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Pocknell S, Fudge N, Collins S, Roberts C, Swinglehurst D. 'Troubling' medication reviews in the context of polypharmacy and ageing: A linguistic ethnography. Soc Sci Med 2024; 352:117025. [PMID: 38850679 DOI: 10.1016/j.socscimed.2024.117025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/04/2024] [Accepted: 05/27/2024] [Indexed: 06/10/2024]
Abstract
Healthy ageing is a global priority. Polypharmacy (the use of 5+ medicines) amongst older people is increasing, with over one-third of adults in England, aged 80-89, prescribed at least eight medications. Although sometimes necessary, polypharmacy can be harmful; the risk of harm increases with age and number of medicines prescribed. Medication reviews are recommended as one way of reducing the potential harms of polypharmacy although evidence of clinically significant benefit of medication reviews as currently delivered is limited. What happens in medication reviews in practice is poorly understood. We used a linguistic ethnography approach to explore how medication reviews proceed and what is accomplished during these consultations. We studied 18 video-recorded medication review consultations from three general practices in England. The consultations involved patients aged 65 or older, prescribed 10+ medications ('higher risk' polypharmacy), and primary care clinicians (general practitioner or clinical pharmacist). Video-recordings were gathered as part of a wider ethnographic study investigating practices of polypharmacy in primary care between 2017 and 2021. We conducted microanalysis of consultation data, drawing on our ethnographic knowledge of the organisational, institutional and domestic contexts of polypharmacy to inform our interpretation of these interactions. Consultations were time-consuming and involved lengthy stretches of interactional trouble: non-understandings; misunderstandings; misalignments. These stretches revealed profound uncertainties as to the effectiveness of medicines in the context of multimorbidity and polypharmacy. These uncertainties seeped further into 'troubles talk' concerning patients' existential concerns relating to enduring illness, ageing and mortality. Although these existential concerns were partially articulated, clinicians and patients left such troubles talk unelaborated, unresolved and unfinished. Participants succeeded in smoothing over interactional difficulties and maintaining respectful relationships but often fell short of addressing problematic polypharmacy more directly.
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Affiliation(s)
- Sarah Pocknell
- Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, UK
| | - Nina Fudge
- Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, UK
| | - Sarah Collins
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, UK
| | - Celia Roberts
- School of Education, Communication & Society, Faculty of Social Science & Public Policy, King's College London, UK
| | - Deborah Swinglehurst
- Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, UK.
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Tsang JY, Sperrin M, Blakeman T, Payne RA, Ashcroft D. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. BMJ Open 2024; 14:e081698. [PMID: 38803265 PMCID: PMC11129052 DOI: 10.1136/bmjopen-2023-081698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 05/11/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention. OBJECTIVES To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions. DESIGN We performed a scoping review as defined by the Joanna Briggs Institute. SETTING The focus was on primary care settings. DATA SOURCES Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024. ELIGIBILITY CRITERIA We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded. EXTRACTION AND ANALYSIS We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions. RESULTS In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention. CONCLUSIONS Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.
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Affiliation(s)
- Jung Yin Tsang
- Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester Division of Population Health Health Services Research and Primary Care, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Matthew Sperrin
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Thomas Blakeman
- Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester Division of Population Health Health Services Research and Primary Care, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Rupert A Payne
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, UK
| | - Darren Ashcroft
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
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Rubæk M, Broholm-Jørgensen M, Andersen S, Jakobsen PR, Rothmann MJ, Langdahl B, Hitz MF, Holmberg T. Development of a program theory for osteoporosis patient education in Denmark: a qualitative study based on realist evaluation. BMC Geriatr 2024; 24:346. [PMID: 38627654 PMCID: PMC11022455 DOI: 10.1186/s12877-024-04957-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Osteoporosis patient education is offered in many countries worldwide. When evaluating complex interventions like these, it is important to understand how and why the intervention leads to effects. This study aimed to develop a program theory of osteoporosis patient education in Danish municipalities with a focus on examining the mechanisms of change i.e. what is about the programs that generate change. METHODS The program theory was developed in an iterative process. The initial draft was based on a previous published systematic review, and subsequently the draft was continually refined based on findings from observations (10 h during osteoporosis patient education) and interviews (individual interviews with six employees in municipalities and three health professionals at hospitals, as well as four focus group interviews with participants in patient education (in total 27 informants)). The transcribed interviews were analyzed using thematic analysis and with inspiration from realist evaluation the mechanisms as well as the contextual factors and outcomes were examined. RESULTS Based on this qualitative study we developed a program theory of osteoporosis patient education and identified four mechanisms: motivation, recognizability, reassurance, and peer reflection. For each mechanism we examined how contextual factors activated the mechanism as well as which outcomes were achieved. For instance, the participants' motivation is activated when they meet in groups, and thereafter outcomes such as more physical activity may be achieved. Recognizability is activated by the participants' course of disease, which may lead to better ergonomic habits. Reassurance may result in more physical activity, and this mechanism is activated in newly diagnosed participants without previous fractures. Peer reflection is activated when the participants meet in groups, and the outcome healthier diet may be achieved. CONCLUSIONS We developed a program theory and examined how and why osteoporosis patient education is likely to be effective. Understanding these prerequisites is important for future implementation and evaluation of osteoporosis patient education.
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Affiliation(s)
- Mette Rubæk
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
- National Research Center for Bone Health, Zealand University Hospital, Køge, Denmark
| | | | - Susan Andersen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Pernille Ravn Jakobsen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Mette Juel Rothmann
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Langdahl
- Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Friberg Hitz
- National Research Center for Bone Health, Zealand University Hospital, Køge, Denmark
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Baby B, McKinnon A, Patterson K, Patel H, Sharma R, Carter C, Griffin R, Burns C, Chang F, Guilcher SJ, Lee L, Fadaleh SA, Patel T. Tools to measure barriers to medication management capacity in older adults: a scoping review. BMC Geriatr 2024; 24:285. [PMID: 38532328 PMCID: PMC10967066 DOI: 10.1186/s12877-024-04893-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/13/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Medication management capacity is a crucial component of medication adherence, particularly among older adults. Various factors, including physical abilities, cognitive functions, sensory capabilities, motivational, and environmental factors, influence older adults' ability to manage medications. It is, therefore, crucial to identify appropriate tools that allow clinicians to determine which factors may impact medication management capacity and, consequently, nonadherence to medications. PURPOSE 1)To identify tools that measure physical, cognitive, sensory (vision, hearing, touch), motivational, and environmental barriers to medication self-management in older adults, and 2) to understand the extent to which these tools assess various barriers. METHODS The scoping review was conducted using Arksey and O'Malley's scoping review framework and the PRISMA Extension for Scoping Reviews checklist. In June 2022, the relevant literature was identified by searching PubMed (MEDLINE), Ovid Embase, Ovid IPA, EBSCOhost CINAHL, APA PsycINFO, and Scopus. RESULTS AND DISCUSSION In total, 7235 studies were identified. Following the removal of duplicates, 4607 articles were screened by title and abstract, of which 4253 did not meet the inclusion criteria. Three reviewers reviewed the full texts of the remaining 354 articles; among them, 41 articles, 4 theses and 1 conference abstract met the inclusion criteria. From the included studies, 44 tools were identified that measured a combination of physical, cognitive, sensory, motivational, and environmental barriers (n=19) or only cognition (n=13), vision (n=5), environmental factors (n=3), auditory (n=1), and motivational factors (n=1). The review also examined the psychometric properties of the identified tools and found that most of them had reported validity and reliability data. Several tools have demonstrated promise in assessing a combination of barriers with validity and reliability. These tools include the Self-Medication Assessment Tool (SMAT), ManageMed Screening (MMS), Self-Medication Risk Assessment Tool (RAT), HOME-Rx revised, and Medication Management Ability Assessment (MMAA). CONCLUSION This scoping review identified 44 validated tools to measure various challenges that older adults encounter with medication management. However, no tool measures all five barriers (physical, cognitive, sensory, motivational, and environmental) to medication-taking at home. Therefore, utilizing a combination of tools would be most appropriate to measure these different aspects comprehensively. Further research is needed to develop a new comprehensive tool that simultaneously measures various barriers to medication self-management.
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Affiliation(s)
- Bincy Baby
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | | | | | - Hawa Patel
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Rishabh Sharma
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Caitlin Carter
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Ryan Griffin
- National Research Council Canada, Ottawa, ON, Canada
| | - Catherine Burns
- Faculty of Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Feng Chang
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Sara Jt Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Linda Lee
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Sara Abu Fadaleh
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada.
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Previdoli G, Alldred DP, Silcock J, Tyndale‐Biscoe S, Okeowo D, Cheong V, Fylan B. 'It's a job to be done'. Managing polypharmacy at home: A qualitative interview study exploring the experiences of older people living with frailty. Health Expect 2024; 27:e13952. [PMID: 39102701 PMCID: PMC10777610 DOI: 10.1111/hex.13952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 08/07/2024] Open
Abstract
INTRODUCTION Many older people live with both multiple long-term conditions and frailty; thus, they manage complex medicines regimens and are at heightened risk of the consequences of medicines errors. Research to enhance how people manage medicines has focused on adherence to regimens rather than on the wider skills necessary to safely manage medicines, and the older population living with frailty and managing multiple medicines at home has been under-explored. This study, therefore, examines in depth how older people with mild to moderate frailty manage their polypharmacy regimens at home. METHODS Between June 2021 and February 2022, 32 patients aged 65 years or older with mild or moderate frailty and taking five or more medicines were recruited from 10 medical practices in the North of England, United Kingdom, and the CARE 75+ research cohort. Semi-structured interviews were conducted face to face, by telephone or online. The interviews were recorded, transcribed verbatim and analysed using reflexive thematic analysis. FINDINGS Five themes were developed: (1) Managing many medicines is a skilled job I didn't apply for; (2) Medicines keep me going, but what happened to my life?; (3) Managing medicines in an unclear system; (4) Support with medicines that makes my work easier; and (5) My medicines are familiar to me-there is nothing else I need (or want) to know. While navigating fragmented care, patients were expected to fit new medicines routines into their lives and keep on top of their medicines supply. Sometimes, they felt let down by a system that created new obstacles instead of supporting their complex daily work. CONCLUSION Frail older patients, who are at heightened risk of the impact of medicines errors, are expected to perform complex work to safely self-manage multiple medicines at home. Such a workload needs to be acknowledged, and more needs to be done to prepare people in order to avoid harm from medicines. PATIENT AND PUBLIC INVOLVEMENT An older person managing multiple medicines at home was a core member of the research team. An advisory group of older patients and family members advised the study and was involved in the first stages of data analysis. This influenced how data were coded and themes shaped.
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Affiliation(s)
- Giorgia Previdoli
- School of Pharmacy and Medical Sciences, Faculty of Life SciencesUniversity of BradfordBradfordUK
- NIHR Yorkshire and Humber Patient Safety Research CollaborationBradfordUK
- Department of Health SciencesUniversity of YorkYorkUK
| | - David P. Alldred
- NIHR Yorkshire and Humber Patient Safety Research CollaborationBradfordUK
- School of Healthcare, Faculty of Medicine and HealthUniversity of LeedsLeedsUK
| | - Jonathan Silcock
- School of Pharmacy and Medical Sciences, Faculty of Life SciencesUniversity of BradfordBradfordUK
| | | | - Daniel Okeowo
- NIHR Yorkshire and Humber Patient Safety Research CollaborationBradfordUK
- School of Healthcare, Faculty of Medicine and HealthUniversity of LeedsLeedsUK
- School of PharmacyNewcastle UniversityNewcastle upon TyneUK
| | | | - Beth Fylan
- School of Pharmacy and Medical Sciences, Faculty of Life SciencesUniversity of BradfordBradfordUK
- NIHR Yorkshire and Humber Patient Safety Research CollaborationBradfordUK
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Fuzesi P, Broadfoot K, Lennon M, Jacob SA, Macaden L, Smith A, Welsh T, Watson MC. The Burden of Managing Medicines for Older People With Sensory Impairment: An Ethnographic-Informed Study. Gerontol Geriatr Med 2024; 10:23337214241253410. [PMID: 38765919 PMCID: PMC11100380 DOI: 10.1177/23337214241253410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/22/2024] Open
Abstract
Background: Older age is associated with increased prevalence of sensory impairment and use of medicines. Objectives: To explore the daily "medicine journey" of older people with sensory impairment. Methods: The study used ethnographic-informed methods (using audio-, photo- and video-recordings, diary notes and semi-structured interviews with researchers) and involved community-dwelling adults (aged > 65) in Scotland, with visual and/or hearing impairment and using >4 medicines. Data analysis used the constant comparative method. Results: Fourteen older people with sensory impairment participated and used a mean of 11.0 (SD 5.0) medicines (range 5-22). Participants reported difficulties with medicine ordering, obtaining, storage, administration and disposal. They used elaborate strategies to manage their medicines including bespoke storage systems, fixed routines, simple aids, communication, and assistive technologies. Conclusion: Older people with sensory impairment experience substantial burden, challenges and risk with medicines management. Tailored medicine regimens and assistive technologies could provide greater support to older people with sensory impairment.
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Affiliation(s)
- Peter Fuzesi
- University of Strathclyde, Glasgow, Scotland, UK
| | | | | | - Sabrina Anne Jacob
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Glasgow, Scotland, UK
| | | | - Annetta Smith
- University of the Highlands and Islands, Inverness, Scotland, UK
| | - Tomas Welsh
- Research Institute for the Care of Older People, Bath, UK
- Royal United Hospitals Bath, UK
- University of Bristol, UK
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Mac Giolla Phadraig C, Asimakopoulou K, Faulks D, Van Harten M, Ledger L, Spencer A, Roux S, Cleary C, Daly B, Waldron C. Using realist methods for intervention development to fill a methodological gap: A case study showing the development of an oral hygiene intervention for people with intellectual developmental disabilities. Community Dent Oral Epidemiol 2023; 51:1130-1140. [PMID: 36759914 DOI: 10.1111/cdoe.12844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 12/03/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Realist methods offer a novel approach to intervention design. Such novelty is needed for effective oral health promotion interventions with people with intellectual developmental disabilities (IDD) and their carers because existing interventions are poorly described and lack theoretical underpinning. In this study, the steps between inception and final intervention development are presented, with an aim to expand understanding of how realist theorizing can be used to develop interventions, and to demonstrate theory-driven intervention development in the field of oral health promotion. METHODS In this intervention development study, the use of realist methods to develop an intervention aiming to improve the oral hygiene of people with IDD is presented. Realist theories (RTs) arising from a mixed synthesis were used to develop the Keep My Teeth intervention. The use of realist theory in intervention development was mapped across seven domains and 18 actions with emphasis on how theory informed key actions. RESULTS Realist theories informed many but not all actions in the development process. Where gaps arose, this was augmented with other systems of intervention development, such as the Behaviour Change Wheel (BCW) and Behaviour Change Technique (BCT) systems. The resulting intervention and underlying theory are presented using TiDieR criteria. CONCLUSIONS It is demonstrated how realist methods could be integrated with substantive theory when developing an intervention. RTs enhanced the contextualization of the intervention that was developed but were insufficient in their own right to guide the development process from conception to intervention. This was overcome by augmenting with substantive theory, in this case, using the BCW and BCT behaviour change systems, to select and specify the behaviours that needed to change. In essence, the BCTs guided which techniques to select, while the RTs guided how to develop and intervene. Robust intervention development in the field of oral health promotion is also presented in this study.
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Affiliation(s)
| | - Koula Asimakopoulou
- Faculty of Dentistry Oral & Craniofacial Sciences, King's College London, London, UK
| | - Denise Faulks
- Universite Clermont Auvergne, CROC, Clermont-Ferrand, France
- CHU Clermont-Ferrand, Service d'Odontologie, Clermont-Ferrand, France
| | - Maria Van Harten
- School of Dental Science, Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
| | | | | | - Sarah Roux
- Health Service Executive, Dublin, Ireland
| | | | - Blanaid Daly
- School of Dental Science, Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
| | - Catherine Waldron
- School of Dental Science, Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
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Sultan N, Swinglehurst D. Living with polypharmacy: a narrative interview study with older Pakistanis in East London. BMC Geriatr 2023; 23:746. [PMID: 37968631 PMCID: PMC10652535 DOI: 10.1186/s12877-023-04392-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/06/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Polypharmacy is a growing and major public health issue. It can be burdensome and risky for patients and costly to healthcare systems. Older adults and those from ethnic minority backgrounds are disproportionately affected by polypharmacy. This study focuses on medication practices among Urdu-speaking Pakistani patients, a significant ethnic group in the UK. Most existing research on medication practices within South-Asian communities centres on adherence, leaving the social and moral dimensions of polypharmacy unpacked. Understanding how British Pakistani patients understand and manage polypharmacy in the context of their daily lives is crucial to avoiding harmful polypharmacy. METHODS In-depth narrative interviews were conducted with 15 first-generation Pakistani patients using the Biographical Narrative Interview Method. Participants were recruited from GP practices in East London. All participants were prescribed ten or more regular medications (a pragmatic marker of 'higher risk' polypharmacy) and were aged over 50. Interviews were conducted with a bilingual researcher at home and were designed to elicit narratives of patients' experiences of polypharmacy in the context of their biographies and daily lives. RESULTS Polypharmacy is enacted through networks of interpersonal and socio-material relationships. The doctor-patient relationship and the family network held particular significance to study participants. In addition, participants described emotional bonds between themselves and their medicines, identifying them as 'forces for good'-substances which allowed them to maintain their health through the intercession of God. Meanings attributed to medicines and enacted through these social, emotional, and spiritual relationships contributed to emerging and sustaining polypharmacy. CONCLUSIONS Patients make sense of and manage treatments in culturally specific ways. Developing an understanding of how medication practices in different communities are enacted is important for informing meaningful and effective conversations with patients about their medicines. Our findings contribute to enabling the integration of culturally sensitive approaches to prescribing.
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Affiliation(s)
- Najia Sultan
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
| | - Deborah Swinglehurst
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Mikkelsen TH, Søndergaard J, Kjaer NK, Nielsen JB, Ryg J, Kjeldsen LJ, Mogensen CB. Handling polypharmacy -a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals. BMC Geriatr 2023; 23:477. [PMID: 37553585 PMCID: PMC10410867 DOI: 10.1186/s12877-023-04131-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/24/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND On average, older patients use five or more medications daily. A consequence is an increased risk of adverse drug reactions, interactions, or medication errors. Therefore, it is important to understand the challenges experienced by the patients, relatives, and healthcare professionals pertinent to the concomitant use of many drugs. METHODS We conducted a qualitative study using focus group interviews to collect information from patients, relatives, and healthcare professionals regarding older patients' management of prescribed medicine. We interviewed seven patients using five or more medications daily, three relatives, three general practitioners, nine nurses from different healthcare sectors, one home care assistant, two hospital physicians, and four pharmacists. RESULTS The following themes were identified: (1) Unintentional non-adherence, (2) Intentional non-adherence, (3) Generic substitution, (4) Medication lists, (5) Timing and medication schedule, (6) Medication reviews and (7) Dose dispensing/pill organizers. CONCLUSION Medication is the subject of concern among patients and relatives. They become confused and insecure about information from different actors and the package leaflets. Therefore, patients often request a thorough medication review to provide an overview, knowledge of possible side effects and interactions, and a clarification of the medication's timing. In addition, patients, relatives and nurses all request an indication of when medicine should be taken, including allowable deviations from this timing. Therefore, prescribing physicians should prioritize communicating information regarding these matters when prescribing.
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Affiliation(s)
- Thorbjørn Hougaard Mikkelsen
- Emergency Department, Hospital Sønderjylland, Aabenraa, Denmark.
- Research Unit of Emergency Medicine, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
- Hospital Sønderjylland, Kresten Philipsens vej 15, indgang F, Aabenraa, 6200, Denmark.
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Niels Kristian Kjaer
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Bo Nielsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Ryg
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Geriatric Medicine, Odense University Hospital, 6 The, Odense, Denmark
| | - Lene Juel Kjeldsen
- Hospital Sønderjylland, Kresten Philipsens vej 15, indgang F, Aabenraa, 6200, Denmark
| | - Christian Backer Mogensen
- Emergency Department, Hospital Sønderjylland, Aabenraa, Denmark
- Research Unit of Emergency Medicine, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Previdoli G, Cheong VL, Alldred D, Tomlinson J, Tyndale-Briscoe S, Silcock J, Okeowo D, Fylan B. A rapid review of interventions to improve medicine self-management for older people living at home. Health Expect 2023; 26:945-988. [PMID: 36919190 PMCID: PMC10154809 DOI: 10.1111/hex.13729] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/15/2022] [Accepted: 02/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored. AIM This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address. DESIGN A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory. RESULTS Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty. CONCLUSION To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system. PATIENT OR PUBLIC CONTRIBUTION A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.
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Affiliation(s)
- Giorgia Previdoli
- Yorkshire Quality and Safety Group, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - V-Lin Cheong
- Medicines Management & Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - David Alldred
- Faculty of Medicine and Health, School of Healthcare, University of Leeds, Leeds, United Kingdom
| | - Justine Tomlinson
- Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom
| | | | - Jonathan Silcock
- Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom
| | - Daniel Okeowo
- Faculty of Medicine and Health, School of Healthcare, University of Leeds, Leeds, United Kingdom
| | - Beth Fylan
- Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom
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Swinglehurst D, Hogger L, Fudge N. Negotiating the polypharmacy paradox: a video-reflexive ethnography study of polypharmacy and its practices in primary care. BMJ Qual Saf 2023; 32:150-159. [PMID: 36854488 PMCID: PMC9985753 DOI: 10.1136/bmjqs-2022-014963] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Polypharmacy is an important safety concern. Medication reviews are recommended for patients affected by polypharmacy, but little is known about how they are conducted, nor how clinicians make sense of them. We used video-reflexive ethnography (VRE) to: illuminate how reviews are conducted; elicit professional dialogue and concerns about polypharmacy; invite new transferable understandings of polypharmacy and its management. METHODS We conducted 422 hours of fieldwork (participant observation), filmed 18 consultations between clinicians and patients receiving 10 or more regular items of medication (so-called 'higher risk' polypharmacy) and played short clips of film footage to 34 participants (general practitioners, nurses, clinical pharmacists, practice managers) in seven audio-recorded reflexive workshops. Our analysis focused on 'moments of potentiation' and traced clinicians' shifting understandings of their practices. RESULTS Participants rarely referenced biomedical aspects of prescribing (eg, drug-drug interactions, 'Numbers Needed to Treat/Harm') focussing instead on polypharmacy as an emotional and relational challenge. Clinicians initially denigrated their medication review work as mundane. Through VRE they reframed their work as complex, identifying polypharmacy as a delicate matter to negotiate. In patients with multimorbidity and polypharmacy it was difficult to disentangle medication review from other aspects of patients' medical care. Such conditions of complexity presented clinicians with competing professional obligations which were difficult to reconcile. Medication review was identified as an ongoing process, rather than a discrete 'one-off' activity. Meaningful progress towards tackling polypharmacy was only possible through small, incremental, carefully supported changes in which both patient and clinician negotiated a sharing of responsibility, best supported by continuity of care. CONCLUSIONS Supporting acceptable, feasible and meaningful progress towards addressing problematic polypharmacy may require shifts in how medication reviews are conceptualised. Responsible decision-making under conditions of such complexity and uncertainty depends crucially on the affective or emotional quality of the clinician-patient relationship.
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Affiliation(s)
- Deborah Swinglehurst
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- QMUL
| | - Lucie Hogger
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Nina Fudge
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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12
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Negoescu E, Marcilly R, Cromie S, Koay A, Grimes T. The medication self-management work system of patients and informal carers from a human factors & ergonomics perspective: A scoping review protocol. HRB Open Res 2023; 6:4. [PMID: 37398919 PMCID: PMC10311124 DOI: 10.12688/hrbopenres.13674.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 08/19/2023] Open
Abstract
Background: Healthcare is increasingly delivered closer to the patients' homes, which increases the level of responsibility that patients and informal carers take for managing their medication-taking, although this is associated with hazards. Medication self-management has been conceptualised as work taking place in non-formal settings ( e.g., households), which are complex systems. Human factors and ergonomics (HFE) models provide a framework for studying such systems. The Systems Engineering Initiative for Patient Safety (SEIPS) is one framework that considers work system elements and how they interact with each other to shape processes that lead to outcomes ( e.g., safety). Given the increasing amount of diverse research on patient and carer work and on system-shaping factors, the objectives of this review are to: (i) identify available evidence in a structured and systems-oriented way, (ii) explore approaches that have been applied and (iii) highlight research gaps. Methods: An evidence-informed patient, public and carer involvement (PPCI) approach will be implemented at all post-protocol stages to ensure the relevance, uptake and translation of the scoping review. The review will systematically search MEDLINE, Embase, PsycInfo, CINAHL and Web of Science to identify relevant qualitative studies. The methodological approach will be guided by Johanna Briggs Institute methodology and will be reported according to the PRISMA-ScR standards. Data charting and qualitative content analysis directed by SEIPS will explore how the work system and its constituting elements have been described in the literature and identify specific gaps and opportunities for future research. Borrowing from realist approaches, included studies will be assessed in terms of richness and relevance to our review question. Discussion: Strengths of this scoping review include PPCI and a converging focus on medication safety, medication self-management and HFE. Ultimately, this approach will advance our understanding of this complex system and guide opportunities to broaden and strengthen the evidence base.
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Affiliation(s)
- Eduard Negoescu
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, The University of Dublin, Dublin, D02 PN40, Ireland
| | - Romaric Marcilly
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, Lille, F-59000, France
- INSERM, CIC-IT 1403, Lille, F-59000, France
| | - Samuel Cromie
- Centre for Innovative Human Systems (CIHS), School of Psychology, Aras an Phiarsaigh, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Aaron Koay
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, The University of Dublin, Dublin, D02 PN40, Ireland
- Institute for Global Health, University College London, London, WC1N 1EH, UK
| | - Tamasine Grimes
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, The University of Dublin, Dublin, D02 PN40, Ireland
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Wilson E, Jones A, Brandt NJ. Sodium-Glucose Cotransporter-2 Inhibitors: Risks vs. Rewards When Caring for Older Adults. J Gerontol Nurs 2022; 48:7-13. [PMID: 36169298 DOI: 10.3928/00989134-20220908-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Managing multiple comorbidities is common in older adults. Thus, when a medication class, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, can potentially treat multiple conditions and prevent progression of chronic kidney disease, multiple guidelines must be followed when using these agents. The current article discusses risks and benefits of SGLT2 inhibitors, especially in the context of new evidence, and presents a case example. [Journal of Gerontological Nursing, 48(10), 7-13.].
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14
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Werner NE, Campbell NL, Boustani M, Ganci A, Holden RJ. Helping the Helpers - A research protocol for user-centered technology to aid caregiver management of medications for people with Alzheimer's disease and related dementias. Res Social Adm Pharm 2022; 18:3680-3686. [PMID: 35396151 PMCID: PMC9308637 DOI: 10.1016/j.sapharm.2022.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Systematically supporting caregiver-assisted medication management through IT interventions is a critical area of need toward improving outcomes for people living with ADRD and their caregivers, but a significant gap exists in the evidence base from which IT interventions to support caregivers' medication tasks can be built. User-centered design can address the user needs evidence gap and provide a scientific mechanism for developing IT interventions that meet caregivers' needs. The present study employs the three phases of user-centered design to address the first two stages of the NIH Stage Model for Behavioral Intervention Development. METHODS We will conduct a three-phase study employing user-centered design techniques across three aims: Aim 1) assess the needs of ADRD caregivers who manage medications for people with ADRD (Stage 0); Aim 2) co-design a prototype IT intervention to support caregiver-assisted medication management collaboratively with ADRD caregivers (Stage IA); and Aim 3) feasibility test the prototype IT intervention with ADRD caregivers (Stage IB). DISCUSSION Our user-centered design protocol provides a template for integrating the three phases of user-centered design to address the first two stages of the NIH Stage Model that can be used broadly by researchers who are developing IT interventions for ADRD caregivers.
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Affiliation(s)
- Nicole E Werner
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA.
| | - Noll L Campbell
- Purdue University, College of Pharmacy, Regenstrief Institute, Inc, USA
| | - Malaz Boustani
- Indiana University School of Medicine, Regenstrief Institute, Inc, USA
| | - Aaron Ganci
- Department of Visual Communication Design, IUPUI Herron School of Art and Design, USA
| | - Richard J Holden
- Department of Health & Wellness Design, Indiana University School of Public Health-Bloomington, Regenstrief Institute, Inc, USA
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15
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Lawson S, Mullan J, Wong G, Zaman H, Booth A, Watson A, Maidment I. Family carers' experiences of managing older relative's medications: Insights from the MEMORABLE study. PATIENT EDUCATION AND COUNSELING 2022; 105:2573-2580. [PMID: 35016779 DOI: 10.1016/j.pec.2021.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 10/18/2021] [Accepted: 12/30/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To explore the burdens experienced by family carers who support older relatives to manage their medications at home. METHODS This study, based on a larger UK medication management study: MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation (MEMORABLE), reports on findings from family carer interviews (n = 16). The five stages of medication management, identified in MEMORABLE, were used to inform the analysis. RESULTS Family carers described being involved in some or all five of the MEMORABLE stages to help manage older relatives' medications. Their capacity to undertake this role was sometimes limited by the complex workload involved as well personal circumstances such as time, distance and relationships. Family carers perceived that their knowledge and skills in medication management improved with experience, but also described stress associated with information lag and gaps, risk and responsibility, and loss. They described medication management burdens that needed mitigation: ambiguity, concealment, unfamiliarity, fragmentation and in particular exclusion, conflicted interests and expectation of coping. CONCLUSION To help mitigate these burdens, family carers should receive better information, training and support for this role. PRACTICE IMPLICATIONS Continued reliance on family carers for medication management requires strategic recognition in policy, funding and practice.
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Affiliation(s)
- Sally Lawson
- School of Life and Health Sciences, Aston University, Birmingham B4 7ET, UK.
| | - Judy Mullan
- School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia.
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK.
| | - Hadar Zaman
- School of Pharmacy and Medical Sciences, Faculty of Life Sciences, University of Bradford, Richmond Road, Bradford BD7 1DP, UK.
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA, UK.
| | - Anne Watson
- Bournville & Northfield PCN, Our Health Partnership, UK.
| | - Ian Maidment
- School of Life and Health Sciences, Aston University, Birmingham B4 7ET, UK.
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16
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Maidment ID, Wong G, Duddy C, Upthegrove R, Oduola S, Robotham D, Higgs S, Ahern A, Birdi G. REalist Synthesis Of non-pharmacologicaL interVEntions for antipsychotic-induced weight gain (RESOLVE) in people living with severe mental illness (SMI). Syst Rev 2022; 11:42. [PMID: 35264212 PMCID: PMC8906356 DOI: 10.1186/s13643-022-01912-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People with severe mental illnesses (SMI) such as schizophrenia die on average 15 to 20 years earlier than everyone else. Two thirds of these deaths are from preventable physical illnesses such as hypertension, cardiovascular disease, and diabetes, which are worsened by weight gain. Antipsychotics are associated with significant weight gain. In REalist Synthesis Of non-pharmacologicaL interVEntions (RESOLVE), a realist synthesis, combining primary and secondary data, will be used to understand and explain how, why, for whom, and in what contexts non-pharmacological interventions can help service users to manage antipsychotic-induced weight gain. METHODS A five-step approach will be used to develop guidance: 1. Developing the initial programme theory An initial (candidate) programme theory, which sets out how and why outcomes occur within an intervention, will be developed. 2. Developing the search The initial programme theory will be refined using academic and grey literature. The proposed initial sampling frame are as follows: Context: people living with SMI, taking antipsychotics, different types of SMI. INTERVENTION non-pharmacological interventions. MECHANISMS triggered by the intervention. Outcomes e.g. weight, metabolic adverse events, quality of life, adherence, burden, economic. Searching for relevant documents will continue until sufficient data is found to conclude that the refined programme theory is coherent and plausible. Lived experience (service users) and stakeholder (practitioners) groups will provide feedback. 3. Selection, appraisal and data extraction Documents will be screened against inclusion and exclusion criteria. The text extracted from these documents will be coded as contexts, mechanisms and their relationships to outcomes. 4. Primary data collection Realist interviews with up to 30 service users and informal carers, and 20 practitioners will gather data to support, refute or refine the programme theory. 5. Data analysis A realist logic of analysis will be used to develop and refine the programme theory from secondary and primary data. The analysis will aim to identify practical intervention strategies to change contexts so that key mechanisms are triggered to produce desired outcomes. Guidance will be produced based on these strategies. DISCUSSION This realist synthesis aims to develop guidance for service users and practitioners on the most appropriate interventional strategies to manage and limit antipsychotic weight gain. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42021268697.
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Affiliation(s)
- Ian D Maidment
- College of Health and Life Sciences, Aston University, Birmingham, B4 7ET, UK.
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Rachel Upthegrove
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Sheri Oduola
- School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Dan Robotham
- The McPin Foundation, 7-14 Great Dover St, London, SE1 4YR, UK
| | - Suzanne Higgs
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Amy Ahern
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Gurkiran Birdi
- College of Health and Life Sciences, Aston University, Birmingham, B4 7ET, UK
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Byrne G, Keogh B, Daly L. Self-management support for older adults with chronic illness: implications for nursing practice. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:86-94. [PMID: 35094539 DOI: 10.12968/bjon.2022.31.2.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Self-management is a key skill that older adults with multiple comorbidities require. Self-management interventions include medication management, self-monitoring and self-awareness and self-management often requires the older adult to manage the emotional consequences of having multiple comorbidities. The benefits of self-management for older adults include reduced reliance on the health system, enhanced quality of life, empowerment of the individual and reduction in the burden associated with chronic illness. Many factors can influence an older adult's ability to self-manage, including health literacy, mental health difficulties and socio-economic factors. Self-management support is the provision of structures, services and programmes to support and enhance the skills of older adults in managing their own conditions. Nurses are in a pivotal position across the continuum of care, using both person-centred care and the 'Making Every Contact Count' approach, to support older adults to self-manage their conditions.
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Affiliation(s)
- Gobnait Byrne
- Assistant Professor, School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - Brian Keogh
- Assistant Professor, School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - Louise Daly
- Assistant Professor, School of Nursing and Midwifery, Trinity College Dublin, Ireland
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18
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Maidment I, Wong G, Duddy C, Upthegrove R, Oduola S, Allen K, Jacklin S, Howe J, MacPhee M. Medication optimisation in severe mental illness (MEDIATE): protocol for a realist review. BMJ Open 2022; 12:e058524. [PMID: 35074825 PMCID: PMC8788310 DOI: 10.1136/bmjopen-2021-058524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Severe mental illness (SMI) is associated with significant morbidity and mortality. People living with SMI often receive complex medication regimens. Optimising these regimens can be challenging. Non-adherence is common and addressing it requires a collaborative approach to decision making. MEDIATE uses a realist approach with extensive engagement with experts-by-experience to make sense of the complexities and identify potential solutions.Realist research is used to unpack and explain complexity using programme theory/theories that contain causal explanations of outcomes, expressed as context-mechanism-outcome-configurations. The programme theory/theories will enable MEDIATE to address its aim of understanding what works, for whom, in what circumstances, to optimise medication use with people living with SMI. METHOD AND ANALYSIS MEDIATE will be conducted over six stages. In stage 1, we will collaborate with our service user/family carer lived experience group (LEG) and practitioner stakeholder group (SG), to determine the focus. In stage 2, we will develop initial programme theories for what needs to be done, by whom, how and why, and in what contexts to optimise medication use. In stage 3, we will develop and run searches to identify secondary data to refine our initial programme theories.Stage 4 involves selection and appraisal: documents will be screened by title, abstract/keywords and full text against inclusion and exclusion criteria. In stage 5, relevant data will extracted, recorded and coded. Data will be analysed using a realist logic with input from the LEG and SG. Finally, in stage 6, refined programme theories will be developed, identifying causal explanations for key outcomes and the strategies required to change contexts to trigger the key mechanisms that produce these outcomes. ETHICS AND DISSEMINATION Primary data will not be collected, and therefore, ethical approval is not required. MEDIATE will be disseminated via publications, conferences and form the basis for future grant applications. PROSPERO REGISTRATION NUMBER CRD42021280980.
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Affiliation(s)
- Ian Maidment
- College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Claire Duddy
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Rachel Upthegrove
- Department of Psychiatry, School of Psychology and College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sherifat Oduola
- Health Service Population Research, University of East Anglia, Norwich, UK
| | - Katherine Allen
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Simon Jacklin
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | - Jo Howe
- College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Maura MacPhee
- School of Nursing, The University of British Columbia, Vancouver, British Columbia, Canada
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Prescribing at 95 years of age: cross-sectional findings from the Newcastle 85+ study. Int J Clin Pharm 2022; 44:1072-1077. [PMID: 35906504 PMCID: PMC9362142 DOI: 10.1007/s11096-022-01454-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/25/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous research has examined prescribing amongst 85-year-olds in English primary care, but less is known about prescribing amongst 95-year-olds in spite of population ageing. AIM We describe the most commonly prescribed medicines in a cohort of 95-year-olds, using 10-year follow-up data from the Newcastle 85+ Study (n = 90). METHOD A total of 1040 participants were recruited to the Newcastle 85+ Study through general practices at 85-years of age, and 90 surviving participants were re-contacted and assessed at 95-years of age. Prescribed medications from general practice medical records were examined through cross-tabulations and classified as preventative or for symptom control based on their customary usage. RESULTS Preventative medications with unclear evidence of benefit such as statins (36.7%), aspirin (21.1%) and bisphosphonates (18.9%) were frequently prescribed. CONCLUSIONS Future research in a larger clinical dataset could investigate this preliminary trend, which suggests that benefit/risk information for preventive medication, and evidence for deprescribing, is needed in the very old.
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20
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Gench M, Sawan MJ, Langford A, Gnjidic D. Tools to evaluate medication management for caregivers of people living with dementia: A systematic review. Health Expect 2021; 24:1570-1581. [PMID: 34289214 PMCID: PMC8483200 DOI: 10.1111/hex.13318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Caregivers often undertake medication management for people living with dementia without formal training. There is a need to evaluate caregiver medication management practices for people living with dementia to identify and address the key issues that contribute to caregiver burden. OBJECTIVES This study aimed to identify and summarize approaches that evaluate medication management for caregivers of people living with dementia and appraise caregiver's involvement in aspects of medication management. SEARCH STRATEGY A systematic search was undertaken in five databases: Medline, Embase, PsycINFO, Scopus and International Pharmaceutical Abstracts. Studies written in English that contained tools and surveys that evaluated aspects of medication management for caregivers of PWD were included. RESULTS A total of 10 studies were included. Medication selection was assessed in six studies, supply and monitoring/review was captured in seven studies, with administration assessed in nine studies. Caregivers were commonly involved in decision-making for medication changes (77.1%-86.8%) and in the ordering (55.9%-86.0%) and collection (87.0%-92.4%) of medications. Reported caregiver involvement in medication administration showed a wide range (44%-94.7%) between the studies. Challenges in administration were commonly related to polypharmacy and dosage regimen complexity. CONCLUSIONS Current tools capture specific aspects of medication management, with medication administration the most evaluated aspect of medication management. Future research is needed to develop a tool to holistically evaluate the complexities of medication management for caregivers of people living with dementia to minimize adverse events at transitions of care. PUBLIC CONTRIBUTION From the authors' previous research, caregivers highlighted the need to address key issues in medication management for people living with dementia.
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Affiliation(s)
- Melissa Gench
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Mouna J. Sawan
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Aili Langford
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Charles Perkins CentreThe University of SydneySydneyNew South WalesAustralia
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Luetsch K, Maidment I, Twigg M, Rowett D. Realist research to inform pharmacy practice and policy. Res Social Adm Pharm 2021; 17:2075-2081. [PMID: 34246570 DOI: 10.1016/j.sapharm.2021.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 05/21/2021] [Accepted: 06/29/2021] [Indexed: 11/28/2022]
Abstract
Theory-driven implementation and evaluation of pharmacy services can enhance their contribution to overall healthcare. As complex interventions most pharmacy practice programmes and services will be adopted and modified during their implementation into various healthcare contexts and systems. Realist approaches to theory-driven evaluation consider these variations in programmes, interventions and the contexts of their implementation and establish theories on how they work best, for whom and why. This paper illustrates the practical application of the realist philosophy of science to pharmacy practice relevant areas of healthcare using two case studies, a realist synthesis of existing literature on medication reviews and a realist review and evaluation related to medicines management. Applying realist logic establishes causative explanations of what could be essential factors in the success of programmes, enabling policy makers in their decision-making and pharmacy practice researchers as well as practitioners in optimising service design.
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Affiliation(s)
- Karen Luetsch
- School of Pharmacy, The University of Queensland, 20 Cornwall St, Woolloongabba, Qld, 4102, Australia; School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, 5000, Australia.
| | - Ian Maidment
- College of Health and Life Sciences, Aston University, Birmingham, B4 7ET, United Kingdom.
| | - Michael Twigg
- School of Pharmacy, University of East Anglia, Norwich, NR47TJ, United Kingdom.
| | - Debra Rowett
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, 5000, Australia.
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Mira JJ. How to reduce medication errors in patients over the age of 65? Expert Opin Pharmacother 2021; 22:2417-2421. [PMID: 34187264 DOI: 10.1080/14656566.2021.1947241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- José Joaquín Mira
- Health Psychology Department, Universidad Miguel Hernandez de Elche, Elche, Spain.,Alicante-Sant Joan Health District, Alicante, Spain
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23
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Maidment I, Young E, MacPhee M, Booth A, Zaman H, Breen J, Hilton A, Kelly T, Wong G. Rapid realist review of the role of community pharmacy in the public health response to COVID-19. BMJ Open 2021; 11:e050043. [PMID: 34135054 PMCID: PMC8210681 DOI: 10.1136/bmjopen-2021-050043] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/13/2021] [Accepted: 04/29/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Community pharmacists and their teams have remained accessible to the public providing essential services despite immense pressures during the COVID-19 pandemic. They have successfully expanded the influenza vaccination programme and are now supporting the delivery of the COVID-19 vaccination roll-out. AIM This rapid realist review aims to understand how community pharmacy can most effectively deliver essential and advanced services, with a focus on vaccination, during the pandemic and in the future. METHOD An embryonic programme theory was generated using four diverse and complementary documents along with the expertise of the project team. Academic databases, preprint services and grey literature were searched and screened for documents meeting our inclusion criteria. The data were extracted from 103 documents to develop and refine a programme theory using a realist logic of analysis. Our analysis generated 13 context-mechanism-outcome configurations explaining when, why and how community pharmacy can support public health vaccination campaigns, maintain essential services during pandemics and capitalise on opportunities for expanded, sustainable public health service roles. The views of stakeholders including pharmacy users, pharmacists, pharmacy teams and other healthcare professionals were sought throughout to refine the 13 explanatory configurations. RESULTS The 13 context-mechanism-outcome configurations are organised according to decision makers, community pharmacy teams and community pharmacy users as key actors. Review findings include: supporting a clear role for community pharmacies in public health; clarifying pharmacists' legal and professional liabilities; involving pharmacy teams in service specification design; providing suitable guidance, adequate compensation and resources; and leveraging accessible, convenient locations of community pharmacy. DISCUSSION Community pharmacy has been able to offer key services during the pandemic. Decision makers must endorse, articulate and support a clear public health role for community pharmacy. We provide key recommendations for decision makers to optimise such a role during these unprecedented times and in the future.
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Affiliation(s)
- Ian Maidment
- College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Emma Young
- The University of Sheffield, Sheffield, UK
| | - Maura MacPhee
- The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Juanita Breen
- College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrea Hilton
- Faculty of Health Sciences, University of Hull, Hull, UK
| | - Tony Kelly
- NHS Birmingham and Solihull Clinical Commissioning Group, Birmingham, UK
| | - Geoff Wong
- Primary Care Health Sciences, University of Oxford, Oxford, UK
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24
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Ellis U, Kitchin V, Vis-Dunbar M. Identification and Reporting of Patient and Public Partner Authorship on Knowledge Syntheses: Rapid Review. J Particip Med 2021; 13:e27141. [PMID: 34110293 PMCID: PMC8235296 DOI: 10.2196/27141] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/12/2021] [Accepted: 05/11/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Patient and public involvement (PPI) in health research is an area of growing interest. Several studies have examined the use and impact of PPI in knowledge syntheses (systematic, scoping, and related reviews); however, few studies have focused specifically on the patient or public coauthorship of such reviews. OBJECTIVE This study seeks to identify published systematic and scoping reviews coauthored by patient or public partners and examine the characteristics of these coauthored reviews, such as which journals publish them, geographic location of research teams, and terms used to describe patient or public partner authors in affiliations, abstracts, or article text. METHODS We searched CAB Direct, CINAHL, Cochrane Database of Systematic Reviews (Ovid), Embase (Ovid), MEDLINE (Ovid), and PsycInfo from 2011 to May 2019, with a supplementary search of several PPI-focused databases. We refined the Ovid MEDLINE search by examining frequently used words and phrases in relevant search results and searched Ovid MEDLINE using the modified search strategy in June 2020. RESULTS We screened 13,998 results and found 37 studies that met our inclusion criteria. In line with other PPI research, we found that a wide range of terms were used for patient and public authors in author affiliations. In some cases, partners were easy to identify with titles such as patient, caregiver or consumer representative, patient partner, expert by experience, citizen researcher, or public contributor. In 11% (n=4) of studies, they were identified as members of a panel or advisory council. In 27% (n=10) of articles, it was either impossible or difficult to tell whether an author was a partner solely from the affiliation, and confirmation was found elsewhere in the article. We also investigated where in the reviews the partner coauthors' roles were described, and when possible, what their specific roles were. Often, there was little or no information about which review tasks the partner coauthors contributed to. Furthermore, only 14% (5/37) of reviews mentioned patient or public involvement as authors in the abstract; involvement was often only indicated in the author affiliation field or in the review text (most often in the methods or contributions section). CONCLUSIONS Our findings add to the evidence that searching for coproduced research is difficult because of the diversity of terms used to describe patient and public partners, and the lack of consistent, detailed reporting about PPI. For better discoverability, we recommend ensuring that patient and public authorships are indicated in commonly searched database fields. When patient and public-authored research is easier to find, its impact will be easier to measure.
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Affiliation(s)
- Ursula Ellis
- Woodward Library, University of British Columbia, Vancouver, BC, Canada
| | - Vanessa Kitchin
- Woodward Library, University of British Columbia, Vancouver, BC, Canada
| | - Mathew Vis-Dunbar
- University of British Columbia Okanagan Library, Kelowna, BC, Canada
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25
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Holmqvist M, Thor J, Ros A, Johansson L. Evaluation of older persons' medications: a critical incident technique study exploring healthcare professionals' experiences and actions. BMC Health Serv Res 2021; 21:557. [PMID: 34098957 PMCID: PMC8182897 DOI: 10.1186/s12913-021-06518-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 05/12/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Older persons with polypharmacy are at increased risk of harm from medications. Therefore, it is important that physicians and nurses, together with the persons, evaluate medications to avoid hazardous polypharmacy. It remains unclear how healthcare professionals experience such evaluations. This study aimed to explore physicians' and nurses' experiences from evaluations of older persons' medications, and their related actions to manage concerns related to the evaluations. METHOD Individual interview data from 29 physicians and nurses were collected and analysed according to the critical incident technique. RESULTS The medication evaluation for older persons was influenced by the working conditions (e.g. healthcare professionals' clinical knowledge, experiences, and situational conditions) and working in partnership (e.g. cooperating around and with the older person). Actions taken to manage these evaluations were related to working with a plan (e.g. performing day-to-day work and planning for continued treatment) and collaborative problem-solving (e.g. finding a solution, involving the older person, and communicating with colleagues). CONCLUSION Working conditions and cooperation with colleagues, the older persons and their formal or informal caregivers, emerged as important factors related to the medication evaluation. By adjusting their performance to variations in these conditions, healthcare professionals contributed to the resilience of the healthcare system by its capacity to prevent, notice and mitigate medication problems. Based on these findings, we hypothesize that a joint plan for continued treatment could facilitate such resilience, if it articulates what to observe, when to act, who should act and what actions to take in case of deviations from what is expected.
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Affiliation(s)
- Malin Holmqvist
- Department of Hospital Pharmacy, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
- The School of Health and Welfare, Jönköping University, Jönköping, Sweden.
| | - Johan Thor
- Jönköping Academy for Improvement of Health and Welfare, the School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Axel Ros
- Jönköping Academy for Improvement of Health and Welfare, the School of Health and Welfare, Jönköping University, Jönköping, Sweden
- Futurum, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Linda Johansson
- Institute of Gerontology, Aging Research Network-Jönköping, the School of Health and Welfare, Jönköping University, Jönköping, Sweden
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26
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Barry HE, McGrattan M, Ryan C, Passmore AP, Robinson AL, Molloy GJ, Darcy CM, Buchanan H, Hughes CM. '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. Int J Geriatr Psychiatry 2021; 36:883-891. [PMID: 33368704 DOI: 10.1002/gps.5488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/22/2020] [Accepted: 12/19/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Identify facilitators and barriers to successful medicines management for people with dementia (PwD) in primary care from the perspectives of community-dwelling PwD and carers. METHODS Semi-structured interviews conducted with PwD and carers in Northern Ireland. The 14-domain Theoretical Domains Framework guided data collection and analysis. Interviews explored participants' experiences and perceptions of medicines management. PwD also completed the Beliefs about Medicines Questionnaire indicating their level of agreement with statements about medicines. Qualitative data were analysed using the framework method and content analysis. Quantitative data were analysed descriptively. RESULTS Eighteen PwD and 15 carers were interviewed. PwD believed they were competent with medicines management ('beliefs about capabilities'). Most PwD reported having strategies to prompt them to take their medicines ('memory, attention and decision processes'). Carers played an important role in supporting PwD with medicines management ('social influences') and monitoring adherence ('behavioural regulation') and anticipated having to take on a greater role as patients' cognitive impairment worsened ('beliefs about consequences'). Participants highlighted assistance provided by community pharmacies with medicines acquisition and delivery ('environmental context and resources') and placed great trust in primary healthcare professionals ('social influences'). PwD had positive attitudes towards medication and believed strongly in the necessity of their medicines. CONCLUSIONS This is the first study to use a theoretical approach to explore medicines management for community-dwelling PwD. The findings provide new insights into the critical role of carers in facilitating optimal medicines management and will inform future intervention development, in which carers' needs assessment and involvement will be key.
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Affiliation(s)
| | | | - Cristín Ryan
- The School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - A Peter Passmore
- Centre for Public Health, Queen's University Belfast, Belfast, UK.,Belfast Health & Social Care Trust, Belfast, UK
| | - A Louise Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Gerard J Molloy
- School of Psychology, National University of Ireland, Galway, Ireland
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27
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Jubraj B, Morris S, Wilcock M. How do your patients use their medicines at home and why is it important to know? Drug Ther Bull 2020; 59:3-4. [PMID: 33132207 DOI: 10.1136/dtb.2020.000030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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28
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Grossi CM, Richardson K, Savva GM, Fox C, Arthur A, Loke YK, Steel N, Brayne C, Matthews FE, Robinson L, Myint PK, Maidment ID. Increasing prevalence of anticholinergic medication use in older people in England over 20 years: cognitive function and ageing study I and II. BMC Geriatr 2020; 20:267. [PMID: 32736640 PMCID: PMC7393714 DOI: 10.1186/s12877-020-01657-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 07/16/2020] [Indexed: 11/23/2022] Open
Abstract
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 = 7635) and 2008-2011 (N = 7762). 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 anticholinergics 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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Affiliation(s)
| | | | - George M Savva
- University of East Anglia, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Chris Fox
- University of East Anglia, Norwich, UK
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29
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Maidment ID, Lawson S, Wong G, Booth A, Watson A, McKeown J, Zaman H, Mullan J, Bailey S. Medication management in older people: the MEMORABLE realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [PMID: 32579319 DOI: 10.3310/hsdr08260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
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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Affiliation(s)
- Ian D Maidment
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Sally Lawson
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anne Watson
- Medicines Management Department, West Heath Hospital, Birmingham Community Healthcare NHS Trust, West Heath, UK
| | - Jane McKeown
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - Hadar Zaman
- Bradford School of Pharmacy, School of Life Sciences, University of Bradford, Bradford, UK
| | - Judy Mullan
- Australian Health Services Research Institute (AHSRI), University of Wollongong, Wollongong, NSW, Australia
| | - Sylvia Bailey
- Patient and public involvement representative, School of Life and Health Sciences, Aston University, Birmingham, UK
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