When dealing with frail elderly people at home, one of the most important considerations is to take into account the patient’s experience and his or her perspective, “because medicines-related problems start at home”, according to Lelly Oboh, consultant pharmacist, care of older people, Guy’s and St Thomas NHS foundation trust (community health services).
Frailty makes people less resilient to minor stressors and unlikely to regain their previous level of independence. This can have a significant impact on the use of medicines.
The starting point when discussing of medicines should always be the patient’s list, says Ms Oboh. The hospital discharge list and the GP’s list often differ from what the patient is actually taking, she said. It is also important to listen for clues in the patient’s narrative when taking a history. For example, one patient did not take her alendronic acid tablets. On further questioning it turned out that the word ‘acid’ made the patient think it would cause acid indigestion.
Ms Oboh describes a 79-year-old woman with a number of medical problems including osteoarthritis, colitis and thyroid disease, who was taking a total of 10 prescribed medicines. She had a good relationship with her pharmacist and was knowledgeable about her medicines. Her main problem was uncontrolled pain in her wrists, feet, hands and back that kept her awake most nights.
She was unable to open the blisters on a medication compliance aid because of the pain in her wrists and fingers and was not taking all her prescribed treatment. She said she would prefer “old-fashioned bottles with easy tops”. After taking a history of the medicines the patient actually took, the pharmacist focused on improving the pain management first and leave other medicines until a later date.
“Frailty is the point where disease-based guidelines are no longer a priority – instead the priority becomes what matters to the patient,” says Ms Oboh. In this case, the pharmacist explained how the treatments could work together and formulated a plan that involved larger doses of gabapentin combined with regular paracetamol and slow-release tramadol.
The patient agreed to try the new regimen and after three weeks her pain was significantly reduced, she was sleeping better and requested a written summary of her treatment plan. Ms Oboh concludes that there is a need for a long-term commissioning strategy, with the pharmacy workforce leading medicines optimisation across care settings.