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

Abstract

Background Increasing numbers of older people are living in the community with multiple diagnoses and medications. Managing multiple medications produces issues of unrivalled complexity for those involved. Despite a growing body of 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, a National Institute of Health Research funded project, used a realist approach to understand causal paths within medication management. Informed by RAMESES guidelines, MEMORABLE involved three overlapping work packages: 1) Realist Review of the literature (specifically 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 The complexity of medication management was viewed from the perspective of ‘implementation’. This enabled the researchers to structure the medication management process into five iterative Stages; three individual Stages carried out by the older person on their own or with family carer support in which they are balancing routines, coping and risk; and two interpersonal Stages where the older person works with a practitioner-prescriber-reviewer, perhaps with carer involvement. Applying Normalisation Process Theory to this process, four steps were identified within each Stage: 1) sense making - information, clarification; 2) action - shared decision making; 3) reflection/monitoring; and 4) relationships that are enduring, 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 then set out for development through further research: a risk screening tool and individualised information.Conclusions By adopting a realist approach and synthesising rich data from evidence and experiential accounts, MEMORABLE has established a transferable evidence and experience-based, theoretical framework, focused on burden, to explore and explain the real world complexity of medication management for and with older people.

‘I just take them because I know the people that give them to me’: A theory‐informed interview study of community‐dwelling people with dementia and carers' perspectives of medicines management

“…This study identified some similar barriers and facilitators to successful medicines management for PwD to those already identified in the literature, such as the importance of carers, having supportive and trusting relationships with healthcare professionals, carers' desire for further information about medicines, and use of cues and reminder strategies 15,16,18,20,21,41,48 . However, we also report some contrasting findings.…”

“…This is one of only two studies, to our knowledge, to use a theory‐based approach to explore experiences of community‐dwelling PwD and their carers about medicines management, and determine beliefs of PwD about medicines 41 . It extends a limited evidence base to provide valuable findings for future intervention development to improve medicines management for PwD.…”

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 …”

“…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 It used a novel and innovative research technique, called realism, to understand the challenges associated with medication management for older people living in the community, taking many different medications, and their family carers. From this, the framework for interventions to address some of the identified challenges was developed.…”

How to reduce medication errors in patients over the age of 65?

“…In this regard, information campaigns have been devised on the role of patients in the safe use of medication, reinforcing its role as a final barrier to adverse events [21]. Research focuses on medication management to provide data on what interventions work and their key points [22].…”