Medication Management Medication Management in Dementia: in Dementia: Key prioritiesKey priorities

Ian Maidment, Ian Maidment, Senior Lecturer in Clinical PharmacySenior 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

• Long-term clinical & research interest medication safety Older People – successful publication

• Anti-psychotics in dementia

– Pharmacist-led medication reviews in Care Homes

• Wider medication management issues

– Exploratory stage

– Qualitative data – the carer perspective

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

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

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

Anti-psychotic • Limit use approved indications

Appropriate Indications

1. Schizophrenia, psychoses, delusional disorders

2. Dementia / delirium hallucinations, continuous crying, yelling, screaming functional impairment or behaviour danger patient / others / interfering care.

Inappropriate Indications

1. Undefined aggression/agitation

2. Agitation or wandering not danger others / individual

3. Uncooperativeness, unsociability, poor self-care, restlessness, nervousness or anxiety

4. Depression, indifference, insomnia, impaired memory

• Reduced antipsychotic use 28 & 36% (NLTCORC, 2011; Furniss, 2002).

• Reduced physical re-strain by 40%

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).

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.

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.

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).

Name / class medicine

N

Lorazepam 4

Anti-psychotics 1

Zopiclone 1

Anti-depressant 2

Non-pyschotropics 3

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.

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

Medication Stopped / to be Reviewed

Medicine N

Anti-psychotics 50

Anti-depressants 24

ACHIs 15

Zopiclone 10

Benzo’s 7

Others 53

• 86 residents

• 162 medicines identified for review or discontinuation

• On average 1.88 medicines per resident

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

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)

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.

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%).

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

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).

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

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

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.

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.

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

• 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

• 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

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.

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

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).

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).”

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

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 Aging 25: 1033-1047. 

• Cotrell V, Wild K, Bader T. 2006. Medication management and adherence among cognitively impaired older adults. J Gerontol Soc Work 47: 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 Pract 3: 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 Gerontol 45: 89-96.

• 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 Community 11: 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