Communicating

about Medicines

with People with

Cognitive

Impairment

Caroline Parker Consultant Mental Health Pharmacist

Communication with patients

What are your main reasons

for talking with patients?

Communication:

Pharmacists skills the evidence

Pharmacy literature didnt often distinguish communication from education (which often refers to compliance)

Why look at this skill?

Counselling > education

Were information providers/advisors

Transmitting information isnt sufficient to change behaviour

Communication:

Pharmacists skills

Consultation / counselling done in

conjunction with patient

Giving patients information about meds

Problems solving, includes:

Assessing patients understanding of regimen

Assessing appropriateness of medicine for patient

Tailoring regimen to that patient

Responding in a way that conveys you understand their

problems

Education may not be face-to-face or verbal

Need same interviewing skills as Drs & nurses Anderson-Harper 1992

Hargie et al. 2000

Objectives

1. To identify what constitutes effective

communication practice in pharmacy

2. To identify & categorise interpersonal skills that

constitute effective performance in pharmacy

15 community pharmacies

Videoed interactions (verbal & non-verbal)

20 consultations each (5 good & bad)

Self and peer ratings

Hargie et al. 2000 - results

1. Building rapport i) Preserving confidentiality

2. Explaining

3. Questioning

4. Listening

5. Non-verbal

6. Suggesting / advising

7. Opening

8. Closing

9. Assertiveness

10. Disclosing personal information

11. Persuading

1 & 2 50% of total skill usage

A wider repertoire of skills judged more effective

Morrow et al. 1993

5 community pharmacies

(self-selected subgroup of Hargie study)

Consultations videoed for 3 hours

Interactions timed, questions counted

Morrow et al. 1993 - results

Approx 10 consultations per pharmacist

Almost all (98%) questions were closed 60% were probes (36% extension)

69% (54-79%) yes / no type

27% (19-37%) identification

24% (11-45%) were leading

Pharmacists asked 4 qu. vs. pt 2.5.

Only 1 open question in 15 hours of tapes!

3 qu.(

Kippist et al. 2011

Community pharmacists response to complaints

of acute insomnia

Simulated scenarios, Australia

Good at pre-supply questions

(who is it for? & investigative qus)

Better at supply advice

(dose, timing, side effects)

Most communication was empathic

(82%, 54/66)

http://www.toothpaintest.com/wp-content/uploads/2010/06/dental-floss.jpg

Q What teaching / training have you had? Q Attended a lecture/talk? Q e-learning module? Q Informal feedback on your observed skills by peers? Q Face to face teaching day or course involving practice & feedback on your skills?

Q None

What were not going to cover

Communication:

The national standards

& expectations

CG76

Communication & Adherence

Trust in professionals.

CG138

CG138

QS15

CG136 CG136

Discuss - Your scenarios?

Q In what settings to you see people with cognitive impairments?

Q What are the more common diagnosis you see causing cognitive impairment?

Q What kind of cognitive impairments do you see?

Q What are you main communication challenges/concerns?

Dementia & cognitive function Memory loss - esp problems with recent memory, e.g.

forgetting information or instructions recently given

Decline in thinking speed and mental agility, e.g.

asking questions repetitively

Decline in ability to understand new information

Decline in language skills - difficulty finding the right

words

Poor judgement

May be apathetic or uninterested in usual activities

May find new things challenging or confusing

May find planning and organising difficult.

Depression & cognitive function

Poor concentration (short)

Lack of interest in things having no motivation

Worse recall (memory)

Speaking more slowly than usual

Find it difficult to make decisions

Continuous low mood or sadness, feeling hopeless

and helpless will affect expectation

Feeling (being) tearful

Poor sleep knock on effects

Parkinson's & cognitive function

Forgetful (difficulties retrieving info

Difficulty concentrating

Difficulty planning or sequencing tasks

Altered judgement

Slowed thoughts and ability to express them

Language difficulties (Word-finding, articulation, v&t)

Loosing train of thought

Difficulty when changing topics quickly

Difficulties in following conversations in large groups

Insomnia & cognitive function May lead to a difficulty in concentrating

Feeling tired and irritable during the day

Cause?

stress and anxiety

mental health conditions, such as depression and anxiety

Medication

Physical health issues

Psychosis & cognitive function

Poor concentration

Distracted by other symptoms, muddled thoughts

Capacity

What is capacity?

Mental Capacity

In order to give valid consent the person must have capacity

The ability to make a decision at the time it needs to be made (Mental Capacity Act 2005 Code of Practice)

A person who lacks capacity does not consent, even if they are co-operating

Principles Assumption of capacity Assist with decision-making (prior to assessment of

capacity) People can make unwise decisions (may be a reason to set aside assumption of capacity

and to test capacity

Best interests Least restrictive alternative (if person assessed as

lacking capacity)

Capacity

Who can test for capacity?

Who can should assess capacity?

The person most concerned with the decision in question

The assessment may be informed by somebody with a particular expertise i.e. mental health professional to determine mental health diagnosis (1st stage of test), pharmacy, psychology, speech and language therapy

Ultimate decision lies with the person most concerned with the particular decision

Second opinion in disputed cases

The Court of Protection for serious decisions where dispute is unresolved

Capacity

How do you test for capacity?

What is consent?

Inability to make decisions

Impairment or disturbance may be affecting ability to make a decision that needs to be made now

2nd Stage (The Functional Test) Understand

Retain

Use or weigh up information

Communicate decision

Inability to do any one suggests lack of capacity

The burden of proof lies with the assessor

Absolute certainty not required

Capacity examples

Providing treatment and care for mental disorder or physical conditions at home or in the community

Prescribing medication for mental disorder or physical condition

Administer such medication orally, or through other routes

Carry out diagnostic tests

Provide dental treatment

Make sexual health decisions around contraception

Assisting with all aspects of personal hygiene

Medicines Worsening Cognitive Functions

o Actively review all medicines

o Cholinergic burden

o Antidepressants avoid TCAs:

anticholinergic, sedating, hypotension, hyponatraemia

o Benzodiazepines - AVOID long acting

hangover effects, accumulation, confusion, falls

o Anticholinergics - AVOID where possible

Constipation, urinary retention, blurred vision

Confusion, worsening of symptoms

e.g. procyclidine, benzhexol, amitriptyline,

clorpromazine, oxybutinin

Tips & suggestions

Focus your message to your patient Adherence

Communication tips

Use concrete, short sentences

Ask only one question at a time

Use direct and literal speech, and enunciate clearly

Choose conversation topics the pt used to be interested in

Non-verbal - also use body language and facial gestures

Use a yes or no format where possible

Involve family & carers, re-enforce message through them

Repetition

Assess the patients capacity to understand your

communication otherwise it was pointless

Communication Tips

If verbal/auditory messages are not effective, use

other options, such as writing, gestures, or pictures,

to communicate

Memory aids such as picture notebooks and wallets can

help the patient function more independently and increase

communication

Compliance aids!

Diary charts

Alarm clocks on phones etc

Written / pictorial reminders etc

Listen

TTAs

Think about how you teach comms skills to others:

Skills training

Feedback on observed skills

Teach about capacity and how to assess

Thanks

& any questions?

http://studymaterials.healthmanagementventures.com/pdf/CognitiveImpairment

http://studymaterials.healthmanagementventures.com/pdf/CognitiveImpairment

Resources List

1. Communication Skills for Pharmacists: Building Relationships, Improving Patient Care, 3rd Edition By Bruce A. Berger ISBN: 978-1-58212-132-1 Publication Date: January 2009 Page Count: 240 pages http://www.pharmacist.com/AM/Template.cfm?Section=Home2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=19009

2. Communication Skills in Pharmacy Practice: A Practical Guide for Students and Practitioners (Paperback) William N Tindall, Robert S Beardsley, Carole Kimberlin, William N. Tindall 5th Edition. January 2007. http://www.amazon.com/Communication-Skills-Pharmacy-Practice-Practitioners/dp/0781765986/ref=reader_auth_dp#noop

3. The Effectiveness of Microtraining in Developing Pharmacists Communication Skills: A study of personality and attitudes Owen D. W. Hargie; Norman C. Morrow . Medical Teacher, Volume 11, Issue 2 1989 , pages 195 - 203

4. Lessons from medicine and nursing for pharmacist-patient communication. NT Landis. Am Jour of Health System Pharmacists, Vol. 53, June 1996, pages 1306-14.

5. Improving Communication Skills of Pharmacy Students Through Effective Precepting. Randy P. McDonough, PharmD, MS,a and Marialice S. Bennett. American Journal of Pharmaceutical Education 2006; 70 (3) Article 58.

6. ABC of palliative care: Communication with patients, families, and other professionals. Ann Faulkner. BMJ 1998;316;130-132

7. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. Wolf Langewitz, Martin Denz, Anne Keller, Alexander Kiss, Sigmund Rttimann, Brigitta Wssmer. BMJ 2002;325;682-683

8. Key communication skills and how to acquire them. Peter Maguire, Carolyn Pitceathly. BMJ 2002; 325: 697700

9. ABC of psychological medicine: The consultation. Linda Gask, Tim Usherwood. BMJ 2002; 324: 15679

10. BMJ e-Learning module: http://learning.bmj.com/learning/searchresult.html?moduleId=6057021&utm_campaign=7010634&utm_content=40861675092&utm_medium=email&utm_source=Emailvision

11.Communicating about risks to public health: Pointers to good practice. DoH. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4039670.pdf

12. Provision of information about drug side effects to patients. Berry D.C., Knapp P., Raynor D.K. Lancet 2002; 359: 853-854.

13. Patient adherence to pharmacotherapy: The importance of effective communication. DiMatteo, Robin; Chow, Moses S.S.. Formulary, Oct95, Vol. 30 Issue 10, p596, 7pages. http://web.ebscohost.com/ehost/detail?hid=12&sid=f200c49b1e734746ba02e3df4f05a599%40sessionmgr15&vid=4&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=heh&AN=9510271447

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