Medicines
Management
Issue no 6, p10-12
November/December
2002
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Medicines
Management |
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Features |
Face to face with elderly patients
The purpose of holding face-to-face structured medication reviews is to improve the pharmaceutical care of the over-75s who are prescribed four or more medicines, in line with the NSF for Older People. These are important when issues arise that are difficult to resolve from a paper review, such as: * queries patients may have about indications, side-effects, dosage etc * to identify and attempt to resolve compliance and concordance issues * to investigate other medicines, herbal or homeopathic remedies, vitamins, etc, that patients may also be taking I started by compiling a list of patients over the age of 75 taking four or more medicines on a practice list. Following a paper review and a talk with their GP, 12 patients were selected. These were taking a large number of medicines and tended to visit their GP frequently and, it was thought, would benefit from talking to a practice-based pharmacist. A letter was sent to them inviting them to attend a structured medication review with a pharmacist. An information sheet about the review was also included (Figure 1) as well as a questionnaire for them to complete. Patients were asked to bring in all their prescribed and OTC medicines. They were also invited to bring a friend or relative.
From the original group, eight were seen, two were spoken to on the 'phone as they could not get into the surgery, one died and one did not contact the surgery at all. The patients were each allocated 30 minutes and their paper notes were available and their computer record was on-screen throughout the consultation. Medication review questions The patients were asked about each drug in turn * How long have you been taking this? * Do you know its name and what it is for? * Do you know when and how to take it? (eg, with meals, at bedtime etc) * Is it in its original container — if not, why have you transferred it into something else? * Do you think you have any side effects from this medicine? They were also asked some general questions * Do you have any allergies? * Do you take any other medicines or remedies that you have bought or borrowed? * Do you take any vitamins, minerals, herbal medicines, homoeopathic remedies or "home remedies"? * If you do take anything else, who recommended them to you? * Do you have any problems opening your medicines? * Where do you store your medicines? * How do you dispose of your medicines? * Do you have any other health-related queries e.g. about diet and vitamins These questions were not necessarily asked in this rigid way, and depended on the particular patient and how much they wanted to say about each point. Sometimes it was rather difficult to get them back on track! As well as asking questions it was possible to check if their medicines were in date, if the labels were clear with specific directions and if there were any duplications. Results I have classified the issues identified under 10 different headings. 1. General housekeeping Old drugs still on the repeat form making it confusing and prone to errors Out of date drugs 2. Inappropriate doses 3. Inappropriate drugs 4. Lack of understanding There was some disillusionment about treatment — particularly pain-relief and some patients did not understand why they had to take their medicine at certain times, eg NSAIDs with food. 5. Side effects 6. OTC medicine use 7. Inappropriate use of OTC medicines and vitamins causing indigestion Using ibuprofen as well as a prescribed NSAID Taking multivitamins and cod liver oil leading to excess intake of vitamins A and D. 8. Testing overdue 9. Problems at the secondary/ primary care interface 10. Compliance issues The face-to-face reviews identified a number of medicines-related problems. Of particular interest was how many patients were buying OTC medicines to treat side effects of their prescription medicines or because they did not feel their prescription medicines were working properly. These are issues that do not usually come out in a six-minute appointment with a GP in which a patient usually just goes to discuss one problem. The medication review clinic gave them the opportunity to talk about the whole picture and not just focus on one issue. It was also helpful to have input from a friend or relative, often a daughter, who brought up queries that they had about medication-related issues. The patients benefited from having time spent counselling them about the appropriate use of their drugs and giving them a better understanding of what they should expect from their medicines. They were grateful for help about pain-control and for advice about the use of OTC medicines. They welcomed the review and would come again. Benefits all round It was beneficial to have the medication review clinic conducted by a practice-based pharmacist with experience in community pharmacy. This gave access to patient-notes, direct access to the GP and appointments could be made straight away if necessary. It also provided a good link between primary and secondary care and expert advice could be given on OTC medicines and vitamins. It would have been beneficial to do domiciliary visits to patients who were housebound, rather than speaking to them on the phone. The practice benefited by freeing up GPs time from their "problem" patients. Patients felt they had a thorough review and I hope issues were resolved before they became major, long-term problems. Sorting out housekeeping issues would result in time and cost-savings for the practice. However, the major benefit is improved patient care by a more pro-active approach. |
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