1. Emma Anderson CPPE tutor
Supporting patients to make the most of their medicines - Taster session
Emma Anderson CPPE tutor
Hello my name is Emma Anderson and I am a CPPT tutor here in the EM and a community pharmacist, where I undertake a regular Saturday morning in Rushcliffe
This taster session is taken from the CPPE Supporting patients. To make the most of their medicines e-learning programme
We will be focusing on section 2 which is about monitored dosage systems and alternatives to this.

2. Welcome and housekeeping
Switch phones and other digital equipment to silent;
Facilities
Fire escapes/fire drill
Temperature check of room, and check everyone can hear. Please move if hot/cold and tell us if you can’t see or hear.

3. Learning objectives – whole programme
Identify how patient’s experience of living with a health condition can affect the way they take their medicines
Summarise the tools that can be used to optimise medicines
Describe the compliance aids and supportive strategies that can help patients to make the most of their medicines
Apply some of the best-practice examples currently used by pharmacy technicians working in medicines support to develop your own role and work place
Apply the principles of medicines optimisation to enable patients to make the most of their medicines
The aim is that we will look at section two of the learning together, this focuses on learning objectives 2 and 3, the intention is that you then work through the other sections of the e-learning after the session so that you can achieve the other learning objectives listed on the screen.

4. Reflective discussion questions
Turn to the person next to you and discuss the following questions
Activity 1:
Before we start to focus your attention on this topic area, turn to the person next to you and discuss the following reflect questions about your current practice and knowledge base.

5. Taking a patient centred approach
Before we go on to look at support options, I think that it is important to consider the patient’s perspective. This image is taken from section 1 of the e-learning. There is which contains more detail, but the key thing is to take time to have a discussion with the patient before deciding on what support is appropriate. With this you cannot get the patient’s perspective or consent.
Taking the time to do this up front and to get things right will reduce the time that you need to spend on issues down the line if inappropriate decisions are made.
Note, under the Equality act, you are only required to make adjustments to support the patient’s need, so adjustments must be in the patient’s best interest [not carer’s or any other parties.]
Importance of seeking consent from the patient [unless someone else has power of attorney]

6. Barriers A patient may be taking an overly complicated regimen
Become confused if they are supplied with a different generic medicine to their usual product
Perceive a stigma attached to taking their medicines
Have another concern about their medicines
When patients have difficulty taking their medicines independently it is important to establish barriers and possible solutions. It could be that you decide to do this within the context of an MUR. If any of the barriers above apply then a compliance aid may not be the answer.
If a patient is intentionally not adhering to treatment then they are unlikely to take it regardless of any reminder tick charts, aids etc. that you provide.

7. Simplifying regimens
There are a number of tools available, although it might be harder to use these in a community pharmacy without the patients notes, you could make recommendations for someone in their GP surgery, who can access the patients full notes to consider, perhaps their doctor or you could involve their practice pharmacist.
There are a number of tools on the screen, I am just going to look at two of these with you and will leave you to consider the others at home. On the next slide we will talk about STOPP/START tools and then go onto ACB, which is anticholinergic burden.

8. STOPP/START tool
There are a number of these tools in circulation. I have given you the reference to a 2017 NHSE version. There are other local ones. It is important that you choose a version that is current. Also some version use a lot of colour coding and are less good if you only have a black and white printer.

9. Anticholinergic burden
Medicines that cause anticholinergic side effects are wide ranging…hence the very small print size on the screen
The extent to the drug causes anticholinergic effects is allocated between 1 and 3 points
The points of all of the patients medicines that cause anticholinergic effects are added to give a total score
In one study of those aged 65 years and over, twenty per cent of participants taking drugs with a total ACB of four or more had died by the end of the two-year study, compared with only seven per cent of those taking no anticholinergic drugs - the first time a link between anticholinergics and mortality has been shown.
For a copy of this chart see

10. Compliance aids
There are a wide range of aids, including those for physical, sensory and cognitive disabilites. We will look at each of these in turn.
This encompasses everything that you might supply to a client to help them take their medicine for example easy open top, reminder chart not just and MDS box.

11. Physical disabilities
Child resistant tops
Blister packs
Tablet crushers and cutters
Liquid medicines
Devices for tubes, eye drops and inhalers
Devices for stockings
People may struggle with grip, strength, co-ordination, pressure application, tremor and dexterity.
Child resistant tops:
The pharmacy is required to provide CRCs by law unless the patient tells us that they do not want these. Therefore you need to record that you have had this conversation.
Larger bottles are easier to open
Blister packs (by this I mean the blister pack that the tablets come in not a multidose compliance aid):
Some people find it hard to remove tablets from the blister pack
The simplest solution is using the end of a teaspoon to break through the foil and drop the tablet into the hand
Note if the patient cannot remove tablets from a blister pack, they are very likely to have issues removing tablets from a “blister pack” multidose compliance aid!
There are commercial devices available
Remind patient to store the medicine the container that it came in so that it can be easily identified
Tablet crushers and cutters
These are available commercially, cutters could give patients the independence to cut tablets themselves and allow the medicine to be stored in the original packaging.
Don’t cut or crush if there is a protective coating! Check the SPC
Liquids and orodispersible tablets might be a better solution
Liquid medicines are hard to pour if you have a tremour
Oral syringe does allow them to remove medicines without spills
Consider smaller bottles if larger bottles are too heavy to handle
If a patient lacks manual dexterity it may be hard for them to remove creams, ointments and gels from tubes and to use eye drops and inhalers
Some products in tubes come with a tube squeezer for example Ibugel
Eye drops
There are a number of products on the market to support people who struggle to use eye drops.
I want to draw your attention to two products that are available on prescription [Pictured]. Firstly, Opticare eye drop dispenser is for people who have a tremor, fear of drops in their eyes or difficulty squeezing the bottle
Secondly the Opticare athro is designed for people with poor hand mobility, very little grip or difficulty lifting their hands to their eyes
Inhalers can be difficult for people who struggle with manual dexterity.
Haleraids [pictured] can be used to support patients to use a metered dose inhaler. But they are not allowed on an FP10 – that said they are inexpensive
It is worth contacting the manufacturers to see what they recommend – for example symbicort provide grips
Spacers help with coordination problems
Alternatively you may wish to consider Easi-breath devices that do not require coordination and may require less hand strength or different hand movements
[CB am I allowed to say] check your local formulary for asthma and COPD they will often highlight devices that are easier to use with poor manual dexterity or hand strength. For example Notts CC recommend Elipta devices may be easier for these patients to use. [CB raising profile of local prescribing guidance is a key LPN aim]
Stockings are hard put on even for people with good dexterity.
The actiGlide device (pictured) is available on prescription.
There is another product for use with OT stockings, The Scholl fitting Socklet available from Scholl’s customer relations department

12. Sensory disabilities – visual
May have impaired vision or no vision
RNIB Arial 14 + black font on yellow background
Could use system of coloured dots or stickers and a key
Large print labels with flags
Different manufacturers packaging
Did you know that patient’s can request their PIL in alternative formats from the RNIB? Telephone
As a general guidance the Royal National Institute for the blind recommend Arial font 14 size or bigger, in black on a yellow background
Some pharmacy professionals use a system of coloured dots or stickers and a separate sheet of large print information with a key
Pragmatically large print labels and flagging may be able to be prepared there and then – whereas other adjustments might need more planning.
Different manufacturers packaging can be an issue. It may be unavoidable, it would be helpful to discuss changes with the patient
Patients can phone the RNIB for patient information leaflets in alternative formats, for example Braille, audio CD and large font

13. Auditory disabilities
This may require adjustments to be made when explaining how to take medicines. Visual aids might be helpful. Ask the patient what would helpful them.

14. Cognitive disabilities
Forget to take medicines
Reminder charts
Often in life people “forget” to do things this could be due to confusion or due to other reasons. For example I forget to organise my asthma check, not because I am not capable of doing this but because it is a lower priority than other activities. Discuss with the people on your table reasons why patients may tell “forget” to take their medicines.
Perhaps the most commonly cited reason for people not taking their medicines is that they simply forget
Reminder charts are a simple solution
Reminder charts should contain: patient details, for example name and address, name of medicine, what it looks like, why taking it, when to take it and the dose to take, GP contact details, pharmacy contact details and other contacts available to the patient if they become confused.
Community pharmacy South Central has a number of templates that you could use.
Mencap also have a number of reminder charts with pictures

15. Other strategies to support memory
Simplify regimen
Situational triggers
Reminder alarms
Diary chart or tick sheet
Verbal prompts
Support from carers
Formal reminder services
Apps for example Pill Manager
“What would you find most helpful?”
Situational triggers for example if a medicine is to be taken twice a day keep it next to your toothbrush
Verbal prompts from family etc.

16. Cognitive disabilities confusion
“Only when all other possibilities have been explored should a compliance box be used”
Patients using MDS may loose ability to identify their tablets, recall their regimens and the purpose of their medicines
Many patients prefer standard containers and appropriate support
RPS Improving patient outcomes - The better use of multi-compartment compliance aids
Reference to bullet point 1: Nummey J, How are multi-compartment compliance aids used in primary care? The Pharmaceutical Journal 2001; 266: Pharmaceutical Journal 2001; 266:
Royal Pharmaceutical society Improving patient outcomes - The better use of multi-compartment compliance aids, 2013 details the patient safety risks associated with the use of MDS systems and that the use of MDS is outside of the product license [CB added point] This document may be useful in discussions with GPs and other healthcare professionals who may request that you supply and aid without you carrying out an assessment.

17. What medicines should not be put in an MDS?
Moisture-sensitive medicines
Light-sensitive medicines eg, chlorpromazine.
Medicines that may be harmful when handled eg, methotrexate
Medicines that should only be dispensed in a glass bottle e.g glyceryl trinitrate.
Medicines that should only be taken when required eg. Analgesics and laxatives
Medicines which vary according to test results for example warfarin
Specialist pharmacy services use of medicines in compliance aids
Moisture-sensitive medicines eg, effervescent tables, soluble tablets, buccal and mucosal tablets, Blistered packs or boxes containing drying agents usually indicate the relative instability of the drug when exposed to moisture.
Use Specialist pharmacy services use of medicines in compliance aids for further detail

18. Activity – putting it all together
Work on your table to create a checklist or tool kit for assessing patients who may require additional support to take their medicines as intended. Present your ideas to the group using a flipchart

19. Learning objectives – whole programme
Identify how patient’s experience of living with a health condition can affect the way they take their medicines
Summarise the tools that can be used to optimise medicines
Describe the compliance aids and supportive strategies that can help patients to make the most of their medicines
Apply some of the best-practice examples currently used by pharmacy technicians working in medicines support to develop your own role and work place
Apply the principles of medicines optimisation to enable patients to make the most of their medicines
The aim is that we will look at section two of the learning together, this focuses on learning objectives 2 and 3, the intention is that you then work through the other sections of the e-learning after the session so that you can achieve the other learning objectives listed on the screen.
To some extent we have also covered objective 5 in creating a checklist or tool kit to support you to assess patients who may need additional support to take their medicines.

20. www.cppe.ac.uk info@cppe.ac.uk 0161 778 4000
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