Developing a framework for a novel multi-disciplinary, multi-agency intervention(s), to improve medication management in community-dwelling older people on complex medication regimens (MEMORABLE)––a realist synthesis

Maidment, Ian; Mullan, Judy; McKeown, Jane; Bailey, Stephen J.; Wong, Geoff

doi:10.1186/s13643-017-0528-1

Cited by 32 publications

(36 citation statements)

References 32 publications

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“…As such a total of 30% of the transcripts were joint coded. Previous research has shown this method is adequate to demonstrate consistency in coding, interpretations and inferences made by the lead researcher [21]. Indeed, this method demonstrated excellent agreement in coding and analysis of the data.…”

Section: Discussionmentioning

confidence: 81%

First point of contact physiotherapy; a qualitative study

et al. 2020

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Objectives First point of contact physiotherapy (FPCP) provides patients direct access to a physiotherapist. Literature demonstrates efficacy of FPCP. Evidence has highlighted the need for cultural shifts from both patient and professional perspectives to optimise FPCP. This study explored stakeholder perceptions of patient awareness and understanding of FPCP to better inform FPCP implementation. Design, setting, participants A qualitative methodology utilised semi-structured interviews and focus groups. Findings from a previous realist review were used to generate a priori topic guides. Participants included patients, physiotherapists, GPs, administration staff, and commissioners. A thematic analysis was undertaken. Results Four themes emerged that are described: level of patient awareness of the FPCP role situated against the GP as first contact practitioner, patients attain an awareness of FPCP from a variety of sources, patient understanding of physiotherapy arises from several sources and is poorly aligned with the FPCP model, characteristics and behaviours of patients influence access to FPCP services. Patient awareness and understanding was poor. Patients tended to view the GP as the default first contact practitioner. Traditional advertising approaches appeared on the whole invisible to patients and there was a reliance on signposting to facilitate patient access. Conclusion Findings from this study can inform implementation of FPCP. Several obstacles to the optimisation of FPCP were highlighted. Improved marketing of physiotherapy generally and FPCP specifically may increase patient awareness and understanding. However, it is likely further time will be required to bring about the cultural shift in public perception required to optimise the potential of FPCP.

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Section: Discussionmentioning

confidence: 81%

First point of contact physiotherapy; a qualitative study

et al. 2020

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“…In light of these challenges, the MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation (MEMORABLE) study seeks to understand how medication management works and to propose interventions that will contribute to making improvements. 30,31 Older people…”

Section: Overviewmentioning

confidence: 99%

Medication management in older people: the MEMORABLE realist synthesis

Maidment

Lawson

Wong

et al. 2020

Health Serv Deliv Res

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Background The number and proportion of older people in the UK are increasing, as are multimorbidity (potentially reducing quality of life) and polypharmacy (increasing the risk of adverse drug events). Together, these complex factors are challenging for older people, informal carers, and health and care practitioners. Objectives MEMORABLE (MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation) aimed to understand how medication management works and propose improvements. Design A realist approach informed three work packages, combining a realist review of secondary data with a realist evaluation of primary interview data, in a theory-driven, causal analysis. Setting The setting was in the community. Participants Older people, informal carers, and health and care practitioners. Interventions Studies relating to medication management and to reviewing and reconciling medications; and realist-informed interviews. Main outcome measures Not applicable. Data sources MEDLINE, CINAHL (Cumulative Index of Nursing and Allied Health Literature) and EMBASE were searched (all searched from January 2009 to July 2017; searched on 1 August 2017). Supplementary articles were identified by the Research Team. Data were also obtained through interviews. Review methods Searches of electronic databases were supplemented by citation-tracking for explanatory contributions, as well as accessing topic-relevant grey literature. Following RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines, articles were screened and iteratively analysed with interview data, to generate theory-informed (normalisation process theory) explanations. Results Developing a framework to explain medication management as a complex intervention across five stages: identifying problem (Stage 1), starting, changing or stopping medications (Stage 3) and continuing to take medications (Stage 4), where older people, sometimes with informal carers, make individual decisions and follow routines that fit medication management into their day-to-day lives, engendering a sense of control. In getting diagnosis and/or medications (Stage 2) and reviewing/reconciling medications (Stage 5), older people and practitioners share decision-making in time-limited contacts: involving four steps – sense-making, relationships, action and reflection/monitoring (normalisation process theory); and conceptualising burden – through a detailed analysis of Stage 5, generating a theoretical framework and identifying five burden types amendable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Proposing interventions: risk identification – a simple way of identifying older people and informal carers who are not coping, at risk and who need appropriate help and support; and individualised information – a short, personalised record and reference point, co-produced and shared by older people, informal carers and practitioners that addresses the experience of living with multimorbidities and polypharmacy. Limitations Few studies directly address the complexity of medication management as a process and how it works. Limitations included, having identified the overall complexity, the need to focus the analysis on reviewing/reconciling medications (Stage 5), the exclusion of non-English-language literature, the focus on non-institutionalised populations and the broad definition of older people. Conclusions MEMORABLE explored the complexity of medication management. It highlighted the way interpersonal stages in the medication management process, notably reviewing/reconciling medications, contribute to the mitigation of burdens that are often hidden. Future work Co-produced studies to scope and trial the two proposed interventions; studies to extend the detailed understanding of medication management, linked to burden mitigation; and a study to clarify the medication management outcomes wanted by older people, informal carers and practitioners. Study registration This study is registered as PROSPERO CRD42016043506. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 26. See the NIHR Journals Library website for further project information.

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“…We also need a clearer understanding of the relative risk versus bene t of anticholinergics and in whom the risk is greatest, and effectiveness interventions to reduce the harm associated with anticholinergics. Interventions to limit the use of inappropriate anticholinergics require development and testing; a realist approach, which focuses on the key importance of context and mechanism offers a promising avenue for such intervention development [35] [36] [37].…”

Section: Future Researchmentioning

confidence: 99%

Increasing prevalence of anticholinergic medication use in older people in England over 20 years: Cognitive Function and Ageing Study I and II

Grossi

Richardson

Savva

et al. 2020

Preprint

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Background: Anticholinergic medication use is linked with increased cognitive decline, dementia, falls and mortality, and their use should be limited in older people. Here we estimate the prevalence of anticholinergic use in England’s older population in 1991 and 2011, and describe changes in use by participant’s age, sex, cognition and disability.Methods: We compared data from participants aged 65+ years from the Cognitive Function and Ageing Studies (CFAS I and II), collected during 1990-1993 (N=7,635) and 2008-2011 (N=7,762). We estimated the prevalence of potent anticholinergic use (Anticholinergic Cognitive Burden [ACB] score=3) and average anticholinergic burden (sum of ACB scores), using inverse probability weights standardised to the 2011 UK population. These were stratified by age, sex, Mini-Mental State Examination score, and activities of daily living (ADL) or instrumental ADL (IADL) disability. Results: Prevalence of potent anticholinergic use increased from 5.7% (95% Confidence Interval [CI] 5.2-6.3%) of the older population in 1990-93 to 9.9% (9.3-10.7%) in 2008-11, adjusted odds ratio of 1.90 (95%CI 1.67 – 2.16). People with clinically significant cognitive impairment (MMSE [Mini Mental State Examination] 21 or less) were the heaviest users of potent anticholinergic in CFAS II (16.5% [95%CI 12.0-22.3%]). Large increases in the prevalence of the use medication with ‘any’ anticholinergic activity were seen in older people with clinically significant cognitive impairment (53.3% in CFAS I to 71.5% in CFAS II). Conclusions: Use of potent anticholinergic medications nearly doubled in England’s older population over 20 years with some of the greatest increases amongst those particularly vulnerable to anticholinergic side-effects.

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Developing a framework for a novel multi-disciplinary, multi-agency intervention(s), to improve medication management in community-dwelling older people on complex medication regimens (MEMORABLE)––a realist synthesis

Cited by 32 publications

References 32 publications

First point of contact physiotherapy; a qualitative study

First point of contact physiotherapy; a qualitative study

Medication management in older people: the MEMORABLE realist synthesis

Increasing prevalence of anticholinergic medication use in older people in England over 20 years: Cognitive Function and Ageing Study I and II

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