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A LEADING pharmacologist says the medical community needs to “get on the same page” when it comes to reviewing medications for older patients, after an Australian study revealed that polypharmacy was not being addressed in acute care hospitals.
Dr Sepehr Shakib, director of the department of clinical pharmacology at Royal Adelaide Hospital, told MJA InSight that “older patients have been on a long journey with their medications, and reviewing which treatments should be continued or stopped is a complicated process”.
“It’s like trying to untangle a knot that has been created by various individuals”, he said.
Dr Shakib was commenting on the study published in this week’s MJA that examined medication changes of 1220 patients aged 70 years or older admitted to 11 acute care hospitals in Queensland and Victoria between 2005 and 2010. (1)
The study authors categorised the number of regularly prescribed medications for each patient as non-polypharmacy (0–4 drugs), polypharmacy (5–9 drugs) and hyperpolypharmacy (more than 10 drugs).
They found that on admission to hospital three-quarters of patients received five or more drugs, and more than a fifth received 10 or more.
Polypharmacy was significantly associated with an increase in comorbidities, presence of pain, and dependence in terms of instrumental activities of daily living.
The authors found that the mean number of prescribed medications per day remained high at discharge, with no clinically meaningful change in the classification (symptoms control, prevention, or both) of drugs prescribed. The prevalence of medications such as statins, opioid analgesics, antipsychotics and benzodiazepines, also did not change significantly.
The results indicated that active attempts were not made in acute hospital wards to deprescribe medications when appropriate, the authors wrote.
However, they said that when and where medications should be rationalised had not yet been established, and home medicine reviews led by pharmacists had so far proven ineffective.
“Perhaps only a medication review underpinned by careful consideration of the health status of the patient concerned, including estimation of life expectancy and exploration of individual goals of care, is likely to result in clinically meaningful outcomes”, the authors said.
Professor Richard Day, director of clinical pharmacology and toxicology at St Vincent’s Hospital, Sydney, told MJA InSight that while the study highlighted a missed opportunity to review patient medication, acute hospital wards generally did not have the resources, or the time, to conduct individual evaluations.
Professor Day instead believed the key to improving the process of medication review was better communication channels between different areas of the health care system.
“We need to be confident that wherever a patient is [in the system], everyone is aware of what medications they are taking”, he said.
Associate Professor Graeme Miller, medical director of the Family Medicine Research Centre at the University of Sydney’s School of Public Health, told MJA InSight that GPs, not hospitals, were the ones best placed to conduct medication reviews, because they had a more detailed understanding of their patient’s history and needs.
He said that individual patient knowledge was vital to the review process, an element which was lacking in the pharmacist-led home medicines review initiative. “This program didn’t do anything. It is drug focused, not patient focused”. (2)
Professor Miller was also concerned that only patients over the age of 70 years were included the MJA study.
“A common erroneous conclusion is that polypharmacy is just a problem for the over-70s, but increasingly younger people are being prescribed preventive medications, like statins”.
The at-risk group for adverse effects from polyphamarcy should be broadened to include patients aged over 45 years, Professor Miller said.
Dr Evan Ackermann, chair of the Royal Australian College of General Practitioners’ National Standing Committee for Quality Care, agreed that medication reviews were largely the responsibility of GPs, but said a multidisciplinary and collaborative approach was still important.
“Medication optimisation does require an extensive patient history and understanding of the prescribing rationale, but it also requires enhanced drug surveillance and monitoring”, Dr Ackermann told MJA InSight.
“Perhaps the time has come where monies devoted to home and residential medicine reviews should be directed to piloting general practice-based pharmacists, and establishing medication services within general practice.”
1. MJA 2015; 202: 373-377
2. Professional Pharmacists Australia. Update on Professional Services: Home Medicines Review
(Photo: Yuri/ iStock)
Maureen perhaps it is better said the patient is the centre of care and the patients GP is the central professional involved. The GP needs time to listen otherwise he or she cannot provide care. And if the GP knows the patient then that central role in care can be undertaken. However poly GP means that central role is lost
Since May 2012 I have been a practice pharmacist in a large, multi-disciplinary general practice in Adelaide. I conduct Home Medicines Reviews (HMRs) in patients’ homes with full access to medical records in real time via enabling technologies. To address discontinuity of care in medication management, GPs in our practice refer patients to me to conduct timely post-discharge reviews. I take the time and effort that Ms Deirdre Criddle highlights is necessary to “listen, and disentangle the truth behind the patient’s medicine story”. Acknowledging that a lack of individual patient knowledge can compromise the HMR process, as highlighted by Assoc. Prof. Graeme Miller, full access to case notes, strong professional relationships with GPs and often a pre-existing relationship with the patient via a previous encounter(s) can greatly enhance the quality of the HMR process, and has been acknowledged in feedback from GPs, patients and community pharmacists. Previous professional roles mean I also have existing professional relationships with hospital-based pharmacists which are valuable when clarification about medication changes made in hospital is needed. Further, my practice pharmacist role enables me to act as a conduit between general practice and community pharmacy. Currently, the only mechanism for me to receive payment for my services is via HMRs. It would seem timely, as suggested by Dr Evan Ackermann, to direct funds to piloting general practice-based pharmacists, and establishing medication services within general practice. This would be a facilitator to “getting on the same page” as has been called for by Dr Sepehr Shakib and a big step towards our common goal of improving patient care, especially patients with polypharmacy.
I am a 77 year old woman with the quaint idea that the patient should be at the centre of patient care, not the GP. In my early seventies, following a series of exeedingly stressful life events, I was diagnosed with hypertension. Within a week of beginning beta-blocking medication, I became very unwell. Repeated visits to several general practitioners (one after the other) resulted the prescription of increasing dosages and more and more medication in spite of my questioning the need. My mental and physical health deteriorated. My protests that I’d worked until I was 65, completed a PhD when I was 68 and my first book had been published the following year fell on deaf ears. It was an effort to string five words together. Nor did they hear that until I turned seventy I swam 1000m three times a week. By the time I was 72 I could barely walk to the letterbox. I was embarrassed and ashamed that I was ill and could get no one to listen.
All of this changed when I confided in one of my daughters. She made an appointment with a physician who listened! I was hospitalised and my medications reviewed and changed to minimal amounts of essential hypotensives. My health improved dramatically. I am now a well, competent person. Thank God for doctors who listen to their elderly patients.
it is essential that the patient’s GP is the hub. Too often have I seen essential antidepressants or other medications removed in hospital when the patient’s history is not known. Good medicine is a collaboration with the GP at the centre of patient care. As specialists we are often best as consultants. If only governments (and all health professionals including us In the medical profession) could understand that and allow GPs to carry out their crucial role instead of undermining them in financial and other ways. The monitoring of ongoing need for medication etc is the responsibility of all doctors especially the GP who has, or should have, all the information from those involved in patient care (though the patient needs to have their own GP and is not involved in the all to regular poly-GP).
Doctors are to blame for polypharmacy, incluidng myself. And I almost laughed when I saw that in this study they called it “hyperpolypharmacy” when the patient was on more than TEN medications!! I am not sure what the largest number I have seen in a hospitalised patient is, but I certainly remember elderly patients on 22, 24, 26 and 28 separate medications. So I am not sure there is any suitable word to describe that number.
I once had an elderly patient who was on more than 20 separate medications (the list had been gradually increased by GPs and hospital doctors over the years). They were generally unwell, and I never really found out why – I took them off everything except five medications which I felt were essential. The patient made a full recovery. And then their relatives said “So, should we restart all those other medications when they go home?”
Doctors and Pharmacists will never be on the same page until pharmacists realise their strengths and stop trying to be doctors. Their knowledge of disease and of therapeutics is poor. Doctors generally are good at thereapeutics and poor at pharmacology. The reverse is true for pharmacists. It should be a match made in heaven. But, alas, it is rarely the case and, in my view, never will be while they continually try to take work away from GPs. Did I hear the AMA is lobbying for the right for GPs to dispense? Sadly not I fear. Role substitiution and the blurring of margins I fear will eventually spell a disaster for some unsuspecting patient.
The only way forward in an increasingly fragmented healthcare system is collaboratively. Every medicine has a story. Sadly, most healthcare professionals are too time poor to listen. It usually takes a sentinel event – such as hospitalisation before anyone asks – how did it come to this? Understandably doing nothing is often easier than actively deprescribing where the knowledge of why, when and who prescribed the medication fades with time. It takes clinicians prepared to work longitudinally with patients and all the members of a patient’s medication management team to confront this growing problem in patients with chronic complex multimorbidity. The red pen sounds attractive, and research seeks answers by studying single interventions. However, history and a plethora of studies shows it isn’t that simple. To effect sustainable change, deprescribing must be done with respect for the patient and their journey. Longitudinal, iterative and collaborative review between all those involved in a patient’s medication management is the only way forward. Is it time to embed pharmacists within General Practice and ensure someone is given the time and the role to listen, and disentangle the truth behind the patient’s medicine story?