Polypharmacy is an increasingly significant problem amongst residential and nursing home patients.1 As patients live longer, they are likely to acquire more diagnoses, with more medications prescribed. These may be initiated in secondary care without an up-to-date knowledge of the patient’s other medication.
As hospital practitioners become more and more sub-specialised, GPs are absolutely critical to ensuring that medications prescribed by individual specialties are appropriate for that person.
This is based on an extensive knowledge of the patient, knowledge of the drug, access to the complete medical record and the shared approach to prescribing that we often apply.
Setting up a medication review
GPs are regularly involved with medication reviews and their approach to medication reviews will vary from practice to practice.
- A formal protocol is useful to ensure that the process is reviewed regularly and to ensure interventions are being monitored.
- Appoint a named doctor and if applicable, use your in-house pharmacist who can provide a valuable source of information, knowledge and help you to maintain regular communication with the residential or nursing home. Appointing a single doctor who can develop a relationship with the patients, relatives and nursing home staff will contribute to the success of your medication reviews.
- Think about who needs to be involved. Setting up these meetings will initially require some organisation between yourselves, the nursing home staff, patients and relatives. However subsequent meetings should become more straightforward. Crucial members of the decision making process will include the patient, relative if applicable, next of kin or appropriate advocate, nurse, doctor and pharmacist.
- How often do you feel the medications review should take place? The ideal scenario would involve a monthly meeting to review interventions although this is unlikely to be practical within most surgeries. With the extreme pressures primary care is facing, two to three reviews per year are likely to be more realistic. Intermediate ward rounds may also be useful.
- Conduct the review in a relaxed atmosphere, where patients or relatives feel at ease and able to ask questions about their care. This is likely to be best placed within the care home.
- Ensure you allocate an appropriate amount of time for discussion and have a comprehensive idea of how many people you wish to review in a session.
- Consider adding a specific code to your computer system so that it is easy to search for allowing interventions to be monitored.
The medication review
There are a number of aims and objectives for medication reviews in nursing homes.
- Safe and rational prescribing
- Appropriate prescribing
- Minimising side effects
- Minimising drug interactions
- Ensuring appropriate monitoring
- Shared decision making so the patients understand why they are taking certain medications.
- Cost effectiveness
- Improving patient quality of life
- Improving concordance
- Reducing nurses’ drug round time thus improving other aspects of nursing home care.
- Reduction in medication queries for GPs
- Overall improved workload for GP surgeries.
- Improved relationships between the doctors, patients, their families and nursing home staff.
Ensure you have a detailed knowledge of the patient you are reviewing. As with any patient you review in a nursing home, establish their level of capacity, their baseline function, resuscitation status and whether an emergency health care plan is in place (EHCP). The patient may also have an advanced directive to refuse treatment (ADRT).
Do they have a next of kin? What medical problems does the patient have? What medications are they on and can you see why these were prescribed? When were they started? Are they clinically appropriate? Is appropriate monitoring taking place?
During the review, establish whether the patient, or if appropriate the next of kin, understands what medical problems they have, what drugs they take and why they take them. You should aim to discuss each drug with the patient, discussing the rationale for it and exploring their thoughts about it.
A shared decision making process requires a discussion of benefits and risk. Often evidence we present to patients often comes from trials that are not performed in elderly patients on multiple medications, with multiple co morbidities, in nursing homes.
This can make it difficult for doctors to put this data into context. Essentially a common sense approach is often necessary based on experience, knowledge of the drug, trial data and more importantly the patient and what they would like.
What interventions may occur?
- Cessation of a drug
- Addition of a drug
- Change in dosage
- Change in frequency
- Change in route of a drug
- Change in preparation
If an intervention is made make sure you are happy that the patient or appropriate person understands why this has been done. Ensure the process is documented clearly, understood by the nursing team and a planned review is in place.
Make sure patients know that they can always change their mind if necessary. They may also require time to think about the discussion before they can make a decision, so provide them with the most appropriate way to convey this decision.
Common side effects and interactions
Adverse drug reactions and drug interactions are a common cause of morbidity and reduced quality of life. Drug interactions can lead to inappropriate side effects, electrolyte disturbances, inappropriate hospital admissions and, in the worst case scenario, death.
Common side effects are listed in table 1 and drugs that can lead to confusion in table 2. This list of interactions is not exhaustive and the more drugs a person takes, the more likely they are to experience some form of interaction or side effect.
|Table 1: Common side effects|
|Drug class||Common side effects|
|Diuretics||Dizziness, falls, renal impairment|
|NSAIDs and aspirin||Upper GI complications such as ulceration|
|Warfarin||Unstable INR, excessive bleeding|
|Antihypertensives||Renal impairment, dizziness, falls|
|Metformin||Diarrhoea, nausea, bloating|
|Bisphosphonates||Upper GI complications|
|Opiates||Drowsiness, constipation, dependence|
|Antipsychotics||Drowsiness, disturbance of lipid profile, movement disorders, disturbance of glycaemic control|
|Proton pump inhibitors||Diarrhoea, increased risk of clostridium difficile and hypomagnesaemia|
|Tricyclic antidepressants||Drowsiness, constipation, fatigue, dry mouth|
|Calcium channel blockers||Swollen ankles|
|Beta blockers||Dizziness, falls, vasoconstriction, exacerbation of peripheral venous disease|
|Anti-anginals||Dizziness, falls, GI ulceration (for example with nicorandil)|
|SSRIs||Upper GI complications, hyponatraemia|
|Table 2: Drugs that lead to confusion|
|Drug class||Specific drugs|
|Opiates||Codeine, tramadol, MST|
|Z drugs||Zopiclone, zolpidem|
|Tricyclic antidepressants||Amitriptyline, lofepramine|
Medication reviews have undoubtedly improved quality of life within our nursing home patients, who now feel empowered regarding their treatment plans.2 The reviews have reduced nursing home workload and also our prescription team workload. The process has also improved relations between the clinicians, nursing home staff, patients and relatives.
There have been significant cost savings due to reduced prescriptions. Within our nursing home, this has amounted to around £10 000. This does not include the reduction in waste, which is difficult to quantify.
Our pharmacist was responsible for setting up this project, after identifying a significant number of inappropriate prescriptions over time. He has provided the necessary link between clinicians and nursing staff to realise the importance of this work as well as engaging patients and their relatives. He also ensures that any interventions taking place are appropriately reviewed.
- Dr Pipin Singh, GP, Northumberland, UK
- Duerden M et al (2013) Polypharmacy and medicines optimisation The King’s Fund
- The Health Foundation (2015) Pills: reviewing medication in care homes