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Medication Management in Dementia: Key priorities Ian Maidment, Senior 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

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  1. Medication Management in Dementia: Key prioritiesIan Maidment, Senior Lecturer in Clinical Pharmacy

  2. 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

  3. Anti-psychotics in dementia • Pharmacist-led medication reviews in Care Homes • Wider medication management issues • Exploratory stage • Qualitative data – the carer perspective

  4. 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

  5. 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

  6. 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

  7. Anti-psychotic • Limit use approved indications • Reduced antipsychotic use 28 & 36% (NLTCORC, 2011;Furniss, 2002). • Reduced physical re-strain by 40%

  8. 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).

  9. 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.

  10. 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.

  11. 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).

  12. 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.

  13. 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

  14. Medication Stopped / to be Reviewed • 86 residents • 162 medicines identified for review or discontinuation • On average 1.88 medicines per resident

  15. 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

  16. 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)

  17. 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.

  18. 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%).

  19. 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

  20. 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).

  21. 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

  22. 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

  23. 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.

  24. 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.

  25. 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

  26. 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

  27. 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

  28. 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.

  29. 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

  30. 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).

  31. 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).”

  32. 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

  33. 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 Aging25: 1033-1047. • Cotrell V, Wild K, Bader T. 2006. Medication management and adherence among cognitively impaired older adults. J Gerontol Soc Work47: 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 Pract3: 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 Gerontol45: 89-96.

  34. 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 Community11: 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

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