Medicines Optimisation in Older People:

Case Management

Catherine Leon

GSTT Community Health Services

October 2012

Case Management Pharmacist

Support patients on Community Matron

caseload who are at risk of medicines related

issues

– Optimise Medicines

– Reduce polypharmacy

– Improve adherence

Background

Community Matrons

– Case Managers

– Act as a single point of contact for patients for

care, support and advice for high intensity

patients

– Patients gathered from GP surgery lists using

computer program

– Patients referred by GP surgery

Patients

Patients at high risk of hospital admission

Complex patients, may have:

– Complex medicines, polypharmacy

– Multiple long term conditions

– Frailty, reduced mobility and dexterity

– Reduced vision, impaired hearing

– Deteriorating renal function

– Reduced cognition

– Social issues e.g. isolation, language or literacy problems

Referral to Case Management Pharmacist

Does the patient need help getting a regular supply of their medicines? Access issues

Does the patient always take his/her medicines the way the doctor prescribed them? Non-adherence issues

Can the patient swallow and use all of his/her medicines and get them all out of their containers? Unintentional non-adherence issues

Does the patient think some of his/her medicines could work better? Clinical issues

Prioritising patients

More than 10 medicines/day or 12 doses/day

Drugs with narrow therapeutic index or increased risk in older people (psychotropics, benzodiazepines, NSAIDs, insulin, opiates)

Swallowing difficulty

Falls risk

Known adherence issues

Communication difficulties

Complex devices

Complex regimens (e.g. warfarin, bisphosphonates, PD meds)

Age over 85

Deteriorating or poor renal function

Uses a dosett box

During the visit

Conversation with patient to gather information

Explore all areas of medicine taking

– Patients beliefs regarding medicines

– Access to pharmacy and GP services

– Physical ability to take medicines (insulin, inhalers, screw

caps)

– How patient is taking their medicines

– Patients knowledge of medicines and side effects

– Any other issues patient is experiencing with health or

medicines

Optimising medicines

Clinical review – Blood tests (e.g. TFTs), adherence to guidelines,

control of disease states

Appropriateness of prescribed medicines – E.g. antihypertensives in patient with falls and low

BP

Efficacy of prescribed medicines – E.g. pain control, number of times salbutamol or

GTN required, blood pressure

Reduce Polypharmacy

Ensure all medicines have an indication

Ensure all medicines are needed

Confirm all medicines are suitable for this patient

Trial withdrawal of medicines where appropriate

Monitor changes

– E.g. BP monitoring, blood tests, patient satisfaction

Improve adherence

Explore non-intentional adherence and find

solutions with patient

– E.g. ability to read, swallow, open bottles, use

inhaler devices or insulin pens and testing

equipment

– Try out devices to improve adherence, e.g.

haleraids, spacers, dosett boxes, medicine record

card, large print labels

Improve adherence

Explore reasons for intentional non-

adherence

Provide rationale and teaching behind

prescriptions where appropriate

Develop plan with patient as to how to

proceed

– e.g. alternative agent, different formulation,

different packaging

Following patient visit

Arrange appointment with GP to discuss clinical

issues

Liaise with community pharmacy

Organise any follow up monitoring by DNs, GP

practice or Community Matrons

Liaise with social services where appropriate

Arrange follow up visits with patient if required for

adherence support and monitoring

– E.g. following up dosett boxes and inhalers etc

Benefits to patients

Opportunity to ask questions, learn about medicines,

get assistance where needed

Appropriate medicines

Reduced pill burden

Empowerment and engagement with medicines

Improved health outcomes

– E.g. breathing easier, pain controlled, diabetes control

improved

Prevention of adverse drug reactions

QIPP Benefits

Reduced polypharmacy – Reduced spend on wasted medicines

Positive patient experience

Increasing skills and knowledge of Community Matrons

Increased collaboration between different health professionals e.g. GPs, community pharmacist, district nurses, community matrons, social services, occupational therapy, physiotherapy

?Reduced use of emergency services

?Fewer medicine related admissions

Example Patient

Mrs S

PMH:

– Hypertension

Most recent BP readings: 198/103 and and 180/94mmHg

– Epilepsy

– Low bone mineral density

– Hypothyroidism

– Vertigo

– COPD

Mrs S - Medicines

Amlodipine 10mg OD

Candesartan 32mg OD

Atenolol 100mg/

chlortalidone 25mg OD

Moxonidine 300mg OD

Doxazosin 8mg twice OD

Levothyroxine 75microg OD

Carbamazepine 200mg TDS

Dosuliepin 75mg at night

Peppermint oil capsules

TDS

Betahistine 8mg three times

daily

Adcal D3 2 daily

Seretide 250microg MDI, 2p

BD

Tiotropium 18microg OD

Salbutamol 100microg PRN

Mrs S - Issues

Adherence

– Medicines in MDS

– Brand changes leading to altered tablet

appearance

– Mrs S felt disempowered and did not trust

pharmacy

– Stopped taking altogether

Mrs S - Issues

Clinical

– BP not controlled despite maximum doses of most meds

– Unable to have zolendronic acid infusion due to

uncontrolled high BP

– Moxonidine should not be used in epilepsy and can cause

dizziness

– Salbutamol MDI not compatible with volumatic spacer

– Dosuliepin increases risk of falls

– Needs TFT levels checked again to ensure not over

replacing thyroid hormones

Mrs S - Actions

Medicines in original packs and medicine reminder chart provided

Discussed with consultant at hypertension clinic – In view of poor adherence, all HT medicines stopped except

amlodipine and candesartan

– BP monitored twice weekly

– Agreed with patient to continue co-tenidone

– Adherence monitored by Case Management Pharmacist

Aerochamber supplied to fit with all inhaler devices

Dosuliepin stopped

Patient reduced peppermint oil capsules to PRN

Mrs S - Outcomes

Better control of blood pressure? – Engagement with patient

– Patient feels control of her BP medicines

– Empowered to adhere to therapy

Reduced polypharmacy and waste – Dosuliepin, moxonidine, peppermint oil capsules

all stopped with no ill consequences (had not been taking)

Patient satisfaction

Thank you!

Catherine Leon

Case Management Pharmacist

GSTT Community Health Services

Catherine.Leon@nhs.net