As a pharmacist who has been involved with frailty and caring for older people for the majority of my career, I am familiar with the challenges of overprescribing.
In my previous roles working within acute hospitals, I saw first-hand the challenges of completing medication reviews and implementing changes to tackle the concerns of overprescribing. Our colleagues in primary care can also agree that there are challenges in completing structured medication reviews. Additionally, a proportion of older patients are housebound and often fall between the cracks of our healthcare service.
Within the North East London Foundation Trust’s services in south west Essex, we realised a unique opportunity to conduct medication reviews for our patients on the virtual frailty ward.
South West Essex prescribing data show that we are above the national average for patients aged over 65 years who are prescribed ten or more medicines. This, coupled with our knowledge of the increasing proportion of housebound patients, led to the implementation of medication reviews.
Frailty is a health state that means patients are more vulnerable to sudden changes in health triggered by ‘small events’, such as infection, medication changes and environmental changes. It also increases the risk of adverse outcomes, such as falls, disability, admission to hospital or the need for long-term care.
Polypharmacy is closely linked with frailty, and this increases the risk of adverse effects, hospital admissions and dependence. Furthermore, those with frailty are more susceptible to the side effects of medicines. Patients with multiple conditions will take multiple medicines and patients are often treated in a single disease-centred approach, potentially causing a prescribing cascade. The evidence base for medicines predominantly excludes the older population and those identified as moderate and severely frail. As such, medicines optimisation to reduce inappropriate polypharmacy is of particular importance in this patient population.
The virtual frailty ward is a model of care that enables certain patients to receive care in their home setting. This allows for healthcare professionals to observe and see the real practicalities of a patient’s day-to-day life and how their comorbidities impact them. With respect to medicines, this is an excellent opportunity to assess adherence, medicines wastage and the overall management of their comorbidities. This encouraged our team to consider how we can include medicines as part of our review process.
Prior to a pharmacist joining the team, medicines were reviewed in accordance with their relation with the concerning complaint. For instance, if a patient had a fall secondary to orthostatic hypotension, then the medicines affecting blood pressure were reviewed.
With the addition of a pharmacist, we embedded a change to include holistic medication reviews as part of our admission protocol. The pharmacist reviews all medicines and discusses potential changes with the patient and with the multidisciplinary team. The virtual frailty ward works with electronic prescribing and therefore the clinicians are able to make medication changes in real time. The pharmacist also ensures medication changes are communicated to the patient, which are reiterated through visits from our nursing colleagues.
These medication reviews have allowed us to engage with patients to promote shared decision making and review the importance of goals and medication aims to our patients. In frailty, we are acutely aware that medicines are related to adverse effects and can contribute to hospitalisation. Patients have often been prescribed medicines for many years that are not necessarily effective or appropriate for their changing clinical frailty picture.
Reviewing medicines when a patient is in their home setting is unique as you are able to equate medicines with their activities and practicalities. For example, it is often challenging to review zopiclone when a patient has been admitted to hospital and is likely to experience insomnia, whereas in a home setting, we are able to engage in conversations to discuss the necessity, trialling a stoppage of medications that can cause harm in a frail older patient.
Our data have shown a direct correlation between medication reviews and medication changes, with 74% of our reviews resulting in changes. Of these, 69% were in relation to deprescribing. Further analysis of our data showed the biggest impact was to medications affecting the cardiovascular system. Our practice has shown that this patient cohort are often aggressively treated, resulting in adverse effects, and reviewing blood pressure targets, heart rate targets and preventative medicines resulted in medication changes. These figures have enabled us to make changes that not only have an economic impact, but also improve the overall quality of life of the patient.
The virtual wards are unique in the way in which we can see the impact of a patient’s condition in their home environment. It seems prudent to use this opportunity to engage with our patients and tackle the mammoth task of overprescribing.
Aziza Qureshi is lead pharmacist, frailty and older People, at North East London NHS Foundation Trust