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Medicine Use Reviews for Falls – Session 2

Medicine Use Reviews for Falls – Session 2. Facilitators: Zoe Aslanpour, Louise Cowan, Mahesh Sodha, Rona Robinson, Nader Siabi, and Nkiruka Opara. MUR – for next week ………. Review list of drugs implicated in contributing to falls;

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Medicine Use Reviews for Falls – Session 2

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  1. Medicine Use Reviews for Falls – Session 2 Facilitators: Zoe Aslanpour, Louise Cowan, Mahesh Sodha, Rona Robinson, Nader Siabi, and Nkiruka Opara

  2. MUR – for next week ……… • Review list of drugs implicated in contributing to falls; • How many patients do you come across in the next week on these drugs? • Doxazosin • All benzodiazepines • Opiate analgesics • ACE inhibitors • Antipsychotics • Long term oral glucocorticoid treatment • Bisphosphonates • Calcium and vitamin D supplements

  3. Which patients are you targeting? • Patients already taking osteoporosis medication • Patients taking oral glucocorticoid therapy for ≥ 3 months OR cumulative dose equivalent to 1.5Gm/year • Patients > 65 taking medications that could increase their risk of falls

  4. Things to remember Exercise Smoking cessation Increase dietary calcium Feet Home safety Reduce alcohol intake Eye and hearing tests

  5. Speaking to patients -The four Es Acknowledging the work of Nina Barnett

  6. What are the four E’s? • Explore • Educate • Empower • Enable

  7. Step 1 - Explore • This ensures it is the patients who decide what they want from their medicines • Ask patients (don’t tell) • What do they know about their illness? • What do they know about the treatment? • What do they know about how to manage their condition? • Have they got any life aims in relation to the disease?

  8. Step 2 - Educate • What we are good at BUT • We educate patients about the issues WE think they need to know INSTEAD • Be guided by what the patient wants to know • Let them lead the discussion • Gives us the opportunity to respond to their needs • Still allows us to discuss evidence of the benefits of the medicines and support for the safe and effective use of medicines

  9. Step 3 - Empower • Need to facilitate behavioural change so patients can achieve their aims from taking the medicines • Mixture of coaching and motivational interviewing • Discuss both necessity and concerns • Patients themselves need to summarise their concerns and the benefit they perceive so they can decide what they want to do • Ask patients • How do you want to manage your illness/medicine taking? • What concerns do you have about your illness/medicines • What do you think are the benefits of this medicine?

  10. Step 4 - Enable • Once a patient has decided to take the medicine we can support and translate decision into action • Ask patient • What do you need to do to achieve your disease/medicine aims? • How are you going to achieve your aim? • When will you do it? • How will you measure your success? • Use coaching techniques to ensure patients themselves suggest methods on how to remember • Good opportunity to discuss follow-up

  11. Discussion points from the case studies

  12. Case 1 Mrs MM Main Issues: • Compliance and concordance with Alendronate and Calcium and Vitamin D preparations • Is the correct preparation of Calcium and Colecalciferol being prescribed? The guidelines suggest at least 500mg of elemental calcium and 10 mcg of colecalciferol twice a day. The prescribed preparation is more expensive than the correct recommended one in Herts. (AdcalD3 forte tablets) • Formulation – alternatives include caplets to swallow available as Adcal D3 (or soluble preparation Adcal D3 • Risk of Falls low but higher risk of fractures

  13. Case 2 Mrs OF Main Issues: • Long term steroid use and over 65 – no primary prevention of osteoporosis • On 3 different anti-hypertensive drugs. Close monitoring of BP, Check for postural hypotension (standing and sitting BP measurements) • Consultant has reduced steroids (wise in view of CKD3) and started azathioprine. Monitoring regular blood tests • Consultant has recommended alendronate and calcium with colecalciferol but missed by GP • Ensure GP aware.

  14. Case 3 Mr DD Main Issues: • Poly pharmacy but most drugs necessary • Isolated Systolic BP difficult to treat – risk of hypotensive episodes when diastolic goes down too far. Also more risk of postural hypotension. Monitor regularly (sitting and standing BP measurements) • Check times of administration. • Tamsulosin best a.m. to maximise urine flow during waking hours • Ramipril best at night risk of postural hypotension • Paroxetine best at night – causes sedation in some patients- has been titrated gradually to the current dose of 30mg so is probably not the cause of dizziness • Complex to manage but anxiety episodes are never easy. Possible solution to suggest is reduce diazepam at night to 5mg and reduce the lorazepam to 0.5mg (half) PRN – May need to seek expert psychiatrist opinion

  15. Feed Back to GPs • Look carefully at choice of words- do not patronise Dr. only make suggestions • Use phrases such as “It appears ..” “ Consider .” “Suggest ....” • Case 3 shows complex poly pharmacy but do not need to find complex solutions • Timing of administration can help • Simple re-assurance goes a long way Mahesh Sodha

  16. References • Barnett, N. 2011. The new medicine service and beyond — taking concordance to the next level. The Pharmaceutical Journal. 287: 653

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