Research tackles hidden 'tablet overload' as COVID isolation fears grow
New research provides a roadmap to help the millions of older Britons struggling with 'shopping lists' of medication, as fears grow that the current coronavirus lockdown could be further isolating the most vulnerable.
With the over-70s and people with existing medical conditions being encouraged to 'shield' or self-isolate in lockdown as much as possible, there are concerns many could be avoiding seeking help from GPs and pharmacies in managing multiple medications, known as 'polypharmacy'.
Around half of the UK's 12m people aged 65 or over regularly take five or more separate medicines for long-term health conditions, also known as comorbidities. And even before the coronavirus crisis, it was estimated that errors such as taking the wrong medication cause or contribute to over 2,400 deaths per year.
The new research from Aston University, conducted between 2017 and 2019 and in collaboration with the universities of Oxford, Sheffield, Bradford and Wollongong and the NHS, has been published in the journal BMC Geriatrics. It aims to provide clinicians such as GPs and pharmacists with a more structured way of managing their patients' medicines.
The team behind the MEMORABLE (MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation) study, funded by the National Institute for Health Research (NIHR) and led by Dr. Ian Maidment, say a new approach rooted in real-world experience is needed to tackle the "unrivalled complexity" many older people and family carers face.
Retired dental secretary Sue Boex, 73, took part in the study while caring for her mother, Edna, who passed away in February 2019 at the age of 96. Towards the end of her life, Edna had dementia while also suffering from heart and digestive problems which meant taking at least six different medicines.
"She didn't know why or what she was taking and relied on me totally," said Sue, from Stourbridge, West Midlands. "It was incredibly stressful. It's not as though you get any training to be a carer, so we had to make it up as we went along."
Sue recalled how her mother would get confused and angry when medicines from different manufacturers were prescribed, because she relied on shape and colour to tell them apart. At one point, she became seriously dehydrated after refusing to take a thickening agent with her drinks to help with a swallowing problem.
Sue's husband Nick, 72, also suffers from a number of long-term conditions for which he takes 12 different tablets. She said that although they were lucky to have an "excellent" local GP and pharmacist who have been able to deliver his medication throughout the COVID-19 crisis, she worried about how others were coping.
"I once visited an elderly gentleman who kept his medicines in an old tobacco tin. He was hospitalised several times for taking too many or not taking them at all. I dread to think how someone in that sort of situation must be coping right now. I think a lot of older people, particularly if they live on their own and don't use technology, must be feeling like they can't ask for help even if they need it."
In the MEMORABLE study, the researchers reviewed existing academic literature and carried out 50 in-depth interviews with older people, their family carers and health and care practitioners.
They identified five 'key burdens' faced by older people and their family carers. These included 'ambiguity', where the purpose of medicines was not explained clearly, through to 'fragmentation' from having to deal with lots of different health and care practitioners and 'exclusion' when older people and family carers were not involved in care decisions.
In response, the team behind the MEMORABLE study propose a five-stage framework for clinicians to help older people and family carers manage medication more effectively. It places greater emphasis on the need for regular reviews of the medications older people are taking involving patients and their carers—something that isn't always done routinely at present.
Clair Huckerby is Chief Pharmacist for Our Health Partnership, a 'super partnership' of 37 GP practices in Birmingham and the wider West Midlands, serving a population of around 400,000.
She said: "The MEMORABLE study is really important because I think historically the NHS perhaps hasn't put enough emphasis on talking to patients about how the complexity of their medication regimes can affect them. It also encourages us to have a more structured approach to medication review and that may well mean deprescribing items that the patient no longer needs."
Our Health Partnership is now looking to 'risk stratify' its large population to identify more vulnerable patients and take a more proactive approach in helping them manage their medication.
Dr. Ian Maidment, from Aston University's School of Life and Health Sciences, said:
"The reality is that many older people are taking what amounts to a 'shopping list' of different medicines. They may all be necessary, but older people and their family carers have told us what a huge burden it can be to remember how and when to take them all. And that was in ordinary times without the added pressures of lockdown.
"Many older people may struggle to access their GP and pharmacy right now and with such bad news every day, may even be avoiding asking for help because they don't want to be putting further strain on the NHS. We urgently need further research on the impact of COVID and I am planning future research in this area.
"What we're hoping to show with this study is that practitioners need to be aware that the burden and risk with medication is often hidden. There needs to be a simpler way of identifying people who are struggling and more emphasis on fitting managing medication into older people's day-to-day lives. When prescribing new drugs, GPs will often consider things like side effects, but they equally need to think about how someone will actually manage taking them.
"That human side needs to be front and centre."Jo Rycroft-Malone, NIHR Programme Director and Chair of the Health Services and Delivery Research (HS&DR) Programme said:
"This research provides important, usable insight into the issues facing older people when it comes to managing their medication. The proposed five step approach will be very useful to practitioners when working with patients and their carers particularly at a time when people may be more concerned about asking for help."