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Medication management in older people – a hidden burden

Ian Maidment

Ian Maidment

Dr Ian Maidment is a Reader in Clinical Pharmacy at Aston University

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Clair Huckerby

Clair Huckerby

Clair Huckerby is a Chief Pharmacist and Consultant in Primary Care Medicines Optimisation at Our Health Partnership

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David Shukla

David Shukla

Dr David Shukla is a GP Partner at Eve Hill Medical Practice and a Clinical Research Fellow at the University of Birmingham

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First published: 15 December 2020
Citations: 5

Abstract

The MEMORABLE study was designed to identify the real-world challenges associated with medication management in older people taking many different medicines. This article summarises the key findings of the study and discusses potential ways in which medication burden could be reduced.

Older people are the major users of medication. During the last few years, the numbers of older people taking many different medicines has rapidly increased. Over a recent 20-year period, the number of older people (aged 65 and over) taking five or more different medications has quadrupled from 12% to 49%, while the proportion of older people not taking any medication has dropped from about 1 in 5 to 1 in 13.1 Thus it appears that for older people, five is the ‘new normal’ in terms of medication.

Polypharmacy is often the result of managing patients with multimorbidity (defined as the presence of two or more chronic medical conditions in an individual).2 Approximately 65% of those aged 65 years or more and 82% of those aged 85 years or more have two or more chronic conditions.3 Practitioners face a challenge in managing several chronic conditions using clinical guidelines that predominantly focus on single disease, not always considering the presence of any co-morbidity. Potentially, a hypothetical 78-year-old woman with past medical history of myocardial infarction, type 2 diabetes, osteoarthritis, chronic obstructive pulmonary disease and depression could be the subject of five UK clinical guidelines, and take a minimum of 11 prescribed medications, increasing to 21 medications as her various diseases progress.4

Problems associated with polypharmacy

While there will often be good reasons for polypharmacy, there are many problems associated with it, particularly in older people. Adherence to medication is more likely to be problematic.5 Older people are more susceptible to both medication-related side-effects and medication errors; medication-related adverse events cause or contribute to over 2400 deaths per year.6, 7 Between 5% and 8% of all unplanned hospital admissions are due to medication issues.8, 9 This rises to 17% in people over the age of 65 years.8 Over 70% of adverse medication reactions are believed to be avoidable.8, 9 Medication-related adverse events have been calculated to cost the NHS £750 million every year.10

Many medications have anticholinergic activity, which can cause confusion and worsen the symptoms of dementia.11 High-risk drugs such as digoxin, warfarin and lithium have the additional ‘burden’ of regular monitoring; this is dependent on the GP surgery having a robust system in place to ensure monitoring is done, and upon patients being able to get their monitoring done when required. This is particularly challenging during the COVID pandemic when social contacts should be minimised.

The MEMORABLE study

The MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation (MEMORABLE) study was funded by the National Institute for Health Research (NIHR), the research arm of the NHS.12, 13

It used a novel and innovative research technique, called realism, to understand the challenges associated with medication management for older people living in the community, taking many different medications, and their family carers. From this, the framework for interventions to address some of the identified challenges was developed. Realism is a theory-driven approach used to understand complexity; it aims to understand how context – the wider environment around the older person – influences outcomes. Realism was chosen because it enabled the research team to work with complex situations and understand how medication management works in the real world.

MEMORABLE involved reviewing the relevant literature from across the world, including the ‘grey’ literature, and interviewing older people, family carers and health and care practitioners (n=50). Data from the literature and interviews were combined to explain how medications are effectively managed, or not, and to identify ways medication management could be improved.

MEMORABLE found that medication management could be explained as a five-stage process:
  • Stage 1: identifying a problem
  • Stage 2: getting a diagnosis and/or medications
  • Stage 3: starting, changing or stopping medications
  • Stage 4: continuing to take medications
  • Stage 5: reviewing/reconciling medications.

Stages 1, 3 and 4 are individual stages, when the older person, sometimes with support from a family carer, balances routines, coping and risk. Stages 2 and 5 are interpersonal stages, when the older person (again sometimes with family carer support), works with a clinician, usually a GP, nurse or pharmacist, to optimise medication.

MEMORABLE found that older people and clinicians may want different outcomes from medication. Older people have clear goals about what they want from treatment, which may be different from practitioner priorities. Things that motivate older people and influence their decisions include feeling well (or avoiding getting worse), fitting managing medications with their day-to-day lives, and if possible taking fewer or no pills. Whereas policy makers, service providers and practitioners may focus on process goals such as ‘adherence’ or ‘optimisation’.

Underpinning older people's views is the need to reduce the burden associated with medication (see Box 1). MEMORABLE found that this burden was often hidden from clinicians, with older people and their family carers struggling often with little or no support. Also, the ability to cope with burden and the total burden of the medication fluctuated over time. The ability to cope decreased if the older person suffered any cognitive impairment. The total burden increased with the complexity of the medication and with increasing polypharmacy. Older people develop complex ways to fit their medication into their day-to-day lives, and therefore any change in the medication regimen could disrupt these established routines and increase burden.

Box 1. Examples of medication burden and possible solutions (based on examples encountered in clinical practice)

Case 1

Mr Smith is on a complex regimen of medication including bendroflumethiazide prescribed 2.5mg once daily. He suffers from moderately severe dementia and his wife manages his medication for him. His wife reports that he is up “half the night” and this means that she can't sleep and feels at the “end of her tether”.

During a medication review, a clinician identifies that Mrs Smith is giving her husband the diuretic in the evening, hence the disrupted night. It was changed to the morning and Mr Smith was much less disturbed at night.

Case 2

Mrs Patel is 82 years old and lives in a care home. She is generally well and very sociable; she really looks forward to the numerous day trips organised by the care home. She has recently developed a mild chest infection and has been prescribed amoxicillin 500mg three times daily. Because the care home staff are responsible for the medication, and are concerned about it being misplaced, their policy is that medication for residents cannot be removed from the premises. Thus, Mrs Patel is denied doing something that she really enjoys.

This is based on similar cases and illustrates the potential impact of medication burden on quality of life. In this and similar cases, three times daily dosing should be avoided, if possible.

Older people valued consistency and getting to know their GP, pharmacist and other clinicians. However, providing consistency was increasingly challenging in an increasingly fragmented health service. Older people have complex social needs. Thus, a holistic approach to care is critical, with health and social care working together to provide the appropriate care.14 Patient-centred care is key to holistic care. Ways to promote patient-centred care and encourage shared decision making include asking patients at the outset of a consultation “what is bothering you most?” or “what would you like to focus on today?” Both can help prioritise the aspects of care that will have the most impact on patients.

Impact of COVID-19

MEMORABLE was conducted before the current pandemic. However, many of the findings are relevant to the current crisis. Older people and their family carers may struggle to access appropriate support during the current pandemic, increasing the burden associated with medication. With self-isolation, older people may avoid seeking help from GPs and pharmacies. Furthermore, supporting older people with their medication may be a lower priority for clinicians due to healthcare pressures associated with COVID-19.

Informal support, in addition to formal support, may be more difficult to access. Older people often rely on a network of friends and family to support them with their medication. Members of this network carry out diverse and key roles, including liaising with GP surgeries and community pharmacies, collecting prescriptions and medication, supporting and monitoring adherence to medication, and detecting side-effects. Thus, the pandemic could increase both the burden (by decreasing the support available for practical aspects of medication management) and the risks associated with medication.

Is deprescribing the solution?

One of the themes that emerged from MEMORABLE was the potential for deprescribing to reduce the burden associated with medication. It costs nearly $1 billion to bring a drug to market. Medicine non-adherence is estimated to be around 50%; therefore, half of that investment could be considered wasted. Deprescribing is increasingly discussed in both clinical and academic circles; in lay terms, it could be described as ‘on trend’.

Deprescribing is the cessation of drugs that are not (or no longer) indicated or are causing side-effects. Deprescribing is seen as ‘good’ whereas non-adherence is viewed as ‘bad’. But isn't non- adherence simply ‘patient-led deprescribing’?

Deprescribing does have a key role, but it shouldn't be imposed on patients. Unless it is properly explained, older people may view deprescribing in terms of cost saving and that services are almost ‘giving up’ on them, although such fears may be exaggerated.15, 16 Deprescribing should be an element that is covered in every structured medication review, and whatever possible should either be patient led or the patient needs to be actively involved in the decision. Deprescribing is increasingly being included in clinical guidelines and clinical care, but further research is needed to determine the long-term effects of medication reduction, particularly in older more frail patients with multimorbidity.17

There are also major challenges in generating the evidence that shows that deprescribing works. Policy makers need to focus on evidence beyond randomised controlled trials (RCTs). Such trials are costly; much of the $1 billion cost of drug development is spent on trials, and they take many years to conduct. There is also an imbalance of investment; deprescribing RCTs are run on limited budgets compared to prescribed drug RCTs.

Finally, deprescribing trials tend to be conducted by expert clinicians and academics based in world-leading centres. Any deprescribing intervention needs to equally work in the ‘back of beyond’ on a busy, wet, dark, dank Friday afternoon in the middle of January.

The way ahead

The problem of polypharmacy and related issues is a long-standing one and will require a co-ordinated response at clinician, policy and research levels. The key implication for clinicians from MEMORABLE is that older people and their family carers frequently find medication management stressful and a burden (see Box 2 for more details).

Box 2. Key messages for clinicians
  • Older people and their family carers often find managing their medication stressful and a burden
  • This burden is often hidden from clinicians, who may not be aware of it
  • Clinicians and all health and social care practitioners should proactively ask older people and their family carers if they are coping with their medication
  • Prescribers often think about side-effects when a new medication is started, or if a dose is changed; they should equally think about the burden when an older person's medication regimen is changed. Does the change increase the medication management burden? Can the older person cope with the new regimen?
  • The burden associated with medication may be particularly acute during the current pandemic

Care needs to be flexible, and a strict guideline approach to treatment pathways may be less applicable in older people where ‘time to benefit’ (see Box 3) is a key consideration.18

Box 3. What is ‘time to benefit’?
Many long-term preventative medications, such as statins, take many years to show any benefit in terms of improving life expectancy. Therefore, in older people the risk versus benefit equation may shift, with the risks increasing – older people are more susceptible to side-effects and errors – with less potential benefit.

Policy makers need to consider the impact of burden related to medication management and place greater emphasis on things relevant to older people. Researchers need to develop interventions that will work in the real world, not just the ‘ivory towers’ of elite academia, and research policy makers need to allow sufficient time and funding for academics to develop effective complex interventions. Without this co-ordinated response, in 20 or more years’ time, older people will still be struggling with their medication.

Declaration of interests

Dr Maidment led the NIHR-funded MEMORABLE study. His research interests include medication optimisation and the role of pharmacy. He regularly tweets about these areas, including his research. His Twitter ID is: @maidment_dr

Funding

MEMORABLE was funded by the HS&DR Programme (project number 15/137/01) and the full report is available in NIHR Journals Library. It presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care. The views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care.