.34), diuretics (OR=1.41, 95%CI 1.04-1.90), beta-blocking agents (OR=1.55, 95%CI 1.21-1.99) and analgesics (OR=1.56, 95%CI 1.02-2.39).

Conclusion:

Drug classes associated with 30-day geriatric readmissions include drugs for acid-related disorder, constipation, antithrombotic agents, antianaemic preparations, cardiac therapy, diuretics, beta-blocking agents and analgesics. Patients on the above drug classes should herald a higher index of scrutiny during admissions, and necessitate closer follow-up upon discharge.

Title: Antibiotic Stewardship Audit in Gerontology wards in Princess Royal University Hospital 

Introduction: Misuse of antibiotics leads to the emergence of antimicrobial resistance, which is an important public health and patient safety issue. Infections caused by resistant organisms are associated with poorer clinical outcomes and undesired side effects.

Aim: Assessing compliance with the antimicrobial stewardship package introduced by the UK Department of Health in 2011 and with the trust guidelines.  

Method:

* Spot checks done across all gerontology wards between January and March 2024 to assess the compliance as described above.

* Intervention: Teaching sessions for junior doctors discussing the first cycle’s results, the main lacking areas, and the takeaway messages.

* Second spot checks in May and June. The results were presented in the Adult Medicine Conference at the trust.

Results:

* Improvement in documenting clinical indications to an average of 90%.

* Compliance with local antibiotic guidelines improved to an average of 80%

* Documentation of a reason for continuing IV antibiotics after 48 hours and factors preventing a per-oral switch improved to an average of 80%.

* Areas of improvement identified in documenting CURB65 score for community acquired pneumonia

Conclusion: The audit and the interventions showed marked improvement in antibiotic prescriptions and compliance with the trust guidelines. Despite being a common basic audit, it encourages junior doctors to check the trust policy and prescribe accordingly. This is important in the geriatric population who are at increased risk of side effects due to co- morbidities and drug interactions because of polypharmacy.

Aim: To achieve compliance in > 90% of patients with the NHS Lothian protocol for 'Management of MSK pain in frail elderly’. 

Background: NHS Lothian Medicine of the Elderly Department expenditure review showed a 3-fold rise in Lidocaine 5% patch costs the last year. Lack of adherence to the protocol and monitoring of patches prescriptions’ effectiveness felt to contribute. 

Methods: A doctors’ team with pharmacy support reviewed expenditure report from April 2023 to April 2024. A prescribers’ survey was sent to evaluate current practises, and another one to nursing staff who administer patches via electronic patient prescribing. PDSA 1 was departmental education based on survey results. PDSA 2 was a focused educational session on MSK protocol and use of the lidocaine patch monitoring form.  

Results:  80% of prescribers used lidocaine before prescribing opiates to avoid adverse effects of opiates. Nurses felt prescriptions were sometimes unclear about application site. 5 patients admitted on lidocaine by GP in May 2024 compared to 3 in September 2024. 13 patients were prescribed lidocaine patches in May 2024 compared to 5 in September 2024 following 2 PDSA cycles. No monitoring forms were used.    

 
Conclusion: The use of lidocaine patches reduced following 2 PDSA. It was harder to challenge the use of patches in patients already with GP prescription. Majority of cases lacking adherence to the protocol. The monitoring form was reviewed and felt not to be suitable for all prescriptions. PDSA 3 will focus on modifying this form to ensure suitability.