Polypharmacy

A CPPE distance learning programme

DLP 177January 2016

PolypharmacyA CPPE distance learning programme

Educational solutions for the NHS pharmacy workforce

© Copyright controller HMSO 2016

Acknowledgements

Lead writer

Julia Blagburn, senior lead clinical pharmacist, Newcastle upon Tyne HospitalsNHS Foundation Trust and visiting Fellow, School of Medicine, Pharmacy andHealth, Durham University

CPPE programme developer

Layla Fattah, lead pharmacist, learning development, CPPE

Project team

Victoria Allum, regional co-ordinator North Wales, WCPPE

Emma Anderson, tutor, CPPE

Nina Barnett, consultant pharmacist, care of older people, London North WestHealthcare Trust

Gemma Battrum, care home support pharmacist, Greenwich CCG

Laraine Clark, tutor, CPPE

Karen Daniels, community pharmacist and LPC

Olivier Gaillemin, consultant in acute medicine, Salford Royal NHS Trust

Lelly Oboh, consultant pharmacist, care of older people

Louise Picton, senior advisor, medicines advice, NICE

Rachel Rose, tutor, CPPE

Katie Smith, director, East Anglia medicines information service, Ipswich Hospital

Natasha Ubhoo, locum pharmacist

Nigel Westwood, patient representative

Steve Williams, consultant pharmacist, medicine and medication safety, UniversityHospital South Manchester

Reviewers

Nina Barnett, consultant pharmacist, care of older people

Liz Butterfield, project lead, KSS Polypharmacy Project and national steeringgroup for medicines optimisation, RPS

Emyr Jones, Macmillan palliative care pharmacist, WCPPE

Louise Picton, senior advisor, medicines advice, NICE

Steve Williams, consultant pharmacist, medicine and medication safety

CPPE reviewers

Sarah Ridgway-Green, regional manager, South East Coast

Clare Smith, senior pharmacist, learning development

Karen Wragg, regional manager, South Central

Editor

Terri Lucas, editor, CPPE

Production

Design and artwork by Miles Wilson Design.

Published in January 2016 by the Centre for Pharmacy Postgraduate Education,Manchester Pharmacy School, The University of Manchester, Oxford Road,Manchester M13 9PT. www.cppe.ac.uk

Printed on FSC® certified paper stocks using vegetable-based inks.ii

Polypharmacy

Contents

About CPPE distance learning programmes v

About this learning programme vii

Glossary of key terms ix

Section 1 The problem with polypharmacy 11.1 Introduction to polypharmacy 1

1.2 Why is polypharmacy important? 1

1.3 Who is affected? 2

1.4 Causes of polypharmacy 3

Lack of shared decision-making 3

Multimorbidity 4

Transfer of care 4

Reflex prescribing 4

1.5 What is the impact of polypharmacy? 7

Individual burden 7

Hospital admissions 8

Adverse drug events 9

Falls 10

Summary and intended outcomes 11

Suggested answers 11

Case studies 7, 8

Exercise 6

Practice points 3, 8, 10

Reflective questions 3

Section 2 Optimising medicines in polypharmacy 14 2.1 A patient-centred approach to medicines optimisation 14

2.2 Identifying people with polypharmacy for review 15

2.3 Medication review tools 16

STOPP START toolkit 17

Medication Appropriateness Index 17

Summary and intended outcomes 19

Suggested answer 19

Exercise 18

Reflective questions 16

Contents

iii

Section 3 Patient-centred approach to managing 20polypharmacy3.1 Following a patient-centred approach to managing 20

polypharmacy in practice

Is the condition self-limiting? 24

Stop or reduce the dose 25

Start a new medicine 26

Summary and intended outcomes 28

Practice points 20, 22, 23, 26, 28

Section 4 Stopping medicines and supporting 29patients4.1 Factors and barriers to deprescribing 29

4.2 Shared decision-making to support deprescribing 31

Framing effect 32

4.3 Adherence strategies 32

John Whitmore’s GROW coaching model 33

How do I get a copy of My Medication Passport? 33

Summary and intended outcomes 34

Suggested answer 34

Exercise 30

Practice points 32, 33

Section 5 Polypharmacy in different settings 355.1 Community pharmacy 35

5.2 Secondary care pharmacy 36

5.3 Primary care/general practice pharmacy 36

Summary and intended outcome 37

Practice points 36, 37

Practice development resources 38

References 39

Index 42

Figures and tablesFigure 1 Polypharmacy facts and figures 2

Figure 2 Example of a prescribing cascade 5

Figure 3 Example of a prescribing vortex 5

Figure 4 Medicines associated with adverse drug reactions 9

Figure 5 Patient-centred approach to managing 21polypharmacy in practice

Table 1 Barriers to deprescribing 30

iv

Polypharmacy

About CPPE distance learningprogrammes

About CPPEThe Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range oflearning opportunities in a variety of formats for pharmacy professionals from allsectors of practice. We are funded by Health Education England to offer continuingprofessional development for all pharmacists and pharmacy technicians providingNHS services in England. For further information about our learning portfolio,visit: www.cppe.ac.uk

We recognise that people have different levels of knowledge and not every CPPEprogramme is suitable for every pharmacist or pharmacy technician. We havecreated three categories of learning to cater for these differing needs:

Core learning (limited expectation of prior knowledge)

Application of knowledge (assumes prior learning)

Supporting specialties (CPPE may not be the provider and willdirect you to other appropriate learning providers).

This is a learning programme.

Continuing professional developmentYou can use this workshop programme to support your continuing professionaldevelopment (CPD). Consider what your learning needs are in this area. You canrecord your CPD online by visiting: www.uptodate.org.uk or use the CPDrecord sheets to plan and record the actions you have taken.

Activities

Exercises

We include exercises throughout this programme as a form of self-assessment. Usethem to test your knowledge and understanding of key learning points.

Practice points

Practice points are an opportunity for you to consider your practical approach tothe effective care of patients or the provision of a service. They are discreteactivities designed to help you to identify good practice, to think through the stepsrequired to implement new practice, and to consider the specific needs of yourlocal population.

We have designed the practice points in this programme to help you and yourteam to make links between the learning and your daily practice and to co-ordinatewith other healthcare professionals.

1 2 3

1

2

3

1

About C

PPE distance learning programmes

v

Case studies

We base case studies on actual or simulated events. They are included to help youto interpret protocols, deal with uncertainties and weigh up the balance ofjudgments needed to arrive at a conclusion. We design the case studies to prepareyou for similar or related cases that you may face in your own practice.

Reflective questions

We have included reflective questions in this programme to give you anopportunity to reflect on what you already know, or on what you have read so far,to reinforce and extend your learning. Thinking about these questions will helpyou to meet the objectives of the programme.

Assessment

As part of your learning for this programme, you may wish to undertake e-challenge number 106, launched on the 23 March 2016. To access this e-challenge after this date go to: www.cppe.ac.uk/e-challenge/archive

References and further readingYou can find references for all the books, articles, reports and websites mentionedin the text, together with a list of further reading to support your learning at theend of the programme. References are indicated in the text by a superscriptnumber (like this3).

Terminology used in this programme To aid your learning we have compiled a glossary of terms you may not be familiarwith (it is assumed that you are familiar with terms routinely used withinpharmacy). CPPE uses the nomenclature structure used in the British NationalFormulary.

Programme guardiansCPPE has a quality assurance process called programme guardians. A programmeguardian is a recognised expert in an area relevant to the content of a learningprogramme who reviews the programme every six to eight months. Following theregular programme guardian review we develop an update to inform you of anynecessary corrections, additions, deletions or further supporting materials. Werecommend that you check you have the most recent update if you are using aprogramme more than six months after its initial publication date.

External websitesCPPE is not responsible for the content of any non-CPPE websites mentioned inthis programme or for the accuracy of any information to be found there.

DisclaimerWe have developed this learning programme to support your practice in this topicarea. We recommend that you use it in combination with other establishedreference sources. If you are using it significantly after the date of initialpublication, then you should refer to current published evidence. CPPE does notaccept responsibility for any errors or omissions.

FeedbackWe hope you find this learning programme useful for your practice. Please help usto assess its value and effectiveness by emailing us at: feedback@cppe.ac.ukvi

Polypharmacy

About this learning programme

Welcome to this CPPE distance learning programme on polypharmacy. Thislearning programme has been designed to provide you with an overview of the keyissues relating to polypharmacy. There is no single cause of polypharmacy, and nosingle solution to supporting people on multiple medicines, so in this distancelearning programme we aim to provide an overview of the issues and thecontribution that the pharmacy team can make to managing and preventingpolypharmacy.

This programme takes a patient-centred approach to polypharmacy. Workingthrough this programme will not only increase your confidence in your knowledgeof polypharmacy but also in applying patient-centred practice when supportingpatients taking multiple medicines

The study time will depend on you, but we estimate that the reading and activitieswill take a total of four hours.

Target audienceThis programme is intended for pharmacists and pharmacy technicians working inany area of practice and we have highlighted a few specific examples below.

Community pharmacy team members are well placed to identify people whomay be suffering adverse effects or struggling with the burden of taking manymedicines.

Hospital pharmacists and pharmacy technicians can ensure medicinesoptimisation for people in hospital who may have been admitted secondary topolypharmacy.

Pharmacy professionals working in primary care can take opportunities toundertake medication reviews and audits to support patients taking multiplemedicines, including on discharge from hospital.

Working through this programmeThe programme is divided into five sections. Depending on your own level ofknowledge or interest, you do not need to work through each section, or in theorder provided.

We have selected and presented information and exercises which we think will beof interest to you whichever sector of pharmacy you work in. You have a key rolein helping people get the most from their medicines. There are many resourcesavailable to support you with this, whether you are discussing polypharmacy issueswith patients or other health and social care professionals. In this distance learningprogramme we signpost you to those and other resources that you can use todevelop your knowledge, understanding and practice skills in this field.

We have designed the programme for self-study, but as you progress through thesections you will find it useful to talk through some of the issues with your teammembers and colleagues.

We also recommend that you engage with local patient groups. We worked closelywith patient representatives throughout the development of this learningprogramme. Why not get in touch with patient or carer groups in your area?

About this learning program

me

vii

Aim

This programme aims to help you to develop your knowledge and skills to improveyour confidence and competence in working with patients and other health andsocial care professionals to enable patients to get the best possible outcomes whenthey are taking multiple medicines.

Learning objectives

You can use our programmes to support you in building the evidence that youneed for the different competency frameworks that apply across your career.These will include building evidence for your Foundation pharmacy framework(FPF) and supporting your progression through the membership stages of theRoyal Pharmaceutical Society (RPS) Faculty.

As you work through the programme consider which competencies you aremeeting and the level at which you meet these. What extra steps could you take toextend your learning in these key areas?

After completing this distance learning programme, you should be able to:

� explain the terminology associated with polypharmacy and what it means forpatients and the health and social care team

� list the causes and consequences of polypharmacy in relation to the patient,their carer and the wider NHS

� identify medicines that cause problems for patients with polypharmacy andtriggers that may indicate that polypharmacy is problematic

� explain the main considerations when stopping a patient’s medicines, whatbarriers might exist and how to overcome these

� describe how you could use decision-making tools and strategies to supportyour practice when consulting with patients on multiple medicines

� explain how you could undertake patient-centred discussions aboutpolypharmacy with patients during a medication review or medicines use review

� work in partnership with the patient to prioritise interventions and agree referralstrategies

� identify and apply suitable resources and tools to support you in identifyingpolypharmacy issues and solutions as part of your clinical judgement andexperience

� describe the process of shared decision-making and recognise its value insupporting adherence in patients taking multiple medicines

� identify a change you could make to your practice to improve your approach tomanaging polypharmacy.

A note about web links

Where we think it will be helpful we have provided web links to take you directly toan article or specific part of a website. However, we are aware that web links canchange. If you have difficulty accessing any web links we provide, please go to theorganisation’s home page or your preferred internet search engine and useappropriate key words to search for the relevant item.

All the web links in this programme were accessed on 6 January 2016.

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Polypharmacy

Glossary of key terms

Before we start learning about polypharmacy, here are some definitions of theterminology commonly used in relation to polypharmacy. We have not used all ofthese terms in this programme, but we hope including them here will help you tounderstand what is meant when these terms are used by colleagues in practice.

Polypharmacy

The use of many medicines together (often more than four or five medicines), or amedicine not matching a diagnosis. In this learning programme we will use thesimple definition use of multiple medicines by an individual.

Appropriate polypharmacy

Multiple medicines, all of which are clinically indicated and accepted by theindividual as improving their wellbeing and achieving the health outcomes that areimportant to them.

Some medical conditions are best treated with multiple medicines, for example,congestive heart failure, HIV infection or diabetes.

Also see problematic polypharmacy below.

Deprescribing

The process of stopping or reducing medicines with the aim of eliminatingproblematic polypharmacy, and then monitoring the individual for unintendedadverse effects or worsening of disease.

It is essential to involve the individual (and their carer) closely in deprescribingdecisions in order to build and maintain their confidence in the process.

Hyperpolypharmacy

Use of ten or more regular medicines by an individual. This is also sometimescalled major polypharmacy or excessive polypharmacy.

Multimorbidity

Multimorbidity is the co-occurrence of two or more chronic medical conditions inone person.

Oligopharmacy

The deliberate avoidance of polypharmacy, ie, using fewer than five regularmedicines and minimising the number of doses an individual has to take in theirday.

This approach is growing in popularity in end-of-life care but may also be usefulfor individuals who place a high value on taking fewer medicines.

Problematic polypharmacy

Also referred to as inappropriate polypharmacy. More medicines than anindividual needs to achieve the health outcomes that are achievable and importantto them, medicines that are having a negative impact on the individual’s wellbeing,medicines that are not adding any value, medicines that result in drug-drug ordrug-food interactions or any other negative impact on the individual’s lifestylethat could be avoided.

Problematic medicines can be stopped (see deprescribing above) or changed toan appropriate alternative.

Also see appropriate polypharmacy above.

Glossary of key term

s

ix

Pseudopolypharmacy

The healthcare record suggests polypharmacy but the individual does not take allthe medicines on their prescription/medicines list. This can occur when medicinesare stopped by the individual or a prescriber but, for a number of reasons, notremoved from the repeat prescription.

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Polypharmacy

Section 1The problem with polypharmacy

Learning objectives

On completion of this section you should be able to:

� explain the terminology associated with polypharmacy and what it means for patients and the health and social care team

� list the causes and consequences of polypharmacy, particularly inrelation to patients and their carers.

This section explains why understanding the issues that surround polypharmacy isimportant to you, your practice and your patients. This section will explain whatpolypharmacy is, what causes it and how taking multiple medicines can affect aperson.

1.1 Introduction to polypharmacyThe term polypharmacy is probably a familiar one to many health and social careprofessionals. Polypharmacy literally means many medicines, but the term hasevolved to mean different things in different contexts and is often mentioned withnegative connotations. However, it is important to note that polypharmacy is notnecessarily a bad thing. For example, secondary prevention of myocardialinfarction often requires the use of four different classes of medicines, and in thisinstance is both rational and required.

Problematic polypharmacy means that medicines are prescribed that are not or nolonger appropriate. This can happen for several reasons, such as:

� there is no evidence-based indication, the indication has expired or the dose isunnecessarily high

� medicines are being prescribed to treat the side-effects of other medicines wherealternative solutions are available

� the medicine fails to achieve the therapeutic objectives intended

� medicines cause unacceptable adverse drug reactions

� the demands of the medicine-taking are unacceptable to the patient or thepatient is unable to maintain adherence.1

We will use the term polypharmacy in this learning programme to meanproblematic polypharmacy.

1.2 Why is polypharmacy important?Polypharmacy is a key issue in health and social care, as evidence suggests thatbeing on multiple medicines increases an individual’s risk of harm and contributesto hospital admissions and poor therapeutic outcomes.2, 3 It also increases cost tothe NHS and can result in medicines waste.4 Polypharmacy has been called a‘common and growing global phenomenon’ by the King’s Fund,5 and it has beenestimated that as many as three million people in the UK will be living with long-term conditions managed with polypharmacy by 2018.6 Polypharmacy is a bigissue for people in receipt of social care. Between 2004 and 2014, almost all peopleaged 65 years and over who needed help with activities of daily living (social care)were taking at least one prescribed medicine. These people were also most likely toreport that they had taken multiple prescribed medicines in the last week: mostwere taking at least three medicines and many were taking at least six.7

Section 1 The problem with polypharm

acy

1

3 millionpeople

By 2018 in the UK will have a long-term condition managed by polypharmacy.6

2 millionprescriptions

are issued each day in England.5

60%

55.2%The number of prescriptionsissued has increased by since 2004.7

300% A person takingten or more medicines is

more likely to beadmitted to hospital.8

A thirdof people

aged 75 yearsand over are taking at least six medicines.7

Approximately of prescriptions are issued to people aged 60 years and over.7

Figure 1 below provides some key facts and figures about polypharmacy.

FIGURE 1 Polypharmacy facts and figures

Patients in both primary and secondary healthcare settings are affected bypolypharmacy. Managing it rationally is the responsibility of all health and socialcare professionals, working together with effective communication across sectorsand across professions.

1.3 Who is affected?The majority of the published work on polypharmacy relates to older people butattention has recently turned to it in other areas, particularly advanced cancer andend-of-life care as well as children and people with learning disabilities. We won’tcover issues specific to these clinical areas in detail in this learning programme, asthe principles we cover apply to all patients. If you are interested in learning moreabout polypharmacy in these specific areas, you may wish to look at the followingresources:

Polypharmacy in end-of-life care:http://ageing.oxfordjournals.org/content/40/4/419.long

Polypharmacy in children: www.dovepress.com/articles.php?article_id=23285

Polypharmacy in people with learning disabilities:www.england.nhs.uk/2015/07/14/urgent-pledge

Older people are more likely to experience polypharmacy than younger people dueto multimorbidities, many of which are age-related (for example, dementia) ormore common in older people (for example, atrial fibrillation). However, there is agreater number of people living with multimorbidities who are under 65 years ofage, and evidence shows that a high proportion of these people are taking multiplemedicines.52

Polypharmacy

Reflective questions

Why is polypharmacy important in your practice?

If you work in community pharmacy or primary care, how many patients do yousee a day who are prescribed five or more medicines? What action do you taketo ensure these medicines are appropriate for the patient?

If you work in hospital pharmacy, how many patients do you see admitted on fiveor more medicines? How many of these patients are started on new medicines inhospital? What action do you take to ensure the plan for new medicines iseffectively communicated on discharge?

Practice pointWatch James McCormack’s Bohemian polypharmacy parody onYouTube: www.youtube.com/watch?v=Lp3pFjKoZl8

This provides a light-hearted overview of some of the evidence onpolypharmacy, and it will get you thinking about some of theissues we will address in this learning programme.

1.4 Causes of polypharmacyPrescribing a medicine is the most common medical intervention for many acuteand chronic conditions. The reasons behind patients taking many, possiblyproblematic, medicines can be complex and multifactorial. It is important to beaware of the causative factors that result in polypharmacy, so you can recognisethese as they occur and think of possible solutions.

Lack of shared decision-making

Many patients will have their own ideas and expectations around medicines andtreatment. If patients are not involved in decisions around their medicines there isa risk that what is prescribed may not match their preferences. This can lead toissues with non-adherence. Applying a patient-centred approach to theconsultation provides a patient with an opportunity to voice concerns when amedicine is started and is key to minimising polypharmacy. We will discuss thisapproach later in this programme.

Section 1 The problem w

ith polypharmacy

3

Applying a patient-centred

approach to the

consultation provides a

patient with an

opportunity to voice

concerns when a medicine

is started and is key to

minimising polypharmacy.

Multimorbidity

Treatment guidelines for single diseases recommend the use of a variety ofevidence-based medicine treatments. While in many instances these areappropriate, there may be a mismatch between prescribing guidelines for specificmedical conditions and the clinical complexity of individual patients; in particularthis may be true for patients who have multimorbidity, frailty, a dominantcondition (eg, dementia) or may be approaching the end of their lives.1 In thesesituations the sum of evidence-based recommendations may not be rational. Youcan read more about multimorbidity and frailty in the Scottish GovernmentPolypharmacy guidance, available from:www.sign.ac.uk/pdf/polypharmacy_guidance.pdf

To add to this, multiple prescribers might be looking after the one patient.Specialists are likely to be prescribing in their own area of expertise, but perhapsnot managing the patient’s medicines as a whole. GPs may be reluctant to reviewmedicines that have been started in secondary care by specialists. A lack of cleardocumentation can exacerbate this problem, leaving a lack of clarity over theindication for medicines or direction for when medicines should be reviewed orstopped.

Transfer of care

Moving between care settings has been shown to result in polypharmacy, forexample, a patient may transfer between hospital, general practice and a carehome, with new medicines being added at each stage.9 There is evidence thatpatients are discharged from hospital with an average of one-and-a-half moremedicines than they were admitted with.10 When patients transfer betweendifferent care providers there is a greater risk of poor communication andunintended changes to medicines.

When patients move from one care setting to another, between 30 and 70 percenthave an error or unintentional change to their medicines.11, 12 The RoyalPharmaceutical Society (RPS) report Keeping patients safe when they transferbetween care providers: getting the medicines right makes some key recommendationsto help ensure medicines information is transferred safely and effectively betweencare settings. You can access this document here: www.rpharms.com/previous-projects/getting-the-medicines-right.asp

NICE guideline NG5: Medicines optimisation: the safe and effective use of medicines toenable the best possible outcomes also makes recommendations on effective transferof information and you can access this document here:www.nice.org.uk/guidance/ng5/chapter/1-Recommendations#medicines-related-communication-systems-when-patients-move-from-one-care-setting-to-another

Reflex prescribing

Polypharmacy appears to occur commonly because of reflex prescribing, alsoreferred to as a prescribing cascade. The prescribing cascade occurs when anadverse drug reaction is misinterpreted as a new medical condition. Newmedicines are started in order to manage the unrecognised side-effects of anexisting medicine,13 and the patient is put at risk of developing additional adverseeffects relating to this potentially unnecessary treatment. Figure 2 on the next pageillustrates one example of what a prescribing cascade might look like. Alternatively,a patient may end up in a situation where a prescribing vortex has occurred, inwhich each medicine causes a side-effect that is treated by the next, as illustrated inFigure 3.

4

Polypharmacy

Moving between care

settings has been shown to

result in polypharmacy.

Ankle swelling

Hypertension

Gout

ArthritisNSAID

Calcium channel blocker

Diuretic

Allopurinol

Oralbisphosphonate

Protonpump inhibitor

Gastrointestinalside-effects

Increasedfracture risk

FIGURE 2 Example of a prescribing cascade

FIGURE 3 Example of a prescribing vortex

For further examples of cascade prescribing with statistics, refer to the BritishMedical Journal article ‘Optimising drug treatment for elderly people: theprescribing cascade’, available at: www.bmj.com/content/315/7115/1096

Section 1 The problem with polypharm

acy

5

Exercise 1The table below contains a list of adverse drug reactions that are known to beassociated with causing a prescribing cascade. For each adverse reaction make alist of medicines that are commonly associated with it. You will be able to use thisin your practice to identify medicines that are commonly associated with aprescribing cascade.

Adverse drug reaction Common medicine(s)

Nausea

Rash

Dizziness

Hypertension

Tremor

Gout

Turn to the end of the section for suggested answers.

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Polypharmacy

Case study 1Recognising the start of a prescribing cascadeGerda Smith is an 84-year-old lady with Alzheimer’s disease. She is newlyprescribed donepezil by the local memory service, and her dose is titrated to 10mg. One week after this, Gerda’s husband (and main carer), Donald, consults theGP because Gerda has become incontinent of urine. Incontinence is anuncommon side-effect of donepezil and it is not recognised by Donald or their GP.

The memory service picks it up as a side-effect at Gerda’s next appointment threemonths later. By that time Gerda has had two empirical courses of antibiotics forsuspected urinary tract infection and has been started on mirabegron by her GP.On top of this, Donald has been under a great deal of strain from the extrahousework and personal care he has had to do while Gerda has been incontinent.

None of the healthcare professionals looking after Gerda initially linked the side-effect to the new medicine. How could you prevent this situation fromoccurring in your practice?

Turn to the end of the section for suggested answers.

1.5 What is the impact of polypharmacy?Polypharmacy has an impact on individual people and the healthcare system, andstudies suggest that for patients it can result in falls, adverse drug events, hospitaladmissions, reduced ability to live independently and impaired cognitivefunction.14 We will examine each of these issues below.

Individual burden

People taking multiple medicines long-term develop their own strategies for fittingthem into their daily routine. But some people struggle physically with the burdenof taking many medicines; others may feel like they have no control over whetherand how they use their medicines. Long-term medicines use has been shown tohave a negative effect on patients’ quality of life.15 It is perhaps no wonder thenthat as many as 50 percent of people on long-term medicines don’t take them asintended.16 A patient who believes the benefits of their medicine will beoutweighed by the personal cost (including time, side-effects, stigma and expense)is less likely to take them.17 So it is important to engage patients in discussionsabout their treatment goals and what factors would be acceptable or unacceptableto them. There may need to be a compromise to achieve treatment goals within thelimits of what is acceptable to an individual patient. Finding out how people feelabout their medicine may not be something you have done routinely before, but itis a key step in a person-centred consultation. We will discuss this in further detailin Section 3.

Section 1 The problem with polypharm

acy

7

Long-term medicines use

has been shown to have a

negative effect on

patients’ quality of life.

Case study 2Recognising medicines burdenRoy Corden is a 76-year-old man with advanced Parkinson’s disease. He is caredfor by his wife, Esther, and supported by carers who help him wash and dress in themornings, get into bed at night and give him his medicines from a weekly traysupplied by his local pharmacy. The carers come five times a day but cannotalways come at the time the medicine is due because they are balancing the needsof all of the patients on the caseload. This is not making a significant difference toRoy’s symptoms but Esther has become essentially housebound because she hasto be at home to let the carers in and does not know what times they will come.

How could you recognise and manage this situation in your practice?

Turn to the end of the section for suggested answers.

Practice point The impact of polypharmacy is very different for different people.Listen to the polypharmacy podcast on the CPPE website to hearhow real patients’ lives are affected by polypharmacy. You canlisten to the podcast at: www.cppe.ac.uk/polypharmacy

Reflect on the impact polypharmacy has on the individual patient on a daily basis.Draw on conversations you have had with people when you were reconciling,reviewing or discussing their medicines.

Hospital admissions

Taking multiple medicines has been found to increase unplanned admissions tohospital for patients with a single medical condition. A study found the risk ofhospital admissions increased by 25 percent with four to six medicines, and by 300 percent with ten or more medicines. For patients who had multiple medicalconditions, however, the effect of polypharmacy on hospital admissions was not asgreat. Patients with six or more medical conditions were more likely to have anunplanned hospital admission if they were taking ten or more medicines. Thisresulted in a 25 percent increase in risk.8

Figure 4 on the next page shows which classes of medicines are most likely tocause hospital admissions due to adverse drug reactions.

8

Polypharmacy

Antiplatelets 16%

Diuretics 16%

NSAIDs 11%

Anticoagulants 8%

Other 49%

FIGURE 4 Medicines associated with adverse drug reactions

Which medicines are most likely to cause hospital admissionsdue to adverse drug reactions?

A systematic review found that just four classes of medicines were associatedwith more than 50 percent of hospital admissions caused by adverse drugeffects, including side-effects, under- or over-treatment and non-adherence.18

Adverse drug events

The more medicines a person takes, the more likely they are to have an adverseevent from one of their medicines. In addition, the proportion of adults with one ormore potentially serious drug-drug interactions in their treatment has more thandoubled in the period from 1995 to 2010.19 The number of medicines dispensedper person increases the risk of an interaction. A study found that 80 percent ofpatients who were dispensed 15 or more medicines had a potentially seriousinteraction on their prescription. The same study found that individuals takingmultiple medicines were more likely to receive a medicine with anticholinergicactivity and the proportion of older people in that population receiving ananticholinergic had grown to 23.7 percent in 2010, despite increasing evidence ofharm from anticholinergic medicines.20

Anticholinergic medicines should be prescribed with caution as elderly patientsare more likely to experience adverse effects, such as constipation, urinaryretention, dry mouth/eyes, sedation, confusion, delirium, photophobia, falls,reduced cognition (may lead to wrong diagnosis of dementia), decreasedsweating and increased body temperature. Research also suggests a link toincreased mortality with the number and potency of anticholinergic agentsprescribed.1

Section 1 The problem with polypharm

acy

9

Practice pointDraw up a list of medicines associated with anticholinergic activity. Once you havecreated your own list, you can check this against the list of anticholinergicmedicines in the NHS Scotland Polypharmacy guidance (Section 3.1, page 43).www.sign.ac.uk/pdf/polypharmacy_guidance.pdf

You may also wish to take a look at the Anticholinergic cognitive burden scale,which highlights specific medicines to be avoided in older people irrespective ofdiagnosis. This is available at:www.agingbraincare.org/uploads/products/ACB_scale_-_legal_size.pdf

Falls

There is often an assumption that polypharmacy is related to falls in older people.However, a study reviewing falls in people over 50 years of age taking four or moremedicines found that they were not more likely to fall and injure themselves thanpeople taking fewer medicines. Instead, it was the choice of medicine that wasimportant. If one of the medicines in their regimen was a benzodiazepine the riskincreased by 40 percent; taking an antidepressant increased the risk by 50 percent.21 Although this was a cohort study, and so a number of potentialconfounding factors are present, it suggests that polypharmacy with certainmedicines is more hazardous than with others. Therefore, we cannot make theassumption that because a patient is taking multiple medicines this is necessarilyinappropriate. When considering a patient’s medicines we instead need to considerthe choice of medicines, identifying those associated with risk, and the patient onan individual basis. We will look at this further in the next section.

Practice point Thinking about the issues raised here about the causes of polypharmacy, which ofthese do you recognise from your own area of practice? What role can you play inidentifying polypharmacy and how can you go about doing this in your practicesetting?

10

Polypharmacy

SummaryPolypharmacy is problematic when medicines cause unintended adverse effects orwhere the intended benefit of the medicine is not realised. Polypharmacypotentially has a wide range of causes, including strict adherence to treatmentguidelines, transfer of care between care settings, and reflex prescribing which mayresult in a prescribing cascade (or vortex). Understanding these potential causes isthe first step to preventing polypharmacy and supporting patients who are alreadytaking multiple medicines. The pharmacy team has an essential role to play inpreventing and recognising polypharmacy.

Intended outcomesBy the end of this section you should be able to: Can you?

� explain the terminology associated with polypharmacy and what it means for patients and the health and social care team

� list the causes and consequences of polypharmacy, particularly in relation to patients and their carers.

Suggested answers

Case study 1Recognising the start of a prescribing cascade (page 7)Gerda Smith is an 84-year-old lady with Alzheimer’s disease. She is newlyprescribed donepezil by the local memory service, and her dose is titrated to 10 mg.One week after this, Gerda’s husband (and main carer), Donald, consults the GPbecause Gerda has become incontinent of urine. Incontinence is an uncommonside-effect of donepezil and it is not recognised by Donald or their GP.

The memory service picks it up as a side-effect at Gerda’s next appointment threemonths later. By that time Gerda has had two empirical courses of antibiotics forsuspected urinary tract infection and has been started on mirabegron by her GP.On top of this, Donald has been under a great deal of strain from the extrahousework and personal care he has had to do while Gerda has been incontinent.

None of the healthcare professionals looking after Gerda initially linked the side-effect to the new medicine. How could you prevent this situation from occurring inyour practice?

Before any new medicines are considered the prescriber should consider whetherthe symptoms are caused by a disease or by one or more medicines that theperson is taking.

If you recognise any new signs and symptoms to be a possible consequence ofcurrent medicine, you should discuss these with the prescriber and together withthe patient consider alternative methods of management.

Before any new medicine treatment is started, the need for the original medicineshould be re-evaluated and a non-pharmacological treatment should beconsidered, if possible. Amending the current medicine to eliminate unwantedside-effects is often better than adding in a new medicine.

If the medicine is necessary, the lowest possible dose should be used or analternative medicine with fewer adverse effects considered.

Section 1 The problem with polypharm

acy

11

Case study 2Recognising medicines burden (page 8)Roy Corden is a 76-year-old man with advanced Parkinson’s disease. He is caredfor by his wife, Esther, and supported by carers who help him wash and dress in themornings, get into bed at night and give him his medicines from a weekly traysupplied by his local pharmacy. The carers come five times a day but cannotalways come at the time the medicine is due because they are balancing the needsof all of the patients on the caseload. This is not making a significant difference toRoy’s symptoms but Esther has become essentially housebound because she hasto be at home to let the carers in and does not know what times they will come.

How could you recognise and manage this situation in your practice?

A complex regimen of multiple medicines, perhaps taken frequently throughoutthe day, can make people feel socially restricted or isolated. People may find itdifficult to organise their many medicines around social life or activities.

Understanding and recognising the impact of medicines on the person and theircarer is an important role for pharmacy teams. Engaging patients, and importantlytheir carers, in discussions about their medicines is key to this.

This is possibly not a situation you can manage alone, as Roy is likely to havecomplex medicines needs and the frequent administration of his Parkinson’smedicines is important for symptom control. Contacting a social worker, who maybe able to arrange a solution, such as a key safe to allow the carers to letthemselves into the house, may allow Esther to regain some control of her life.

12

Polypharmacy

Exercise 1 (page 6)The table below contains a list of adverse drug reactions that are known to beassociated with causing a prescribing cascade. For each adverse reaction make alist of medicines that are commonly associated with it. You will be able to use thisin your practice to identify common medicines that are associated with aprescribing cascade.

Adverse drug reaction Common medicine(s)

Nausea ACE inhibitorsOpioidsLoop diureticsNSAIDsCorticosteroids

Rash AntiepilepticsClopidogrel Antibiotics

Dizziness AntihypertensivesOpioidsSedativesDiuretics

Hypertension NSAIDsCorticosteroidsCiclosporin

Tremor Selective serotonin reuptake inhibitors (SSRIs)AntipsychoticsValproate

Gout Thiazide diureticsCiclosporinCytotoxic medicines22

Section 1 The problem with polypharm

acy

13

Section 2 Optimising medicines inpolypharmacy

Learning objectives

On completion of this section you should be able to:

� identify how to recognise medicines that cause problems for patients with polypharmacy

� list trigger factors that may indicate that polypharmacy is an issue

� describe how you could use decision-making tools and strategiesto support patients on multiple medicines.

In the previous section we outlined the issues relating to polypharmacy, andshowed that members of the pharmacy team have an important role to play inidentifying and engaging patients to address polypharmacy. This section considershow you might go about optimising medicines for patients taking multiplemedicines, including how you may identify someone for review and the triggersigns that may alert you to the fact someone is struggling with their multiplemedicines.

2.1 A patient-centred approach to medicinesoptimisation

Medicines optimisation encompasses many aspects of improving medicines use, andis fundamental to addressing the challenges posed by polypharmacy. A definition ofmedicines optimisation is that it ‘requires evidence-informed decision-making aboutmedicines, involving effective patient engagement and professional collaboration toprovide an individualised, person-centred approach to medicines use, within the availableresources’.23

There can be a tendency when identifying patients for review or using medicationreview tools to get focused on medicines rather than patients’ needs andpreferences. Patient-centred care is about ensuring that the care provided for apatient takes into account their knowledge, beliefs, culture and values. Patientsshould be treated as equal partners in the decision-making process, and anydecisions regarding the review of treatment should include the patient and theircarer at all stages. The key is that the decisions should be informed decisions sopatients should be given the information they need in order to engage in thedecision.

Bear this in mind as you work through this section and consider the tools youcould use.

All pharmacy professionals have access to the CPPE distance learning programmeConsultation skills for pharmacy practice: taking a patient-centred approach. This isone part of an extensive six-step learning and development pathway that considersthe skills and techniques you can develop to put the patient at the centre of yourpractice.

You can access Consultation skills for pharmacy practice: taking a patient-centredapproach here: www.cppe.ac.uk/programmes/l/consult-p-02/

14

Polypharmacy

Patient-centred care is

about ensuring that the

care provided for a patient

takes into account their

knowledge, beliefs, culture

and values.

If you haven’t done so already, read the first chapter on patient-centred care for anoverview of the key skills you will need to engage patients in a patient-centred way.

You can access the Consultation skills for pharmacy practice website here:www.consultationskillsforpharmacy.com

2.2 Identifying people with polypharmacy for reviewDepending on which sector of practice you work in, there are a number of waysthat people taking multiple medicines might be identified or may present to youfor a medication review. Individuals may refer themselves or the person they carefor on an ad-hoc basis to their GP or usual pharmacist. Alternatively, cliniciansmay identify patients taking multiple medicines who would be suitable for a review.GP practices, commissioners or NHS boards may use electronic prescribing ordispensing systems to identify people considered at high risk of hospital admissionor adverse drug events. Many intermediate care services refer patientsexperiencing problems with their medicines to a clinical pharmacist from thehospital, commissioning support service, GP practice or community pharmacy.Secondary care institutions may identify people using hospital readmission riskprediction tools, such as Emergency Admission Risk Likelihood Index (EARLI)24

or Scottish Patients at Risk of Readmission and Admission (SPARRA).25

Trigger questions can offer a way of highlighting a patient’s potential need forreview across four areas. We have listed these trigger questions below. Originallydesigned for use in older people, they can be used in several ways. They allowpatients or carers to assess their own needs, trained health and social care staff toguide their assessments of patients’ needs, and pharmacists to assess how patientsuse their medicines.

1. Do you need help getting a regular supply of your medicines? (Identifies accessissues)

2. Do you always take all of your medicines the way that your doctor wants you to?(Identifies adherence issues)

3. Can you swallow and use all of your medicines and get all of your medicines outof their containers? (Identifies day-to-day management issues)

4. Do you think that some of your medicines could work better? (Identifies clinicalissues)

You can find further information here: www.pharmaceutical-journal.com/libres/pdf/articles/pj_20060218_olderpeople.pdf

NHS Scotland has put together a list of high-risk prescribing indicators. Theseindicators may not necessarily mean prescribing is problematic, but they flag thesepatients as requiring regular review.

� Older person (75 years or older) prescribed an antipsychotic medicine

� Older person (75 years or older) prescribed an NSAID withoutgastroprotection

� Older person (65 years or older) currently taking an ACE inhibitor/angiotensinreceptor blocker and a diuretic, who is prescribed an NSAID (the ‘triplewhammy’)

� Older person (65 years or older) currently taking aspirin or clopidogrel, who isprescribed an NSAID without gastroprotection

� Current anticoagulant user prescribed an NSAID without gastroprotection

� Current anticoagulant user prescribed aspirin or clopidogrel withoutgastroprotection

Section 2 Optim

ising medicines in polypharm

acy

15

Along with the high-risk prescribing indicators above, there are other trigger signsthat might alert you to the fact that someone has potentially problematicpolypharmacy. You could use these signs in your own practice to identify peoplewho would possibly benefit from a medication review. These include:

� multiple high-risk medicines, such as medicines with anticholinergic side-effectsor those listed in the Patient safety guide to reducing harm from high-risk medicines(available at: www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/How-to-guides-2008-09-19/Medicines%201.1_17Sept08.pdf )

� multiple medicines affecting renal function, eg, NSAIDs, diuretics, ACE inhibitors

� a problem raised in new medicine service or medicines use review

� unusual quantities of medicines returned from a patient

� patient is receiving social care or moving into a care home

� patient is taking ten or more medicines

� potentially harmful drug interactions present on prescription, for example:� amiodarone and dabigatran� a course of macrolides with colchicine or simvastatin.

The above methods may help you to identify a patient who may benefit from areview, but a key consideration should be how to engage a person in the reviewprocess. Patients might be quite happy with their medicines regimen, and theremay be some apprehension or even fear at the thought of change. There may beclinician/patient trust issues to consider. Involving a patient in the decision-makingprocess includes attempting to understand their views and their perspective ontheir treatment. We will cover how you might do this in the following section.

Reflective questions

What alerts might you put in place for your medicines counter assistants to use toidentify polypharmacy?

What alerts might you put in place for the pharmacy technician to use whenchecking patients’ medicines?

What could the pharmacists do to recognise polypharmacy?

2.3 Medication review toolsOnce you have identified a patient who might be suitable for review, you will alsoneed to consider how you might identify and prioritise problem medicines.Medication review tools are not a substitute for careful clinical judgement but areuseful for directing your attention to potential medicines-related problems. Using atool can help guide your discussion with a patient taking multiple medicines but itis only a part of the process and one factor to consider. Using your professionaljudgement and experience is essential in managing polypharmacy issues. Mostpolypharmacy issues are complicated and will involve different health and socialcare team members and several aspects about the patient (life, health, medicines,general wellbeing, circumstances, etc). In the next section we will present a patient-16

Polypharmacy

Using your professional

judgement and experience

is essential in managing

polypharmacy issues.

centred framework to guide your practice, so for the moment we will just focus onthe medication review tools available.

Here are two medication review tools that illustrate:

� an explicit criterion-based tool

� an implicit judgement-based tool.

As you look up both tools, consider what their advantages and disadvantages might be.

STOPP START toolkit27

The STOPP START toolkit is designed to support medication reviews. STOPPstands for Screening Tool of Older People’s potentially inappropriatePrescriptions and START stands for Screening Tool to Alert doctors to Right(ie, appropriate, indicated) Treatments. STOPP START is supported byobservational data and a randomised controlled trial and is recommended in theNICE medicines optimisation guideline.12

Designed to be used with patients aged 65 years and over, it covers varioussections of the BNF and suggests areas for review.

Follow the link below to access the STOPP START Cumbria toolkit:www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/StopstartToolkit2011.pdf

STOPIT is a tool modified from STOPP START for use in hospital andintermediate care. Follow the link below to find out more about STOPIT:www.gmjournal.co.uk/intermediate_care_25769807927.aspx

Alternatively, the Medication Appropriateness Index (MAI)28 is used as animplicit, judgement-based approach of reviewing medicines.

Medication Appropriateness Index28

MAI uses ten criteria for each medicine a patient is taking, assessing indication,effectiveness, dosage, directions, drug-drug interactions, drug-diseaseinteractions, expense, practicality, duplication, and treatment duration. Eachcriterion is rated as appropriate, marginally appropriate or inappropriate.

Ten explicit criteria1. Indication: the sign, symptom, disease or condition for which the medicine is

prescribed.

2. Effectiveness: producing a beneficial result.

3. Dosage: total amount of medicine taken per 24-hour period.

4. Directions: instructions to the patient for the proper use of a medicine.

5. Practicality: capability of being used or being put into practice.

6. Drug-drug interaction: the effect that the administration of one medicinehas on another drug; clinical significance connotes a harmful interaction.

7. Drug-disease interaction: the effect that the drug has on a pre-existingdisease or condition; clinical significance connotes a harmful interaction.

8. Unnecessary duplication: non-beneficial or risky prescribing of two or moredrugs from the same chemical or pharmacological class.

9. Duration: length of therapy.

10. Expensiveness: cost of drug in comparison to other agents of equal efficacyand safety.5

Access more information about the MAI criteria here:http://c.ymcdn.com/sites/www.wsparx.org/resource/resmgr/imported/RCT%20Pharmacist%20elderly%20polypharmacy.pdf

Section 2 Optim

ising medicines in polypharm

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17

Exercise 2Read about the STOPP START toolkit and the MAI. What are the advantages anddisadvantages of the two different tools? Do you have a preference for one or theother? You may already have a medication review tool that you use in yourpractice. How do these two tools compare to it?

Turn to the end of the section for suggested answers.

Other tools that are commonly used while carrying out medication reviews arelisted below.

� Beers Criteria (updated 2012)www.healthcare.uiowa.edu/minimedicalschool/documents/BeersCriteriaPublicHandout041012.pdf

� Drug effectiveness summary (NHS Highland tool)www.nhshighland.scot.nhs.uk/publications/documents/guidelines/polypharmacy%20guidance%20for%20prescribing%20in%20frail%20adults.pdf

� NO TEARSwww.wales.nhs.uk/sites3/documents/814/PrescribingForFrailAdults-ABHBpracticalGuidance%5BMay2013%5D.pdf

Further information on these and other tools can be found in Table 1 of the King’sFund publication Polypharmacy and medicines optimisation: making it safe and sound,which is available at:www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf

When using any medication review tool it is important to interpret it in the clinicalcontext, taking into account your patient. The King's Fund proposes taking apragmatic approach to identifying higher-risk polypharmacy and combining themethods we have discussed above. It suggests a pragmatic approach that focuseson the following groups of at-risk patients:

� all patients with ten or more regular medicines

� patients receiving between four and nine regular medicines who also:

� have at least one prescribing issue that meets criteria for potentiallyinappropriate prescribing

� have evidence of being at risk of a well-recognised potential drug-druginteraction or have a clinical contraindication

� have evidence from clinical records of difficulties with medicine-taking,including problems with adherence

� have no or only one major diagnosis recorded in the clinical record � are receiving end-of-life or palliative care.518

Polypharmacy

Section 2 Optim

ising medicines in polypharm

acy

19

SummaryIn this section we looked at a couple of the most commonly used medicationreview tools and prompted you to think about how you could use these in yourpractice. We have looked at how you might identify a patient taking multiplemedicines for review, remembering to take a patient-centred approach andconsider the patient as a whole. In the next section we will build on this to considerhow you might implement a patient-centred approach to undertake a medicationreview consultation with a patient.

Intended outcomesBy the end of this section you should be able to: Can you?

� identify how to recognise medicines that cause problems for patients with polypharmacy

� list trigger factors that may indicate that polypharmacy is an issue

� describe how you could use decision-making tools and strategies to support patients on multiple medicines.

Suggested answer

Exercise 2 (page 18)Read about the STOPP START toolkit and the MAI. What are the advantages anddisadvantages of the two different tools? Do you have a preference for one or theother? You may already have a medication review tool that you use in yourpractice. How do these two tools compare to it?

STOPP START

Advantages Disadvantages

Can be applied with little clinical Doesn’t take into account patient judgement preferences or co-morbidities

Low cost

MAI

Advantages Disadvantages

Focus on the patient Time-consuming

Addresses the medicines regimen as Low reliabilitya whole

Section 3Patient-centred approach tomanaging polypharmacy

Learning objectives

On completion of this section you should be able to:

� explain how you could undertake patient-centred discussions about polypharmacy with patients during a medication review or medicines use review

� prioritise, in conjunction with the patient, what interventions tomake, and make referrals to suitable professionals.

This section presents a practical approach to how you might engage a patientand/or their carer in a review of their multiple medicines, review the patient andtheir medicines in a patient-centred way and make recommendations bycommunicating effectively with the wider health and social care team. We will takeyou through this seven-part approach in a step-by-step manner.

3.1 Following a patient-centred approach to managingpolypharmacy in practiceHaving a structured approach to your medication review is helpful in delivering ahigh-quality process and good outcomes for the patient, but remember to allowsome flexibility to respond to the needs of the patient during the consultation. A patient-centred approach to managing polypharmacy29 provides a framework forundertaking a patient-centred approach (see Figure 5 on the next page) and isdescribed in full in this section. You can find out more information about thepatient-centred approach to managing polypharmacy here: www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/Service-deliv-and-devel/Older-people-care-homes/Polypharmacy-oligopharmacy—deprescribing-resources-to-support-local-delivery/

Practice pointThis section is accompanied by two Polypharmacy in practice consultation videosto illustrate how this approach might look in practice with a real patient. Thisapproach is relevant to anyone undertaking a polypharmacy review in any area ofpractice. Watch these videos. You may wish to watch the videos before you readthis section, and revisit them again afterwards. Alternatively, you may wish thewatch the videos in stages, allowing you to read the sections and watch the visualillustration at the same time.

You can access the two Polypharmacy in practice consultationvideos in full here: www.cppe.ac.uk/polypharmacy

20

Polypharmacy

Assess patient

Define contextand overall goals

Identify medicineswith potential risks

Assess risks andbenefits in context

of individual patient

Agree actions tostop, reduce dose,continue or start

Communicateactions with allrelevant parties

Monitor andadjust regularly

FIGURE 5 Patient-centred approach to managing polypharmacyin practice

Source: Barnett et al, 201529

Before we start, it is important to remember that the majority of pharmacyprofessionals will not carry out medication reviews in a multidisciplinary meeting.As a pharmacy professional you have an important role to play in reviewing apatient’s medicines, and this should be done as part of the wider health and socialcare team with good communication to and from all parties. We’ll come to talkabout this within this framework.

Step 1: Assess patientThe purpose of this first step is to assess the patient’s needs byidentifying any potential issues and most importantlyestablishing the patient’s perspective on their medicines andmedicines-related problems.

Before you can do this, you need to introduce yourself to thepatient, explain your role and your agenda for the consultation,and gain consent from the patient to ensure that they are happyto discuss their treatment with you.

You can start this with a simple, “Hello, my name is…”.

“It is about making a human connection, beginning a therapeutic relationshipand building trust… it is the first rung on the ladder to providing compassionatecare.” Dr Kate Granger, founder of the #hellomynameis campaign, on theimportance of introductions when delivering care.

If you haven’t heard about this campaign before, find out more at:http://hellomynameis.org.uk/

Section 3 Patient-centred approach to managing polypharm

acy

21

Assess patient

Define contextand overall goals

Identify medicineswith potential risks

Assess risks andbenefits in context

of individual patient

Agree actions tostop, reduce dose,continue or start

Communicateactions with allrelevant parties

Monitor andadjust regularly

It should go without saying that you should always treat your patient with respect,kindness, dignity, compassion, understanding, courtesy and honesty.30 Fullinformation on how to provide patients with the best possible experience isavailable in the NICE patient experience guideline(www.nice.org.uk/guidance/CG138/chapter/1-Guidance#knowing-the-patient-as-an-individual).

You should find out what matters to the patient (and carer) by sharing the agendawith them and finding out what they want to get out of the review. You can do thisby using open questions, for example, “While we are here is there anything inparticular you would like to discuss?” or “If there is one thing we could do aboutyour medicines today, what would it be?” Ask how they feel about their medicinesand how well the medicines fit into their day-to-day life. Establish what supportthey have with their medicines and from whom – their social situation can placelimitations on the content and timings of their medicines regimen. At this time, youshould also complete a medicines reconciliation as per NICE guideline NG5:Medicines optimisation. You can find out more about medicines reconciliation here:www.nice.org.uk/guidance/ng5

Practice pointHow do you approach patients generally to talk about their medicines? Have youever thought about the language you use and what impact this might have onsomeone’s engagement in the medication review process?

Step 2: Define context and overall goalsThe next step, based on what you have found out above, is todiscuss and agree with the patient a focus for the review. It maybe better to focus on a small number of priorities and/ormedicines rather than a whole list in one session. Find out whatthe patient’s expectations are; their priority may be different toyours. Focus on the outcomes that can be gained for theindividual from medicines, remembering to focus on what’simportant to the patient, not necessarily to you. But rememberto make sure you address any patient safety issues.

Take a holistic approach, considering health, social wellbeing,physical capabilities, environment, home and work life, familyand carers. You will also need to obtain a medical, social and

drug history from available health records. And you will need pathology results inrelation to medicines, including monitoring if these are available, eg, renal functionin relation to NSAID or ACE inhibitor use, liver function in relation to statin use.

22

Polypharmacy

Assess patient

Define contextand overall goals

Identify medicineswith potential risks

Assess risks andbenefits in context

of individual patient

Agree actions tostop, reduce dose,continue or start

Communicateactions with allrelevant parties

Monitor andadjust regularly

You may also wish to consider the following factors, depending on the age of yourpatient and their medical conditions.

� Consider mobility and how socially active a person is. Someone who is nowbedbound probably does not need their bisphosphonate, while someone whohas a very active lifestyle may find a diuretic medicine restrictive, so timingscould be adjusted.

� Is your patient approaching the end of their life? Use prognostic tools forshortened life expectancy, such as the Gold standard framework, alongsideclinical judgement. The Gold standard framework talks about the surprisequestion: ‘Would you be surprised if this patient were to die in the next months,weeks, days?’31 The Gold standard framework can be accessed here: www.goldstandardsframework.org.uk/cd-content/uploads/files/General%20Files/Prognostic%20Indicator%20Guidance%20October%202011.pdf

� If your patient suffers from three or more of the following symptoms, they areprobably frail:

� unintentional weight loss (ten or more pounds within the past year)

� muscle loss and weakness

� a feeling of fatigue

� slow walking speed

� low levels of physical activity.31

Frailty is a medical condition, not an age, and while it can sometimes be improvedthrough exercise or medicine adjustment it is a predictor of very poor healthoutcomes. Similarly, someone with a short life expectancy as the result of advanceddisease, such as cancer, heart failure or COPD, is unlikely to achieve a benefit fromcontinuing preventative therapies. Removing unnecessary medicines can helppeople to live well in the last years of their life and choosing a tool specific to frailtyfor the polypharmacy review is recommended (see Step 4). You can read moreabout frailty in the NHS England document Safe, compassionate care for frail olderpeople using an integrated care pathway, which is available here:www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf

Practice pointAiming to understand the patient’s perspective is key to this process. This beginsright from the start of the consultation, where you should aim to understand whata patient does and does not want from their treatment and from this consultation.After all, the patient is the only person who can choose whether or not they takethe medicines they have been prescribed. Watch the Polypharmacy in practiceconsultation videos on the CPPE website to see how the pharmacist aims tounderstand what the patient wants from their medicines. How do you do this inyour practice?

You can access the two Polypharmacy in practice consultationvideos in full here: www.cppe.ac.uk/polypharmacy

Section 3 Patient-centred approach to managing polypharm

acy

23

Step 3: Identify medicines with potential risksYou can now review the patient’s medicines according tothe best available evidence. You may find it useful to useone of the medication review tools outlined in Section 2,such as the STOPP START toolkit.

Another useful resource for this is the NICE Do not dosafety and productivity recommendations: a database drawnfrom current clinical guidelines and treatment appraisals,searchable by medicine name or medical condition. You canfind more information here:www.nice.org.uk/savingsAndProductivity/collection?page=1&pageSize=2000&type=Do%20not%20do&published=&impact=Unclassified&filter

Step 4: Assess risks and benefits in context ofindividual patient

Work with the patient and/or carer to assess the potentialbenefits and harms of each medicine in the context of theirpriorities. This will enable you to identify actualproblematic medicines and confirm or refute the potentiallyinappropriate medicines you have identified in the previousstep. It will also allow you to identify anything that is ofimmediate concern to you, the patient or both. To exploregeneral risks and benefits for each medicine, first considereach symptom and each medicine in terms of benefit andpotential adverse effects – consider medicines as guilty untilproven innocent and conditions as medicine-related untilproven otherwise.

When undertaking this review, you may wish to undertake the steps listed below.

� Consider which conditions are active, inactive, time-bound or resolved.

� Ask what is bothering the patient most and link this to the patient’s goals, whichmay need to be revisited at this time.

� Find out what perceived and actual harms or benefits they are experiencing foreach medicine in relation to their condition.

� Decide if there is a valid indication for each medicine, if the symptoms arevague or subjective, or if there is objective evidence of harm or benefit.

� Identify and manage new symptoms or conditions. It is important to note thatthese may be linked to starting a new medicine or relate to medicines started totreat a side-effect, ie, a prescribing cascade.

It is helpful to begin with open questions and focus on potential problemsidentified by the patient with closed questions; for example, “Tell me about yourpain medicines” (open question) and move towards more specific, “Do you thinkthe medicine is working?” (closed question).

Is the condition self-limiting?How do we know the answer to this question? Sometimes, the only way to knowis just to recommend, with the patient’s agreement, that the medicine is stopped.This should come with the caveat that medicines can be reintroduced at a laterdate if symptoms return. This is particularly true for medicines that have beenprescribed years ago for treating conditions such as vertigo. How do we knowthat it hasn’t resolved on its own if we keep prescribing? Sometimes during amedication review you have to challenge the status quo, even if the patientinitially thinks that everything is OK with their medicines and is having no issues.

24

Polypharmacy

Assess patient

Define contextand overall goals

Identify medicineswith potential risks

Assess risks andbenefits in context

of individual patient

Agree actions tostop, reduce dose,continue or start

Communicateactions with allrelevant parties

Monitor andadjust regularly

Assess patient

Define contextand overall goals

Identify medicineswith potential risks

Assess risks andbenefits in context

of individual patient

Agree actions tostop, reduce dose,continue or start

Communicateactions with allrelevant parties

Monitor andadjust regularly

Essential medicines are those that usually should not be stopped and should bediscussed with the patient’s specialist before suggesting any changes. The NHSScotland Polypharmacy guidance contains a list of these medicines in Table 2b(page 11).1 You can access this document here:www.sign.ac.uk/pdf/polypharmacy_guidance.pdf

Use your clinical judgement and experience, in relation to specific risks andbenefits for each medicine in the context of the individual patient, and consider thefollowing:

� Does each medicine have a matching indication; is the indication still valid?

� Does the medicine produce limited benefit for that indication?

� What is the evidence for benefit in older people and is this outweighed byunfavourable side-effects?

� Is the overall regimen tailored to the patient’s circumstances, morbidities,preferences, overall clinical and social situation and ability to adhere to theagreed regimen? Does each medicine fit in or conflict with the patient’s overallgoal?

� Will the patient live long enough to benefit?

Step 5: Agree actions to stop, reduce dose, continue or startIn most instances, you will be agreeing actions with thepatient first and then making these recommendations to theprescriber. Most commonly in polypharmacy you will bemaking recommendations to stop a medicine or reduce adose. Sometimes during a review of medicines you mayidentify that a medicine is missing, so in thesecircumstances it might be appropriate to suggest a medicineis started.

Stop or reduce the dose

Stopping medicines is often referred to as deprescribing.We will cover deprescribing more fully in the next section,but at this stage in the cycle you will need to decide if amedicine meets any of the following criteria:

� there is no valid indication for the medicine or the indication has expired

� the medicine is failing to achieve the intended therapeutic objective(s) despitetitration to a reasonable dose and good adherence by the patient for a reasonableamount of time

� the medicine, or the combination of medicines, is causing an unacceptableadverse drug reaction

� the known possible adverse drug reactions outweigh the possible benefits

� there is a risk of cumulative toxicity if particular medicines are taken together

� the patient is choosing not to take the medicine as prescribed or intended

� the patient is unable to take the medicine as prescribed or intended (there willoften be an alternative device or dose form available)

� the medicine is unlicensed/a special and an alternative licensed formulation ormedicine will provide the same benefit

� non-drug measures can provide the same benefit without adverse effects.1

If the medicine meets the criteria above, discuss the advantages and disadvantagesof stopping it with the individual (and their carer, if appropriate) and what suitablealternatives are available.

Section 3 Patient-centred approach to managing polypharm

acy

25

Assess patient

Define contextand overall goals

Identify medicineswith potential risks

Assess risks andbenefits in context

of individual patientAgree actions to

stop, reduce dose,continue or start

Communicateactions with allrelevant parties

Monitor andadjust regularly

Practice pointReport any adverse effect for a black triangle drug and all serious adverse drugeffects to the MHRA, using the Yellow Card Scheme. You can find out more on theMHRA website: https://yellowcard.mhra.gov.uk/the-yellow-card-scheme/

Once agreed with the patient, give some thought to the safest way to stop themedicine or medicines. You will need to have a discussion with the patient aboutthe risks and benefits of stopping medicines and together agree a course of actionthat you are both happy with. Make sure you have documented your joint decision.We have outlined some suggestions of how you might approach recommendingcertain medicines are stopped. But this does not override joint decision-makingwith the patient and considering individual patient factors when making arecommendation.

� Preventative therapies such as multivitamins or statins – consider stoppingtreatment.

� Blood pressure/blood glucose control medicines – consider reducing dose andmonitor blood pressure/sugar after two weeks. If no problems, reduce furtherand reassess in two weeks. If still no problems, consider stopping the medicine.

� Symptom control medicines, such as proton pump inhibitors, NSAIDs,hormone replacement therapy – talk to the patient about finding the dose thatcontrols their symptoms. Reduce dose and evaluate over a few days to a week; ifno problems, reduce further and stop after another week if possible.

� Essential medicines – it may not be possible to stop these medicines, and if it is,slow withdrawal may be needed over months rather than weeks. Consult thepatient’s specialist for advice.

Again, it is important to have a person-centred conversation (see above) about eachmedicine and the sequence in which medicines are stopped, based on the patient’spriorities and preferences. Try to provide the patient with a written record of howto reduce or stop the medicine. This document should also include:

� a list of signs or problems they should look out for

� contact details for a healthcare professional in case they have any questions

� a follow-up appointment (if one is needed).32

Start a new medicine

Not all medication review tools will help you to identify underprescribing, aproblem which is known to be prevalent in older people. Prescribers mayoverestimate the risks and underestimate the benefits of preventative therapies inolder people or make an assumption that older people do not wish to haveintensive treatments or an increased medicine burden.33 This has been called thetreatment-risk paradox because older people often have the highest absolutebaseline risk of poor outcomes and, therefore, the most to gain from treatment.34

Consider Asif Khan, a 75-year-old man with non-valvular atrial fibrillation whohas fallen twice in the last year but is otherwise well. The number needed totreat (NNT) for anticoagulation to prevent a stroke in Asif is around 60 and thenumber needed to harm (NNH) for anticoagulation causing a major bleed isaround 250.35 The benefits of anticoagulation are therefore likely to significantlyoutweigh the risks for Asif, but there is a 50/50 chance that Asif would beinappropriately denied anticoagulation because he has a history of falls.36

26

Polypharmacy

In addition to anticoagulants, the following classes of medicines are commonlyunderused in older people:

� calcium (osteoporosis)

� SSRIs (depression)

� ACE inhibitors, oral hypoglycaemics (diabetes)

� inhaled anticholinergic bronchodilators (COPD)

� beta-blockers(heart failure)

� antiplatelets, beta-blockers (acute myocardial infarction).37

Although treatment guidelines are not always applicable to older people, guidelinesand standards of care should not be ignored purely because an individual hasreached an advanced age. The NHS Scotland publication Polypharmacy guidance(available at: www.sign.ac.uk/pdf/polypharmacy_guidance.pdf ) is a usefulresource for establishing whether or not an individual may have an unmet need formedicine treatment or is being prescribed a medicine that they are unlikely to gainbenefit from because they are in the last years of their life.

Step 6: Communicate actions with all relevant partiesThe majority of pharmacy professionals will not carry outmedication reviews in a multidisciplinary meeting.However, polypharmacy cannot be managed independentlyand no pharmacy professional should go it alone.

Interprofessional and interdisciplinary working is veryimportant; as failure to communicate properly with theindividual, their carer and the health and social careprofessionals who support them can prevent successfulimplementation of an agreed action plan.

Communication with other members of the health andsocial care team also needs to be person-centred. Toachieve this you could:

� talk about “our patient”, not “my” or “your” patient

� explain problems using the patient’s language, not your own

� think holistically about the patient’s support network to identify the bestapproach for each individual patient.

Think about the following points when communicating with the prescriber toagree a plan.

� Where possible, arrange a face-to-face meeting with the prescriber (unless youare the prescriber yourself).

� Prepare a range of options for each medicine – discuss with the prescriber asappropriate.

� Present in a simple format, for example, by:

� medicine (try an ICARUS grid: indication, continuing problem, appropriatedose, reduction, uncontrolled symptoms, available at:www.dementia.jennerhealthcentre.co.uk/documents/oct11/ICARUS%20Grid.pdf )

� group of medicines to treat a condition

� being clear what action to take for each medicine.

Follow up with a written summary, highlighting rationale, agreed action for eachmedicine change, and monitoring, with a copy to the patient.

Section 3 Patient-centred approach to managing polypharm

acy

27

Assess patient

Define contextand overall goals

Identify medicineswith potential risks

Assess risks andbenefits in context

of individual patient

Agree actions tostop, reduce dose,continue or start

Communicateactions with allrelevant parties

Monitor andadjust regularly

Step 7: Monitor and adjust regularlyThe follow-up a patient needs after stopping a medicine(s)is as in-depth as the monitoring needed when a medicine isstarted. The vast majority of deprescribing is likely to besuccessful38 but some will not be and you should prepareyour patient for that eventuality. Agree a clear plan of actionwith the patient: what will be done and by whom if thepatient experiences withdrawal effects or a relapse in theirmedical condition. Make sure any changes you have madeare clear and communicated to the relevant people (withthe patient’s consent).

Practice pointSummarise what you have learnt in this section by listing five things you will do toensure you conduct patient-centred consultations.

1.

2.

3.

4.

5.

SummaryIn this section we have highlighted that managing polypharmacy is not as simple asstopping “problem” medicines, as inappropriate medicines for one individual maybe appropriate for another. The review process needs to take into account thepatient’s wants and needs, as practising person-centred care will help patients andtheir carers to take ownership of their treatment. Likewise, the process shouldinvolve other members of the health and social care team to promote effectivemultidisciplinary and cross-sector working.

Intended outcomesOn completion of this section you should be able to: Can you?

� explain how you could undertake patient-centred discussions about polypharmacy with patients during a medication review or medicines use review

� prioritise, in conjunction with the patient, what interventions to make, and make referrals to suitable professionals.

28

Polypharmacy

Assess patient

Define contextand overall goals

Identify medicineswith potential risks

Assess risks andbenefits in context

of individual patient

Agree actions tostop, reduce dose,continue or start

Communicateactions with allrelevant parties

Monitor andadjust regularly

Section 4Stopping medicines andsupporting patients

Learning objectives

On completion of this section you should be able to:

� explain the main considerations when stopping a patient’s medicines, what barriers might exist and how to overcome these

� describe the process of shared decision-making and recognise itsvalue in supporting adherence in patients taking multiplemedicines.

In the previous section we looked at a method of undertaking a patient-centredconsultation with a person taking multiple medicines. We briefly mentionedstopping medicines as part of this approach to reviewing polypharmacy, and wewill revisit this in more depth in this section. We will consider some of the barriersthat exist to stopping medicines and how you could help to overcome these. In thissection we will also explore shared-decision making and how you can bettersupport patients to take their medicines as intended.

4.1 Factors and barriers to deprescribingPatients do not need to take most medicines for their whole life, but while there islots of advice for prescribers on starting medicines, there is far less support fordecisions to stop medicines.

Stopping medicines sounds simple, but in fact there are many factors to considerwhen recommending a patient’s medicine or medicines are discontinued. You mayencounter barriers to deprescribing among prescribers, your colleagues, patients ortheir carers and even perhaps within yourself.39 It is a normal response to havesome difficulty dealing with uncertainty.40 Take care not to make assumptionsabout the person’s reasons for objecting; take time to understand their perspective.You may find they have a misunderstanding that can be resolved by discussion orperhaps a piece of information that you did not have. Common barriers todeprescribing and their potential solutions are presented in Table 1.

Section 4 Stopping medicines and supporting patients

29

There are many factors

to consider when

recommending a patient’s

medicine or medicines

are discontinued.

TABLE 1 Barriers to deprescribing

Barrier Potential solutions

Patients and prescribers Reframe the issue to one of high-quality, underestimate the risks of person-centred care. Consider using a patient polypharmacy information leaflet, such as the NHS Highland leaflet

on polypharmacy (available at:www.nhshighland.scot.nhs.uk/Publications/Pages/PolypharmacyPILs.aspx), in advance of or during your consultation.

Incentives to overprescribe Be prepared to discuss the evidence behind guidelinesand the benefits and harms to patients.

If one particular medicine seems to be problematic in a practice, arrange a time to talk with the prescribers to understand the factors driving the prescribing behaviour and reach a consensus on what to do about it.

Narrow focus on lists of Target patients at highest risk of adverse drug events potentially problematic holistically through the practice database or referral medicines systems instead of or in addition to medicines.

Patients and prescribers Reassure the patient that this isn’t a final decision, unwilling to discontinue a rather an experiment of them working with you to medicine for fear of what will optimise treatment which can be restarted if happen clinically required.

Start by targeting the medicine(s) more likely to benon-beneficial.

Have an open and honest discussion about the advantages and disadvantages of stopping medicines,being sure to listen for at least as much time as youtalk.

Stop medicines over an extended timeframe with a monitoring schedule and plan to restart the medicine or an alternative if needed. Make sure the agreed plan is acceptable to the patient.

Uncertainty about The General Medical Council has issued clear effectiveness of strategies to guidance for doctors about keeping up to date in areas reduce polypharmacy relevant to their practice (this is available at:

www.gmc-uk.org/static/documents/content/Prescribing_guidance.pdf).

You can access the references used in this guide toprepare yourself with effective strategies and engageknowledgeably on the topic with others.

Exercise 3When making suggestions to stop medicines, you are bound to encounteruncertainty.

1. How will you help your patient to deal with uncertainty?

30

Polypharmacy

2. How will you deal with your own uncertainty?

Turn to the end of the section for suggested answers.

4.2 Shared decision-making to support deprescribingMany people wish to be active participants in their own healthcare and to beinvolved in making decisions about their medicines. Patient decision aids cansupport health professionals to adopt a shared decision-making approach in aconsultation to ensure that patients, and their family members or carers whereappropriate, are able to make well-informed choices that are consistent with theperson’s values and preferences. This shared decision-making approach isimportant when starting or stopping medicines.

Adopting a shared decision-making approach includes the following steps:41

� Explore the patient’s ideas about the nature of the problem and potentialsolutions. You could ask, “Did you know there was a choice?” Sometimes theissue of patient safety may override a patient’s choice, but it is important to tryto involve the patient in the decision.

� Identify how much information the patient would like and tailor yourinformation to meet those needs. Patient.co.uk has a range of decision aids thatcan be accessed online or printed, NICE guidelines have a plain Englishsummary and NICE has produced two patient decision aids for preference-sensitive decisions – atrial fibrillation and lipids – which are available at:www.nice.org.uk

� Check the patient understands the advantages and disadvantages of theiroptions. A blank option grid can be a useful tool to complete during theconsultation (a number of evidence-based option grids are available through theNHS England website at: www.england.nhs.uk/ourwork/pe/sdm/tools-sdm/option-grids) and for the patient to take away with them afterward.

� Establish what the person needs to make their decision and provide it (eg, moreinformation, time to consider or discuss with family, to know what you mightchoose in their position).

� Action the decision and arrange follow-up.

Sometimes when there are decisions to be made, ie, where two or more treatmentshave a very similar chance of good outcome or where the treatment choices havevery different outcomes and very different side-effects, you may need to presentthese to a patient in a way they can understand. In these instances the right choicedepends on the values and preferences of the individual. You will need to discussoptions with the patient and agree a way forward (including explaining referral tothe prescriber).

Section 4 Stopping medicines and supporting patients

31

Framing effectA framing effect is an example of cognitive bias, in which people reach aparticular choice in a different way depending on how it is presented. In ahypothetical case, participants were asked to choose between treatment A andtreatment B.

� People who take treatment A have a 33 percent likelihood of survival.

� People who take treatment B have a 66 percent chance of dying.

A study found that 72 percent of participants would choose treatment A, whichwas positively framed, and only 22 percent would take treatment B, which wasnegatively framed.42

Although this is a hypothetical case, we must be careful to avoid introducingbias by presenting both the risks and benefits of treatments objectively and in away the patient can understand. NICE makes recommendations on this, whichyou can find in the NICE guidelines Patient experience (CG138) and Medicinesoptimisation (NG5).

Practice pointHow do you present treatment choices to a patient? Have you ever put yourself intheir shoes and considered how your decisions may be interpreted by a patient?

Use the shared decision-making approach we have explored to ask a familymember or friend about their condition. Get some feedback from them on yourapproach.

4.3 Adherence strategiesAs part of your polypharmacy review, you may identify that patients are not takingtheir medicines, despite having an apparently long list. Given some of thechallenges of taking multiple medicines that we discussed in Section 1, this isperhaps not surprising. Aiming to understand these reasons is important, and oneway of doing this is through health coaching. People who are not adhering to theirmedicines regimen can identify the reasons for this and effectively work aroundtheir own barriers through health coaching. You may be lucky enough to haveaccess to a health coach in your work; if not you could adopt some behaviourchange and coaching techniques in your patient encounters. For furtherinformation, see the four Es approach in the CPPE Consultation skills for pharmacypractice: taking a patient-centred approach distance learning programme (available at:www.cppe.ac.uk/programmes/l/consult-p-02/), which is based on the GROWmodel, an effective method of empowering patients to achieve their health goals.

32

Polypharmacy

John Whitmore’s GROW coaching model43

G Goal: What benefit(s) do you want to get out of your medicines?

Help the patient set a specific, measurable, achievable goal so they will know when they have achieved it.

R (Current) Reality: What are the issues and challenges? How far away are

you from your goal?

O Options (or Obstacles): What is stopping you achieving your goal?

What could you do about that?

W Will (or Way forward): Which of those options are you going to choose?

When will you do that?

Practice pointWhat approaches do you use in your practice to make decisions and agree a planof action with patients and/or their carers? Have you ever used health coaching,the four Es or GROW? If you haven’t done so before, try it out in your next patientconsultation.

When agreeing changes to a patient’s medicines, it’s important to provide themwith verbal and written information about what you have suggested. You may wishto provide written information in the form of a patient-held medicines record, forexample, a medication passport. This is a pocket-sized record of a patient’smedicines and can also include patient and prescriber details, medicines theycannot take and why, and changes to current medicines and why. This wasdesigned by patients for patients. The passport can help empower patients, helpthem understand the reasons for their medicines and changes that are made. It canalso help them to keep all the information in one place when they move betweendifferent healthcare settings.

This could work well for this purpose but remember to choose a method that suitsthe individual – they may already carry a record of their medicines or prefer to usea smartphone app, for example.

You can find more information about medication passports at: http://clahrc-northwestlondon.nihr.ac.uk/resources/mmp

How do I get a copy of My Medication Passport?You can get a hard copy that the patient can carry around and a copy on asmartphone (www.networks.nhs.uk/nhs-networks/my-medication-passport/my-medication-passport-on-smart-phones). You can also obtainpaper booklets of the passport through an online order form.

Section 4 Stopping medicines and supporting patients

33

SummaryIn this section we have reviewed the barriers that exist to stopping medicines andhow you could overcome these, making sure you address both the patient’s andyour own uncertainties. We have considered some of the ways you can fully engagethe patient through shared decision-making. We have also considered how you canbetter support patients to take their medicines as intended, using patient-heldmedicines records and a GROW approach to health coaching.

Intended outcomesOn completion of this section you should be able to: Can you?

� explain the main considerations when stopping a patient’s medicines, what barriers might exist and how to overcome these

� describe the process of shared decision-making and recognise its value in supporting adherence in patients taking multiple medicines.

Suggested answer

Exercise 3 (page 30)When making suggestions to stop medicines, you are bound to encounteruncertainty.

1. How will you help your patient to deal with uncertainty?

2. How will you deal with your own uncertainty?

1. Helping your patient to deal with uncertainty

� Encourage them to express their feelings about the decision.

� Put yourself in your patient’s shoes; is the decision in line with what they want toget out of the consultation?

� Use a shared decision-making approach to involve the patient.

� Give them enough time to weigh up their options. If you are deferring thedecision to a later time, consider giving your patient an option grid, printedinformation or address of the website you have used in your discussions.

� Ask if they would like to discuss their options with someone else in their family orhealthcare team.

� Reassure them that they can come back to you and review the decision.

2. Dealing with your own uncertainty

� Use a shared decision-making approach. Two options that are similar to youmay be different from the perspective of your patient.

� Keep the patient and their desired outcomes at the centre of all decisions.

� Sometimes there is no obvious right answer. Remind yourself of all the times youhave coped with uncertainty in other areas of your life; your patient also hasthose coping skills to a lesser or greater degree. It is OK to discuss youruncertainty with your patient; this process relies on you being honest with eachother and it will help them if you explain the reasons for your uncertainty.

� You are not alone; talking it through with another healthcare professional canhelp clarify things in your mind. Is there someone you can call upon in yourteam, the GP practice or your clinical network? Nurses tend to be particularlyskilled at reflective practice and might ask you just the right question.

34

Polypharmacy

Section 5Polypharmacy in differentsettings

Learning objective

On completion of this section you should be able to:

� identify a change you could make to your practice to improve yourapproach to managing polypharmacy.

Many of the issues highlighted in the previous sections will be relevant to cliniciansand patients, regardless of their setting. In this section we will describe key areas offocus for different sectors of pharmacy, based on evidence for particular barriersin each setting. We will encourage you to identify a change you could make to yourpractice to better recognise polypharmacy and improve the support you offer topatients taking multiple medicines.

5.1 Community pharmacyIf you work in community pharmacy you have a key role to play in recognisingpolypharmacy, as patients present to you every time they collect a prescription.You and your team can identify people who are suffering from adverse effects oftheir medicine(s) or who are struggling to cope with a medicines burden. You cando this when patients present for over-the-counter medicines by looking out forpeople presenting with certain trigger symptoms that might be related to amedicine side-effect. This relies on the whole team being able to recognise theseand refer appropriately.

The whole team also has a role to play in recognising when a patient or their carermight be struggling with their medicines. Throw-away comments from patientsabout their medicines being a burden should be explored in more detail. When youoffer a service such as a medicines use review or the new medicine service you canidentify not only adverse effects but also patients who are taking medicines whichmay no longer be needed.

Closer multidisciplinary working between general practice and communitypharmacy has been highlighted as an area for development. The King’s Fundsuggests that regular meetings between GPs and pharmacists allows pharmacists tohighlight significant medicines issues and recommend how these should be dealtwith.5 Likewise, GPs would have the opportunity to engage in discussion withpharmacists about any dispensing errors or suggest appropriate advice to be givento patients.

Repeat dispensing systems, if used appropriately, are a valuable resource forpatients. In order to make sure medicines are being ordered appropriately, thepharmacy team should make sure they check the necessity and continuation ofmedicines use by the patient to avoid unnecessary waste or confusing patientsand/or carers by supplying discontinued medicines.

Section 5 Polypharmacy in different settings

35

You and your team can

identify people who are

suffering from adverse

effects of their medicine(s)

or who are struggling to

cope with a medicines

burden.

Regular meetings between

GPs and pharmacists

allows pharmacists to

highlight significant

medicines issues and

recommend how these

should be dealt with.

Practice pointIf you work in community pharmacy, what will you do to make sure that yourpharmacy team has the required knowledge to support patients taking multiplemedicines?

5.2 Secondary care pharmacyIf you work in hospital, you will have a key role in medicines reconciliation andreviewing patients at admission. This is an opportunity to recognise patients whomay have been admitted to hospital due to adverse effects of polypharmacy, aspatients taking many medicines are more likely to be admitted to hospital. You candiscuss this with the medical team and ensure that medicines that are causingadverse effects or are no longer needed are stopped.

This is also an opportunity to find out how a patient is managing with theirmedicines. We know that transferring between care settings can have an impact onthe accuracy of patients’ medicines, making reconciliation on admission andeffective communication on discharge vital.

As we’ve already highlighted, patients admitted to hospital are likely to bedischarged on more medicines than they are admitted with. If this change has beenmade by a consultant, there can be a reluctance to review or make any changes tothese medicines once the patient is discharged. Sharing discharge documents on apatient’s discharge from hospital can be an important step in improvingcommunication between sectors and ensuring that medicines are reviewed/stoppedas intended by secondary care.12 Clearly documenting plans for medicines to bereviewed or stopped on discharge documents can be really valuable for colleaguesin primary care and will reduce the likelihood of medicines being continuedunnecessarily.

Practice pointIf you work in secondary care, what will you do to make sure information iscommunicated effectively when patients are transferred between care settings?

5.3 Primary care/general practice pharmacyIf you work in primary care you have a key role in engaging with patients todiscuss their medicines as part of an annual medication review. Focusing onpatients taking multiple medicines may already be part of your focus. Primary careteams who work within GP practices have the opportunity to talk directly withprescribers to share messages and highlight areas for change in practice. You areable to optimise medicines and highlight patients who may be taking potentiallyproblematic medicines, for example, patients taking multiple medicines withanticholinergic properties. 36

Polypharmacy

Transferring between

care settings can have an

impact on the accuracy

of patients’ medicines,

making reconciliation on

admission and effective

communication on

discharge vital.

Primary care teams who

work within GP practices

have the opportunity to

talk directly with

prescribers to share

messages and highlight

areas for change in

practice.

Following up patients who have recently been discharged from hospital can help toidentify patients who have been started on new medicines that need to be reviewedor discontinued at a later date.

For pharmacy professionals who support care homes, this is an area in which youcan have a significant impact on polypharmacy. A study into medicines in carehomes found that care home residents were taking an average of eight medicineseach, and identified problems with the way these medicines were managed.9

Pharmacy professionals have a key role in the review of medicines, particularly forpatients taking riskier medicines.

Practice pointIf you work in primary care/general practice, how will you engage your colleaguesto ensure you all recognise polypharmacy and take a joined up approach tosupporting patients taking multiple medicines?

SummaryPolypharmacy is a significant and growing issue, affecting patients in all healthcaresettings. It is a complex issue and possibly the result of many factors. In many ways,polypharmacy is a necessary evil, particularly for patients with multiplemorbidities who require multiple medicines to manage their conditions. However,there are still large numbers of patients who are prescribed multiple medicinesinappropriately, and these individuals may not benefit from these treatments ormay suffer side-effects and adverse events as a result.

Everyone has a role to play in supporting patients taking multiple medicines, andwe have highlighted a wide range of resources to support you in this process. Wehope this learning programme has highlighted to you some of the key issues in thisarea and the actions that you can take in your own area of practice.

Intended outcomeOn completion of this section you should be able to: Can you?

� identify a change you could make to your practice to improve your approach to managing polypharmacy.

Section 5 Polypharmacy in different settings

37

Practice development resources

NHS PrescQIPP website

This website includes polypharmacy and deprescribing resources, e-learning and avirtual support group for NHS healthcare professionals. It’s free to register butsome resources are only available to professionals working in primary care. www.prescqipp.info/projects/polypharmacy-and-deprescribing

Welsh Polypharmacy guide (July 2014)

This document offers guidance and advice for prescribing in frail adults.www.awmsg.org/docs/awmsg/medman/Polypharmacy%20-%20Guidance%20for%20Prescribing.pdf

NHS Scotland Polypharmacy guidance (March 2015)

This resource may help you structure your medication reviews. Please note thatthe patient data and cost-benefit calculations are specific for Scotland.www.sign.ac.uk/pdf/polypharmacy_guidance.pdf

Specialist Pharmacy Services (Medicines Use and Safety Division) A patient-centred approach to polypharmacy (2015)

This resource provides a structure for undertaking a patient-centred consultationwith patients taking multiple medicines. We have covered this approach in detail inSection 3 of this programme.

You can download this resource by clicking the link at the bottom of this web page:www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/Service-deliv-and-devel/Older-people-care-homes/Polypharmacy-oligopharmacy--deprescribing-resources-to-support-local-delivery/

NICE Local practice collection

This is a searchable database of successful quality and productivity projects andshared learning. Sign up for weekly email updates.www.nice.org.uk/localPractice/collection

Person-centred care website

This website provides information about the benefits of and barriers to person-centred care, including practice examples; explore The Health Foundation’s

person-centred care resource centre.http://personcentredcare.health.org.uk/

Consultation skills for pharmacy practice: taking a patient-centredapproach distance learning programme and programme update(November 2015)

Effective consultation skills are essential for person-centred care; CPPEhas a distance learning programme and workshop to support you to meetyour professional responsibilities for the new practice standards forconsultation skills. www.cppe.ac.uk/programmes/l/consult-p-02

We also have a searchable database of learning programmes on ourwebsite which cover a wide range of skill development needs, such asassertiveness, and knowledge development needs, such as antipsychoticreview in dementia or inhaler technique assessment.www.cppe.ac.uk/programme-listings/a-to-z

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Polypharmacy

References1. Scottish Government Model of Care Polypharmacy Working Group.

Polypharmacy guidance. Second edition. 2015.www.sign.ac.uk/pdf/polypharmacy_guidance.pdf

2. Pirmohamed M et al. Adverse drug reactions as a cause of admission tohospital: prospective analysis of 18,820 patients. BMJ 2004;329: 15-19.

3. Kongkaew C et al. Risk factors for hospital admissions associated with adversedrug events. Pharmacotherapy 2013;33(8): 827-837.

4. World Health Organization. Medicines: rational use of medicines. Fact sheet no. 338,May 2010. www.wiredhealthresources.net/resources/NA/WHO-FS_MedicinesRationalUse.pdf

5. Duerden M et al. Polypharmacy and medicines optimisation: making it safe andsound. The King’s Fund. 2013.www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf

6. Department of Health. Long-term conditions compendium of information. Thirdedition. Crown Copyright. 2012.www.gov.uk/government/uploads/system/uploads/attachment_data/file/216528/dh_134486.pdf

7. Health and Social Care Information Centre. Prescriptions dispensed in thecommunity, statistics for England – 2004-2014 [NS]. 2015.www.hscic.gov.uk/catalogue/PUB17644

8. Payne RA et al. Is polypharmacy always hazardous? A retrospective cohortanalysis using linked electronic health records from primary and secondarycare. British Journal of Clinical Pharmacology 2014;77: 1073-1082.

9. Barber ND et al. Care homes’ use of medicines study: prevalence, causes andpotential harm of medication errors in care homes for older people. Qualityand Safety in Health Care 2009;18(5): 341-346.

10. Betteridge TM et al. Polypharmacy – we make it worse! A cross-sectional studyfrom an acute admissions unit. Internal Medicine Journal 2012;42: 208-211.

11. Picton C and Wright H. Keeping patients safe when they transfer between careproviders – getting the medicines right. Royal Pharmaceutical Society. 2012.www.rpharms.com/previous-projects/getting-the-medicines-right.asp

12. National Institute for Health and Care Excellence. Medicines optimisation: thesafe and effective use of medicines to ensure the best possible outcomes (NG5). 2015.www.nice.org.uk/guidance/ng5

13. Rochon PA and Gurwitz JH. Optimising drug treatment for elderly people: theprescribing cascade. BMJ 1997;315: 1096.

14. Fried TR et al. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. Journal of the American GeriatricsSociety 2014;62(12): 2261-2272.

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References

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NNO TEARS tool 18

Ppatient-centred approach to managingpolypharmacy in practice 20-28

patient-centred care 14-15

polypharmacy, causes 3-7, 10

polypharmacy, definition 1

primary care/general practicepharmacy team, role of 36-37

Rreflex prescribing 4-5

Ssecondary care pharmacy team, role of 36

shared decision-making 3, 31-32

STOPP START toolkit 17-18

Ttransfer of care 4

trigger signs 15-16

IndexAadherence 1, 3, 9, 15, 18, 33

adverse drug events 9, 30

anticholinergics 9-10, 27

BBeers Criteria 18

Ccare homes 16, 37

community pharmacy team, role of 35-36

consultation skills 14-15, 33, 38

Ddeprescribing 25, 28, 29-30, 38

drug effectiveness summary 18

Eend of life 2, 18

Ffalls 7, 9, 10, 26

frailty 4, 23

Framing effect 32

GGROW coaching model 33

Hhospital admissions 1, 8-9

MMedication Appropriateness Index (MAI) 17-18

medication review tools 16-19, 26

medicines optimisation 4, 14, 18

medicines reconciliation 22, 36

multimorbidity 4

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