This study identified a high prevalence of PIP in community-dwelling PWD. Future interventions may need to focus on certain therapeutic categories and polypharmacy.
Background: People with dementia (PwD) face unique challenges with medicines management, yet little is known about these challenges from the perspectives of primary healthcare professionals, particularly general practitioners (GPs) and community pharmacists. Few medicines management interventions have been developed which are aimed at community-dwelling PwD. This study sought to develop an intervention to improve medicines management for PwD in primary care using a theory-informed approach. Methods: Semi-structured interviews were conducted with GPs (n = 15) and community pharmacists (n = 15) to explore participants' views and experiences of medicines management for PwD, and their perceptions of barriers and facilitators to successful medicines management for PwD. The 14-domain Theoretical Domains Framework was the underpinning theoretical guide, allowing key theoretical domains to be identified and mapped to behaviour change techniques (BCTs) which are considered the 'active ingredients' of an intervention. Draft interventions were developed to operationalise selected BCTs and were presented to GPs and community pharmacists during task groups. Final selection of an intervention for feasibility testing was guided by feedback provided during these task groups and through application of the APEASE (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity) criteria. Results: Participants expressed a number of concerns about medicines management for PwD, particularly monitoring adherence to medication regimens and conducting medication review. Two draft interventions comprising selected BCTs ('Modelling or demonstration of behaviour'; 'Salience of consequences'; 'Health consequences'; 'Social and environmental consequences'; 'Action planning'; Social support or encouragement', 'Self-monitoring of behaviour') were developed, each targeting GPs and community pharmacists. Following the task groups and discussions within the research team, the community pharmacy-based intervention was selected for future feasibility testing. The intervention will target community pharmacists to conduct a medication review (incorporating an adherence check) with a PwD, delivered as an online video demonstrating key behaviours. The video will include feedback emphasising positive outcomes of performing the behaviours. Action planning and a quick reference guide will be used as complementary intervention components.
There is concern internationally that many older people are using an inappropriate number of medicines, and that complex combinations of medicines may cause more harm than good. This article discusses how person-centred medicines optimisation for older people can be conducted in clinical practice, including the process of deprescribing. The evidence supports that if clinicians actively include people in decision making, it leads to better outcomes. We share techniques, frameworks, and tools that can be used to deprescribe safely whilst placing the person’s views, values, and beliefs about their medicines at the heart of any deprescribing discussions. This includes the person-centred approach to deprescribing (seven steps), which incorporates the identification of the person’s priorities and the clinician’s priorities in relation to treatment with medication and promotes shared decision making, agreed goals, good communication, and follow up. The authors believe that delivering deprescribing consultations in this manner is effective, as the person is integral to the deprescribing decision-making process, and we illustrate how this approach can be applied in real-life case studies.
Rationale, Aims and Objectives: In 2011, ‘Transforming Your Care’ outlined the remodelling of Health and Social Care in Northern Ireland (HSCNI) UK, specifically recommending better integration of hospital and community services for older people. This work aimed to evaluate consultant pharmacist case management for older patients admitted from acute to intermediate care continuing back into the community setting, given the importance of such a transition to person-centered healthcare. Method: On transfer to intermediate care, the consultant pharmacist determined the Medication Appropriateness Index (MAI) for each drug prescribed. Individualised pharmaceutical care plans were implemented with clinical interventions recorded and graded using Eadon criteria. Cost savings resulting from interventions which prevent medication errors/Adverse Drug Events (ADEs) have been estimated using the model as described by the University of Sheffield School of Health and Related Research (ScHARR); these were applied. Drugs stopped/started were costed using the NHS dictionary of medicines and devices (dm+d). Case management continued via communication with GPs and/or community pharmacists and post-discharge patient telephone calls/home visits. Results: Three hundred and fifty-five patients had 3674 drugs assessed for medication appropriateness; both individual and total drug MAI scores on admission to and discharge from intermediate care, were significantly reduced (Wilcoxon signed rank test, p<0.001, n=355). An average of 2.5 clinical interventions per patient were made, with 84% being self-graded as Eadon ≥ Grade 4 (significant interventions resulting in improved care standards). Clinical interventions yielded potential savings of £63-144k pa whilst annual drug cost savings were £68k. Conclusion: This project demonstrated consultant pharmacist case management results in both cost savings and more appropriate prescribing with safer, seamless and more person-centered care.
Background People with dementia (PWD), and their carers, face challenges with medicines management activities. As interventions to support medicines management for PWD are developed, consideration must be given to the outcomes chosen to measure their effectiveness. A Core Outcome Set (COS) is a minimum set of outcomes to be measured in all trials in a particular clinical area, which seeks to reduce heterogeneity of outcome reporting across trials. Objective To develop a COS for trials assessing the effectiveness of medicines management interventions for PWD in primary care. Methods A comprehensive list of outcomes was compiled through a systematic review and semistructured interviews with PWD (n=18), their carers (n=15), community pharmacists (n=15) and general practitioners (n=15). These outcomes were rated by a Delphi panel (n=52) on a 9-point Likert scale from 1 (limited importance) to 9 (critical) during three sequential rounds of questionnaire distribution. The Delphi panel comprised participants with expertise in dementia and medicines management, including academics and healthcare professionals. An outcome was eligible for inclusion in the COS if ≥70% of participants rated it critical and <15% of participants rated it of limited importance. Results Twenty-nine outcomes identified from the systematic review and stakeholder interviews were presented to the Delphi panel. Consensus was reached on twenty-one outcomes, of which the seven most highly rated were recommended for inclusion in the COS. Conclusion This study used robust methodology to develop a COS for medicines management interventions for PWD. Future work should identify the most appropriate tools to measure these outcomes.
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