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Medication Management in Dementia: Key priorities Ian Maidment, Senior Lecturer in Clinical Pharmacy.

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Presentation on theme: "Medication Management in Dementia: Key priorities Ian Maidment, Senior Lecturer in Clinical Pharmacy."— Presentation transcript:

1 Medication Management in Dementia: Key priorities Ian 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 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%

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). Name / class medicine N Lorazepam4 Anti-psychotics1 Zopiclone1 Anti-depressant2 Non-pyschotropics3

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 MedicineN Anti-psychotics50 Anti-depressants24 ACHIs15 Zopiclone10 Benzo’s7 Others53 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 (accessed 24 th 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 (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.

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 (accessed 25 th 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 (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

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