It would seem that polypharmacy is on the increase and that is no surprise to me. I am occasionally asked to review medication as part of a team providing direct care and I often hold my head in my hands.
We may call this process medicines optimisation, but it is half a job and the medicines optimisation specialist pharmacist within General Practice are making a mistake when they review individual patients and make recommendations about their medicines. This does not change prescribing behaviours and we should consider a new approach.
Having reviewed some elderly patients on multiple medication the key question is not what we should do now – that is usually simple – but how and why have we arrived here. So with a group of prescribers I have asked those questions using case examples in a non-judgemental way.
The discussion is always interesting and often I have to agree that it might have seemed a good idea at the time; often it fitted with a guideline or a protocol. But the discussion generates further questions:
- So what were you hoping to achieve with that prescription (what was the goal)?
- Was it something that was important for the patient? Would it make a difference to their quality of life?
- What were the chances of that medicine achieving that goal, bearing in mind the patient’s condition and the evidence supporting the medicine in that patient?
- Was there an intention to review and what criteria were you going to use to define success?
- Was there any other way of achieving the desired result without medicines?
- What support was necessary as an adjunct to the medicine to achieve the desired goal?
- What was the strategy if that medicine did not achieve the desired effect and had you explained that to the patient/carer?
The discussion was peppered with a variety of phrases including:
- That medicine is not actually licenced for that indication
- There is little evidence of benefit in this age group
- The medicine is unlikely to achieve that goal
There were many obvious comments:
- no medicine is indicated for loneliness (still waiting for social prescriptions)?
- A pain killer is only likely to reduce the pain by 50% so how does the patient manage the remainder?
- What are you hoping to achieve with that medicine (often a statin or aspirin) in an 85 year old?
- What potential expected side effects are likely to be detrimental (falls, hypos or confusion etc)?
At the end of the session I am happy with the question – should we stop this medicine – and even happier with the recognition – perhaps we shouldn’t have started it in the first place. Sometimes the questions are much more exciting – how are we going to manage a group of patients with these problems in the future – and we might look to involve local voluntary, charitable and housing services along with community pharmacy in solutions.
So if you want to effect polypharmacy and optimise medicines, don’t think about what you do now, but reflect on how you have got here and most importantly how you avoid this situation again.