Helping to tackle poor medicine management in older people
Between a third and half of prescription medication is not taken correctly by older patients, leading to heath risks and wastage
Older people are the major users of prescription medication, with many taking five or more each day. However, between a third and half of prescription medication is not taken correctly; so-called 'non-adherence'. Non-adherence appears to increase with the number of medications taken; cognitive impairment may also be associated with non-adherence.
Medication related adverse events appear to be associated with approximately 5,700 deaths every year in the UK. These deaths result in additional costs of up to £750 million with a further £300 million lost on medicines that are not taken at all. Internationally, medication-related issues are the fifth most common cause of death in the USA.
Research into ways to improve medication management is necessary to ensure the appropriate use of medication. Such research will allow patients to adequately benefit from their prescribed medicines and reduce medication-related deaths.
Dr Ian Maidment is Reader in Pharmacy at Aston’s School of Life and Health Sciences. Prior to joining academia, Maidment worked for over 20 years as a practising pharmacist specialising in old age and adult mental health.
His research expertise lies in medication management in vulnerable elders, including those living with dementia, and people living with mental health problems. He is member of Aston’s Pharmaceutical & Clinical Pharmacy Research Group (PCPRG).
The research process
Research within this project comprised of a variety of related studies that have the common aim of improving medication management among older people.
The team worked to develop a way to assess the risks and benefits of medication in older people. Maidment worked with international, interdisciplinary colleagues to develop a methodological approach, which assesses the anti-cholinergic side effects of commonly used medicines such as anti-histamines, anti-depressants, heart medication and painkillers.
The MEDREV feasibility study developed and tested ways to manage behaviour that challenges in people living with dementia in care homes. The overall aim was to develop approaches to reduce the use of medication including anti-psychotics. Annually, anti-psychotics are associated with 1,800 deaths in the UK in people living with dementia.
The study determined whether it is feasible to implement and measure the effectiveness of a combined pharmacy and health psychology intervention to reduce the use of psychotropics to manage behaviour that challenges.
The intervention consisted of a training package for care home staff and GPs, promoting person-centred care and treating behaviours that challenge as an expression of unmet need, and a medication review. A specialist pharmacist in collaboration with the general practitioner, care home staff and any family carer reviewed any medication used to treat behaviour that challenges.
Maidment also led two qualitative studies that aimed to shed new light on the challenges associated with medication management in older people living in the community who are currently taking many different medications.
Research conducted by Maidment during this project has successfully improved the use of medication in older people with additional benefits to quality of life, NHS policies and professional practices.
The Anti-Cholinergic Scale, co-developed by Maidment at an international consensus summit in Indiana, has achieved national and international influence at policy level.
Medicines Optimisation Polypharmacy Prescribing Comparators recommended in 2017 that all NHS Clinical Commissioning Groups in England use the Anti-Cholinergic Burden (ACB) Scale to assess prescribing quality. The most recent NICE Guidance on the treatment of dementia also cited the scale. Internationally, the scale has been used, across 13 countries, including 14 US states, with over one million participants in over 50 published studies. More than 10,000 patients have benefited from this work in a single US state alone, demonstrating the international reach of this research.
Additionally, the MEDREV feasibility study was featured in a NIHR Best Practice Review on Advancing Care in care homes. Maidment was invited to be the international expert for the National Dementia Office in Ireland, Clinical Guideline Group because of his expertise in this area (as demonstrated by MEDREV). The group developed guidance on the appropriate use of antipsychotics in people living with dementia.
Maidment’s research into anti-cholinergic burden, has also led directly to improvements in the quality of life of older people in the UK.
NHS England, in particular, noted that the research has had a direct impact on improving patients’ quality of life, while the Hertfordshire Partnership NHS Trust which provides services to over 400,000 people went on to state that "Maidment's research has led to the direct improvement to the care of our patients".
The MEDREV study also led to improvements in quality of life; 164 care home staff, GPs, nurses and pharmacists received training on how best to manage behaviour that challenges in people living with dementia. Following the training, staff were able to offer residents more holistic care, resulting in reduced medication use. It was noted that: MEDREV directly improved the quality of life of a significant number of care home residents with dementia.
Research findings have been presented at numerous regional, national and international events for practitioners including: Royal Pharmaceutical Society meetings, Alzheimer’s Association International Conference, British Journal of General Practice Research Conference and the International Conference on Preventing Over-diagnosis amongst others.
Maidment’s research has informed medical literature such as 'Seminars in Old Age Psychiatry'; one of the most widely used textbooks for practitioner training. It has also influenced Aston University’s Postgraduate Psychiatric Pharmacy programme, which is the only programme of its kind available globally. Up to 90 practitioners per year from countries including Australia, Hong Kong, USA and Denmark study the programme.
Maidment’s research has increased public awareness of the issue through media engagement.
Many other engagement activities included a presentation at the British Festival Science, an Age UK Blog, articles for the Daily Mail, Express, Telegraph, Times, and Choice Magazine which has a readership of 160,000.
Being on many different medications increases the risk of harm, hospital admissions and poor outcomes. Inadequate management of these medications is a significant issue in the UK where around 5,700 people die from medication related adverse events each year.
Elders continue to be prescribed many different medicines. Maidment’s work has improved the use of medication in older people with multiple and had far-reaching direct impacts including improving the quality of life of older people.