Medicines Management

I had an email request from Xavier asking a number of questions about medicines management. The main theme was, "how do you, as a
practitioner who commonly works with geriatric patients requiring various psychotropic medications, work to prevent ADEs in your everyday work?"

ADEs is, I presume, adverse drug events, or what we'd call side effects or treatment emergent adverse events.

The short answer is that I don't prescribe medication unless there's clear, rational grounds to do so. Local audit showed I prescribe at substantially higher doses than peers, but prescribe a lot less often. This doesn't surprise me - either medication shouldn't be used (and homeopathic doses to placate folk is not just an easy option/a con, it's a potential cause of harm) or it should be used at a therapeutic dose and evaluated.

The commonest intervention is to reduce medication. Many patients were started on medication, appropriately, but as time's moved on the "need" for such medication diminishes, if considering a risk:benefit ratio or NNT (Number of patients Needed to be Treated to get one patient to respond beneficially to that treatment). If on a betablocker, say, at age 87, what is the NNT to avoid one serious adverse event over the next year? What's the NNH (Number Needed to Harm) and is it comparable to the NNT? If the chance of beneficial treatment is comparable to the chance of harm, should the drug be used? Sometimes yes, since the issues are so significant, but often the benefit is modest and the utility of the drug can be contested (which is a polite way of saying it can be reviewed and stopped).

As well as often seeing a list of medication that's grown over years and can be reduced, there's also the dose regimen. Taking medication twice a day is much better than taking it four times a day, in terms both of concordance with prescribed use and in delivering care (with carers supporting this through monitored dosage systems). Muddled folk taking extra meds or missing meds can then be optimised which matters for side effects profiles of many drugs but is vital (in the true sense of the word) in the safety of others (like digoxin, warfarin, lithium).

Having looked at rationalising the drug regimen then optimising appropriate concordance with the prescribed regimen and support the next consideration is non-drug strategies. Can the clinical issue be managed without medication? Or can it be managed with medication but with other whatnots too, reducing the prominence of medication (and thus hopefully reducing the polypharmacy/dose)? This is often the case. We don't have tablets to stop people shouting or stop them wandering; management of behavioural problems invariably profits from behavioural solutions. Medication is, at best, usually just an adjunct.

Really, this is a major issue. The DoH have published the National Dementia Strategy and Prof Sube Banerjee's report highlight the need to prescribe seldom, but prescribe in an evidenced manner, in dementia care. The NHS also touts this view. So do the Alzheimer's Society. The National Institute for Health and Clinical Excellence offer support in dementia care through the NICE Clinical Guideline, CG 42.

Politics, the NHS, voluntary/patient advocate groups and expert bodies all saying the same thing. Amazing! Continued routine use of antipsychotics is grabbing headlines and, validly, is seen as poor practice. The evidence that such drugs cause strokes and death mean we really need good evidence to countenance their use, in our patient's best interests.

What about antidepressants? In mainstream psychiatry we've known they're mostly used as snake oil linament, a trifle to offer folk to take whilst nature takes it's course and things get better. What's big news is that arguably the world's biggest mainstream (not mental health) medical journal published a paper this year, a meta-analysis of antidepressant use, that shows how antidepressants in clinical depression of mild, moderate and severe depression are as effective as placebo. Only in very severe depression was their statistical difference between antidepressants and placebo.
Antidepressants arguably have a tiny or no role in Primary Care, which is why non-directive counselling and IAPT and CBT blossomed.

Obviously, I do prescribe antipsychotics and antidepressants. But invariably I want to see evidence of what the problems are before prescribing, then start drugs at a decent dose and ramp them up to a very decent dose for a decent duration, then evidence if there's improvement. And if not, the drug's stopped.

Really, drugs often don't help. We know that. We see it in clinical practice. We know it from theoretical models (if you've structural brain changes from dementia, why should fiddling with brain chemistry fix anything?!). But although evidence on effectiveness in clinical practice (rather than drug companies' research on efficacy) shows effectiveness of drugs, generally, to be pretty much approaching zero. So statistically they don't often do a whole hill of beans. But for individual patients you can get stunningly good results.

Part of the approach is offering something. It's not as if you get drugs or you get nothing. Our team supports staff/carers working with our patients, offering other solutions. This may be seeing a patient in day hospital every week over a month to see how they interact with others and respond when being encouraged to complete a task, to better inform their spouse how to manage with tasks in company like when they go around a supermarket or journey on a bus. It may be our staff going in to a care home at 7.00am to show the carers how to get someone out of bed and washed and dressed, successfully. It's sitting down with someone and showing them how to facilitate engagement with meals, so the patient won't wander off after 5 minutes or start throwing food or fiddle with other peoples' plates. Our team does teaching at 9.00pm to support night staff in optimal care. These interventions when successful often save staff time. Not using drugs can only viably be part of a care plan if there're other successful, meaningful options being offered instead.

The subsequent use of medication needs to be considered over time. Although it may be that psychotropic medication's used reasonably, with evidenced benefit, it then needs review at a later date to ensure it's continued use remains appropriate. whether it's a mental health team or community pharmacist or GP/Primary Care that do it, there needs to be a system for medication review. Being obsessive, I go through every MARS sheet in every care home in my patch, doing medication clinics, so review all medication that anyone's prescribed (GPs or out of hours or people moving into the area) of everyone, to minimise medication use. I can't see how we can undertake effective medicines management without regular review.

So there we have it, the themes I'd suggest to minimising medication use and thus reducing adverse drug events are :
- Stopping medication that's no longer necessary/of significant benefit
- Ensuring concordance is supported through reduction of number of doses
- Ensuring concordance is supported through Monitored Dosage Systems, if relevant, reducing medication errors/accidental overdose
- Use non-pharmacological strategies with practical support of staff showing people what to do
- Documented objective evidence of problems to address, then introduction of medication, then documented objective evidence of effectiveness (and withdrawl of the drug of it's not proven to be useful)
- Medication review