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 and dementia 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 Â£750 million with a further Â£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 team published research using this approach and the scale developed, which identified an association between medication with anti-cholinergic activity and dementia, in the BMJ.
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 and from this develop key practice-facing recommendations.
The initial exploratory study funded by Pharmacy Research UK identified the key issues and lead too: the NIHR-funded MEMORABLE study, which developed ways to optimise medication management in older people living in the community. In particular MEMORABLE identified that the burden associated with medication management in older people and that this burden is often hidden from doctors, nurses and pharmacists. The results from MEMORABLE have published in: Detailed full report, Summary academic publication
Research conducted by Maidment 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 has also led directly to improvements in the quality of life of older people in the UK. Referring to his work on anti-cholinergic burden, NHS England have highlighted a potential impact on 1.5 to 2.0 million people.
The MEDREV study also led to improvements in quality of life in a significant number of care home residents with dementia across the West Midlands; staff acted in a more patient centred way with less reliance on medication. MEDREV also has wider reach. For example, in Kent and Medway NHS Partnership Trust, which serves over 1,860,000 people, MEDREV directly impacted patient care, improving the quality of life of people living with dementia by limiting the inappropriate use of potentially toxic medication.
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 includes a Certificate, Diploma and MSc, and 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.
His work is regularly featured in the lay media.
His interview with the BBC about MEMORABLE gained over 1,000 views on YouTube. He was also interviewed by the BBC about the link between medication with anti-cholinergic activity and dementia. This research was featured across the world, for example with CNN.
Dr Maidment has also been interviewed by ITV, the BBC World Service; many other engagement activities included a presentation at the British Festival Science, an Age UK Blog, articles for the Daily Mail including polypharmacy and , Express, Telegraph, Times, and Choice Magazine which has a readership of 160,000.
His Conversation article gained over 7,000 reads, with 80% originating from outside the UK.
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.
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