Help older patients by tackling overprescribing
Polypharmacy puts many older people at risk of serious side effects
Polypharmacy puts many older people at risk of serious side effects
- Report shows medicines prescribed to older people in excessive numbers and unsafe combinations
- Nurses, including non-prescribers, are well-placed to spot inappropriate polypharmacy
- Reducing or stopping drugs can have important benefits, such as improved mobility and alertness
When Anna Mould sees a new patient at the acute hospital where she works as an older people’s mental health liaison nurse, one of the most effective things she does is check their medications.
Simply by reviewing what they are taking – or not taking – and rationalising it where required, she says she can make a huge difference to people’s health and their lives.
‘Her mobility improved, just with two drugs being taken away’
‘Quite often they’ve got two or three drug charts and you read through and think, “Where did all these come from?” I had a lady last year who was in her eighties, and she was on about 16 or 17 drugs,’ she says.
‘Five of them were psychiatric medications, and looking back through her history there were a couple that I couldn’t even find when they were started or why. She was very unsteady on her feet, she had issues with constipation and we diagnosed her with dementia.
‘My job was to look at the drugs that she was on and start chipping away. We managed to get her off an antipsychotic and reduced, then stopped, amitriptyline, and in the short time she was in hospital her mobility improved, just with those two drugs being taken away. She was more engaged, she was brighter – she still had cognitive difficulties but she wasn’t so withdrawn and slumped.’
Two million older people are on seven or more prescription medicines
This patient is by no means alone. A report published in August by Age UK revealed that nearly two million older people were on seven or more prescription medicines, putting them at risk of potentially serious or even life-threatening side effects.
The report, More Harm than Good, warns that medicines are sometimes being prescribed in excessive numbers, in unsafe combinations, without the consent or involvement of the older person concerned and without the support that older people need to take them.
Age UK is calling on the government to take into account the harmful effects of inappropriate polypharmacy on older people as part of a review of overprescribing in the NHS.
Nurses have a role to play in preventing and addressing medication problems in older people, says Tom Gentry, senior health influencing policy manager at Age UK, not least in being prepared to have open and honest conversations with their patients.
‘One of the issues we’ve encountered many times over the years is that when someone is told that we want to reduce their dose or stop a medicine, they sometimes feel they’re going to get less care – they feel they’re being given up on. So on one level we wanted to demonstrate to the public that it’s not good to be on double figures of medicines except in exceptional cases, and there are good reasons for doing it,’ says Mr Gentry.
‘When someone is told that we want to reduce their dose or stop a medicine, they sometimes feel they’re going to get less care’
Tom Gentry, Age UK
On the other hand, when asked about how they manage their medicines, many people will respond that they hate it because it’s too difficult, which can also affect adherence. Speaking to them one-to-one tends to lead to them being happy to have levels of medicines reduced, says Mr Gentry.
One reason why nurses can contribute is that they have a good overview of the many prescribing decisions – often taken in isolation by people from different specialties or parts of the health system – that affect an older person.
‘Nurses are in some ways in a perfect position,’ says Mr Gentry. ‘Some will of course be prescribers themselves, but when you are providing daily care or doing reviews or changing dressings – doing things that are important to a person’s health or even helping people take their medicines – you’re in a position to look across all of these things.’
Polypharmacy and older people – what can nurses do?
Tips from Bernadette Rae, associate professor and course director for non-medical prescribing at London South Bank University:
- Ask patients if they know what they are taking and why they are taking it
- Ask if they are taking their medicines – if not, explore why this is
- Check that patients know how to take medications – and ensure they have any support they need to do so
- If a patient isn’t taking medicines properly, don’t assume that another clinician hasn’t done a good job – there are multiple reasons why a patient does not adhere to treatment
- Particularly in the community, check whether patients are stockpiling medications
- When administering drugs, make sure it is done safely
- Communication with colleagues and good record-keeping are key
Nurse prescribers in particular:
- Nurse prescribers have a responsibility to follow through on anything that they initiate, for example setting up reviews if that’s appropriate, making sure they give the right information and, if monitoring is required, letting the patient know when that’s going to be
- Be aware that there might be particular risks to a particular patient – for example, someone with diabetes might react differently to a particular drug because of their condition
- Use your judgement and be careful about information you give about side-effects as they are likely to affect each individual
- Electronic prescribing systems that flag up possible risky drug interactions are useful, but not perfect – they can’t replace clinical judgement
- The British National Formulary is your friend – learn to use it and be savvy with making the most of it
‘There’s not enough focus on deprescribing, consolidating or rationalising prescriptions’
‘You can consider which of the medications is necessary, potentially even starting that conversation with the person and introducing the concept that stopping someone’s medications could be beneficial for them. And they have the skills and knowledge to explain that in a bit more detail.’
Polypharmacy is also a concern flagged in the World Health Organization’s new suite of tools to improve care of older people. The ICOPE handbook, launched on 1 October, warns of the risk of polypharmacy in older people, including depression – which in turn could lead to more polypharmacy.
This focus – and the Age UK report – do not surprise London South Bank University School of Health and Care associate professor Bernadette Rae. ‘Sadly it didn’t come as a great shock to me,’ she says. ‘The problems with polypharmacy are rampant, and there’s maybe not enough focus on stepping things down, or deprescribing, or consolidating or rationalising somebody’s prescriptions.’
There are several factors behind the problem, says Ms Rae, who is course director on non-medical prescribing. ‘We have an ageing population, and this may be speculation rather than evidence-based, but we also have increasingly stretched services with the size of the population outgrowing the number of clinicians. So they may be a victim of stretched services, and there may be a failure to do adequate medication reviews.’
Nurses have an important role to play, she says. ‘They are traditionally front-line and closest to the patient, so they have a responsibility to be aware of what’s going on with their case load of patients.’
‘Never assume that patients know how to take their medications’
Nurses should never assume that patients know how to take their medications, she says. ‘When I was a hospital nurse, I saw an older lady on the ward with her amoxicillin suspension still sitting in front of her. I reminded her to take it and she dipped her finger in and wiped it on her cheek. It was quite fluorescent and I can understand she looked at the colour of it and thought, “Well, what do I do with that?”
‘They may be a victim of stretched services, and there may be a failure to do adequate medication reviews’
Bernadette Rae, associate professor at London South Bank University School of Health and Care
‘It had just been plonked in front of her, and the nurse who had administered it had not followed through or stayed just long enough to say, “This is your antibiotic. You need to drink it.” A few seconds would have put that right.’
Nurses should not, however, be quick to blame the previous clinician if a patient is not taking their medication properly. ‘There are many reasons for non-adherence and they’re not necessarily predictable’, she says.
‘When I worked in general practice I was the lead nurse for diabetes and I had a chap come for his review. I noticed the last time we’d issued the drug, and he should have run out a while ago, so I asked him about this and he had completely got the wrong end of the stick: he knew he’d been diagnosed with diabetes and he took the tablets and thought he was better. He didn’t grasp that he had to keep taking them. It might not be that he wasn’t told – it could have been a psychological defence.’
‘Some patients don’t realise it will be an ongoing treatment’
Similarly, she says, some patients do not realise when they are initially prescribed vitamin B12 that it will be an ongoing treatment.
Ms Mould is already at the forefront of trying to tackle this issue – not just in her job as an older people’s mental health liaison nurse with Southern Health NHS Foundation Trust, which is based in Southampton, but also in her research.
She has been looking at anticholinergic burden – the cumulative effect of taking multiple medications with anticholinergic potential. Medications with this mechanism are used to treat a host of conditions including Parkinson’s disease, depression, chronic obstructive pulmonary disease, unstable bladder, nausea and pain.
Drugs for different conditions may act in the same way
The problem is that while the drugs are for different conditions they may act in the same way, with potentially serious consequences.
‘Part of my focus when I’m looking at the drug chart is to consider if this is a factor in this person’s current presentation, and if there is anything we can take out that’s going to improve their longer term health,’ says Ms Mould.
Anticholinergic drugs include common medicines such as amitriptyline and antipsychotics – basically anything that acts on the cholinergic system. They carry a risk of side effects and there is a cumulative effect if a patient is taking more than one.
‘It’s things that can cause increased confusion, falls, constipation and cardiac issues,’ says Ms Mould. ‘Lots of the drugs that we prescribe as mental health practitioners have anticholinergic activity, and we’ve got to be mindful that we’re adding to that burden. So another part of my role is asking if we really need to prescribe, as well as deprescribing drugs that patients no longer need.’
Typically, Ms Mould’s patients take medication for blood pressure. ‘They might also be on an antidepressant that was prescribed years ago, they might be on an opioid analgesic that’s not been reviewed. They might be on something for their bowels. They might be on something for dementia if that’s their diagnosis, or something for Parkinson’s.
‘A lot of these counteract each other, so if someone’s on a particularly anticholinergic antidepressant it is going to be counteracting the treatment for their dementia, because they work in opposite ways.’
How Age UK wants to reduce polypharmacy
The charity is asking the government to ensure that:
- There is zero tolerance of inappropriate polypharmacy
- Older people are fully supported and involved in decisions about their medicines
- High quality medicine reviews are routine for all older people taking medicines on a long-term basis
- Care planning and new prescribing decisions take full account of existing medicines
- Care homes maintain an appropriate clinical pharmacy lead and an accurate record of medicines
- Polypharmacy (taking four medicines to treat one or more health conditions) is a core competency of clinicians working with older people
- Older people, especially those with dementia, have access to the support they need to manage their medicines
Nurses should take note of medicines prescribed – and be prepared to act
Deciding to prescribe or deprescribe a drug has consequences for other medications, she says. For example, if someone no longer needs an opioid analgesic they might not need medication for their bowels.
‘It’s all about unpicking what’s been prescribed for what, when it was prescribed, and if it has been reviewed. For example, patients who have been on multiple medications for blood pressure – it was fine when they were in their fifties but they’ve carried on and carried on, and all of a sudden they’re having repeated falls.
‘It’s about asking what their blood pressure is now, and do they really need to be on three different medications for it. But I suppose it’s also about having the time to sit down and go through it all.’
She says the patient in her eighties who was on 16 or 17 drugs, mentioned at the start of this article, had an anticholinergic burden score of ten – and anything above three is a concern. Although an extreme case, it is not the only one. This is why nurses should take note of the medicines that are prescribed to patients – and be prepared to act.
Jennifer Trueland is a health journalist
Find out more
- More harm than good: Why more isn’t always better with older people’s medicines (Age UK)
- Review into overprescribing in the NHS (Department of Health and Social Care)
- Integrated Care for Older People (World Health Organization)