Towards an understanding of the burdens of medication management affecting older people: the MEMORABLE realist synthesis

Abstract

Background: More older people are living in the community with multiple diagnoses and medications. Managing multiple medications produces issues of unrivalled complexity for those involved. Despite increasing literature on the subject, gaps remain in understanding how, why and for whom complex medication management works, and therefore how best to improve practice and outcomes. MEMORABLE, MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation, aimed to address these gaps. Methods: MEMORABLE used realism to understand causal paths within medication management. Informed by RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines, MEMORABLE involved three overlapping work packages: 1) Realist Review of the literature (24 articles on medication management exploring causality); 2) Realist Evaluation (50 realist-informed interviews with older people, family carers and health and care practitioners, explaining their experiences); and 3) data synthesis and theorising from 1) and 2). Results: Medication management was viewed from the perspective of ‘implementation’ and structured into five stages: identifying a problem (Stage 1), getting a diagnosis and/or medications (Stage 2), starting, changing or stopping medications (Stage 3), continuing to take medications (Stage 4), and reviewing/reconciling medications (Stage 5). Three individual stages (1, 3 and 4) are conducted by the older person sometimes with family carer support when they balance routines, coping and risk. Stages 2 and 5 are interpersonal where the older person works with a practitioner-prescriber-reviewer, perhaps with carer involvement. Applying Normalisation Process Theory, four steps were identified within each stage: 1) sense making: information, clarification; 2) action: shared-decision-making; 3) reflection/monitoring; and 4) enduring relationships, based on collaboration and mutual trust. In a detailed analysis of Stage 5: Reviewing/reconciling medications, adopting the lens of ‘burden’, MEMORABLE identified five burdens amenable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Two initial improvement propositions were identified for further research: a risk screening tool and individualised information. Conclusions: Older people and family carers often find medication management challenging and burdensome particularly for complex regimens. Practitioners need to be aware of this potential challenge, and work with older people and their carers to minimise the burden associated with medication management.

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“…We also need a clearer understanding of the relative risk versus benefit of anticholinergics and in whom the risk is greatest, and the effectiveness of 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].…”

Medication management in older people – a hidden burden

“…The MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation (MEMORABLE) study was funded by the National Institute for Health Research (NIHR), the research arm of the NHS 12,13 …”

Supporting patients to get the best from their osteoporosis treatment: a rapid realist review of what works, for whom, and in what circumstance

“…Drawing on the project team’s expertise, this review is informed by previous qualitative research syntheses relating to osteoporosis [ 13 , 14 ], and a recent realist synthesis about medicine management in older people which helped us develop an understanding of the context and problem [ 15 ]. We used a conceptual framework about levels of interventions to address determinants of non-adherence, which we felt would also have relevance for medicines optimisation: the ‘adherence lollipop’ (Supplementary Fig.…”