Nina Barnett

Switching of prescription drugs to over-the-counter status: is it a good thing for the elderly?

Prescription medicines are increasingly being switched to over-the-counter (OTC, nonprescription) status in the developed world, with the support of government policy. These changes may provide greater choice for individuals and offer potential savings in government spending on health while expanding the market for pharmaceutical companies. However, there is concern regarding the safety of these reclassifications.Elderly people are the largest consumers of prescription and OTC medicines and are more vulnerable to drug adverse effects and the risks of multiple or inappropriate medications. Commonly purchased agents such as NSAIDs have recognised adverse effects which have been shown to be more common in the elderly. Furthermore, all sedatives, including antihistamines, have a propensity to cause falls in older people. As many doctors do not ask patients about OTC medicine use, problems related to use of these drugs may go undetected. Furthermore, the increased availability of OTCs may result in a delay in patients consulting medical practitioners for potentially serious conditions, although this has not so far been investigated. In the UK, the recent switch of a low-dose HMG-CoA reductase inhibitor (statin) to OTC status has caused concern. Although there might theoretically be some benefits from improved access to medications used in primary and secondary prevention of heart disease, the actual outcomes of use of this reduced dose of the statin will be difficult or impossible for patients or practitioners to monitor.OTC drug use implies a mutual responsibility for communication between patients and health professionals that in practice is not always achieved. Epidemiological research is needed to investigate patterns of OTC use and evaluate the potential risks of OTC medicines in elderly people. Governments, regulatory bodies, professionals and the drug industry have a responsibility to ensure that robust systems are in place if the increased use of OTC medicines by elderly people is to be safe and effective.

Drug therapy and the older person: role of the pharmacist.

Older people in the UK receive a disproportionate amount of medication. They comprise 18% of the population but receive 45% of all prescription items. Not surprisingly they experience drug-related illnesses — in 1980, 1 in 10 admissions to acute geriatric units were wholly or partly due to adverse drug reactions. Drugs which should be used with particular care or even avoided in older people include benzodiazepines, warfarin, digoxin, aminoglycosides, tricylic antidepressants, antipsychotics and long-acting oral hypoglycaemic agents.Pharmacists can promote safer prescribing practices by advising both patients and doctors. The community pharmacist can assist in drug compliance by providing patients with additional information about individual drugs, identifying potential adverse drug reactions and interactions, supplying appropriate drug containers or compliance aids, and even arranging home visits for patients unable to visit the pharmacist. Some community pharmacists provide pharmaceutical advice and services to residential and nursing homes. Pharmacists’ advice to doctors can include one to one discussions in either primary or secondary care, assisting in medication review, providing information to prescribing committees, compiling drug formularies, assisting in auditing of prescribing practices and organising disposal of unwanted medicines and poisons campaigns.

A pilot survey of junior doctors’ attitudes and awareness around medication review: time to change our educational approach?

Objectives Our aim was to explore junior doctors’ attitudes and awareness around concepts related to medication review, in order to find ways to change the culture for reviewing, altering and stopping inappropriate or unnecessary medicines. Having already demonstrated the value of team working with senior doctors and pharmacists and the use of a medication review tool, we are now looking to engage first year clinicians and undergraduates in the process. Method An online survey about medication review was distributed among all 42 foundation year one (FY1) doctors at the Chelsea and Westminster Hospital NHS Foundation Trust in November 2014. Descriptive statistics were used for analysis. Results Twenty doctors completed the survey (48%). Of those, 17 believed that it was the pharmacists duty to review medicines; and 15 of 20 stated the general practitioner (GP). Sixteen of 20 stated that they would consult a senior doctor first before stopping medication. Eighteen of 20 considered the GP and consultant to be responsible for alterations, rather than themselves. Sixteen of 20 respondents were not aware of the availability of a medication review tool. Seventeen of 20 felt that more support from senior staff would help them become involved with medication review. Conclusions Junior doctors report feeling uncomfortable altering mediations without consulting a senior first. They appear to be building confidence with prescribing in their first year but not about the medication review process or questioning the drugs already prescribed. Consideration should be given to what we have termed a ‘bottom-up’ educational approach to provide early experience of and change the culture around medication review, to include the education of undergraduate and foundation doctors and pharmacists.

Patient-centred management of polypharmacy: a process for practice

Medicines are the most common intervention to improve health. The number of medicines taken by older people in the UK has been steadily increasing for the last three decades. Polypharmacy is a term that refers to either the prescribing or taking many medicines. Concerns about the risks of polypharmacy in primary and secondary care are growing, supported by evidence which associates polypharmacy with increased adverse drug events, hospital admissions, increased healthcare costs and non-adherence. In the UK, this can largely be attributed, over the last 20 years, to the greater availability of evidence-based treatments promoted through therapeutic guidelines which are designed for single conditions, rather than addressing the multimorbidity that affects many older people. There is also currently a paucity of evidence-based national guidance around reducing and stopping medication and incorporating the patient perspective. This paper reviews current UK literature around polypharmacy including a description of four key resources which all make use of international literature and all focus on the medication aspects of polypharmacy from a clinicians perspective. The patient-centred approach combines both clinical health professionals and patient perspective. Developed using existing resources, it is designed to assist with collaborative (patient and clinician based) medication review to inform decisions around deprescribing and address polypharmacy as part of overall strategies to optimise medicines for the patient. Presented as a diagrammatic representation in seven steps, it also includes guidance on points to consider, actions to take and questions to ask in order to reduce polypharmacy and undertake deprescribing safely.

Patient-centred consultations in a dispensary setting: a learning journey

Background Hospital dispensary consultations usually focus on telling your patients how to take medicines. However, patient views are not always considered. We suggest that the value of a consultation lies in helping patients get the best health outcome from their medicines and this requires more than education. Pharmacy teams need to think differently about the way in which consultations are undertaken in order to improve effectiveness of medicines. Objectives To explore development of patient-centred consultations in a hospital dispensary environment using a health coaching approach. Method In April 2014, London North West Hospitals NHS Trust Pharmacy Department commissioned a 2-day health coaching course for 18 pharmacists to improve patient focus in consultations. Using learning from the course and knowledge of dispensary processes, a flow chart was created to support management of the three categories of patient. Pharmacy staff trained to tailor their consultation to patient need using a coaching approach, including use of principles of the 4Es (Explore, Educate, Empower, Enable), a pharmacy-based model for short consultation. Results Preliminary findings from the new approach included improved staff satisfaction, improved skill mix and positive feedback from patients. The main perceived disadvantage of using the above consultation style was the fear of increasing the time for consultations, however, this appears unfounded. A need for a dedicated counselling area to improve privacy in consultations was identified. Conclusions Provision of a patient-centred consultation framework in a dispensary environment, using a coaching approach, has improved focus on patient needs, continuing the journey towards patient-centred care.

A coaching approach to improving concordance

The word concordance, which was first introduced into the pharmacist’s vocabulary nearly 20 years ago, continues to create much misunderstanding. Many people still use the term interchangeably with compliance or adherence, or talk about patients ‘concording’ with their medication, which has no meaning in either sense or concept. It seems that we are still waiting for the paradigm shift. This move, from a focus of compliance to concordance, supports a patient-centric attitude. In the UK, recent government policy embraced this approach and included the phrase ‘no decision about me without me’. This shift is a way of addressing the waste associated with issuing medicines to patients who do not want to take them, a practice that is unsustainable politically, financially and ecologically. The first step towards this change is recognition that concordance is a process and not an event. It involves the development and, vitally, the maintenance of shared understanding between the patient and the clinician around the purpose and aims of the treatment. In this article we argue that this process must begin at the point of diagnosis, before a decision to use medicines is even contemplated. Additionally, we attempt to generate a common sense and ‘universal’ method, applicable to the majority of our patients and to move practice, through use of a coaching approach, towards the attainment of concordance.

Using Theory to Explore the Determinants of Medication Adherence; Moving Away from a One-Size-Fits-All Approach

Non-adherence to prescribed medicines has been described as “a worldwide problem of striking magnitude”, diminishing treatment effects and wasting resources. Evidence syntheses report current adherence interventions achieve modest improvements at best, and highlight the poor progress toward the longstanding aim of a gold-standard intervention, tailored to meet individual need. Techniques such as motivational interviewing and health coaching, which aim to facilitate patient-centred care and improve patient resourcefulness, have shown promise in supporting adherence, especially in patients with psychological barriers to medicine-taking, such as illness perceptions and health beliefs. Despite a plethora of research, there is little recognition that the nature and complexity of non-adherence is such that a one-size-fits-all approach to interventions is never likely to suffice. This commentary re-visits the call for adherence interventions to be tailored to meet individual need, by considering what this means for day-to-day practice and how this can be achieved. It provides an update on advances in psychological theory to identify the root cause of an individual’s non-adherence to encourage matching of provided adherence support. It also provides a practical perspective by considering exemplars of innovative practice and evaluating the day-to-day practicalities of taking a novel approach.

Why we should understand the patient experience: clinical empathy and medicines optimisation

To critically discuss the need for pharmacists to underpin their consultations with appropriate ‘clinical empathy’ as part of effective medicines optimisation.

Impact of an integrated medicines management service on preventable medicines-related readmission to hospital: a descriptive study

Background Medication contributes to 5–20% of hospital admissions, of which half are considered preventable. An integrated medicines management service (IMMS) was developed at a large general hospital in London to identify and manage patients at risk of a preventable medicines-related readmission (PMRR) to reduce the risk of PMRR. Objective To investigate the effect of the pharmacy IMMS on the rate of PMRR within 30 days of the first discharge. Method 744 patients were identified between October 2008 and October 2014, using the PREVENT tool. Patients at risk were managed by the IMMS with medication reconciliation, review, consultation and follow-up, as required. Results Of 744 patients, 119 were readmitted within 30 days of discharge, with a PMRR for 2 patients (1.7%). The main reason for referral to the service was to assess the need to start a compliance aid. Most interventions involved communication: 84% included patient consultations with 50% involving discussion with the patient’s community pharmacist and 32% with their general practitioner surgery. Conclusions An IMMS may be an effective method of reducing the rate of PMRR. Further work is needed to establish the cost-effectiveness of the service.

When less is more: the challenge of polypharmacy

We know that in the UK, up to 50% of medicines in England are not taken as intended, and this has been demonstrated in the US. Studies have shown that there is a clear relationship between medication adherence and improved outcomes, and a recent report suggests that up to £500 m could be potentially saved if adherence was improved in five key health categories. Over the past 10 years, a number of comprehensive reports have been published which describe the many factors that affect medication adherence. There have been many attempts to predict non-adherence in order to allow clinicians to effectively identify patients who need support with medication adherence. However, the findings are inconsistent with regard to demographic, socioeconomic and clinical factors. Pharmacists are experienced in managing practical problems that patients may have about medicines. The evidence base for a behavioural approach to medicines adherence is growing and while all the interventions differ in their approach, the four Es have been suggested as overarching principles which can be applied to many of the interventions. In the UK, the structured approach of the funded New Medicines Service provides guidance to community pharmacists on undertaking discussion with patients, and can be used with the four Es to support adherence.