Chapter 48 Services for vulnerable patients
Vulnerable patients can be described as those in need of care services because of mental ill health, disability, age or illness. They may require protection from harm and exploitation, or may need support to lead healthy and fulfilled lives.
Pharmacists are often involved in the care of vulnerable people. Most commonly these include children and young people, the elderly, drug misusers, people with mental ill health and those who live in care homes.
When developing services for vulnerable people it is important to consider why they are vulnerable. Vulnerable patients tend to experience problems with communication, reduced mental capacity, diminished legal status with regard to treatment or a physical inability to care for themselves.
It is taken for granted that when ill or in need, a person can talk to a healthcare professional to get advice. However, some groups may have problems communicating their needs. Babies and small children cannot talk about how they feel; some who have experienced stroke or head injury can have problems talking; and people suffering with a mental disability may not be able to describe their symptoms or problems. Healthcare professionals may also encounter vulnerable people who are too embarrassed or scared to communicate their needs.
Children and those with learning difficulties or mental health problems may not have the mental capacity to understand disease and treatment; they rely on parents, carers and healthcare professionals to explain matters on a level that they can understand. When some people are suffering from mental ill health, they may not be able to think clearly enough to understand their disease.
When a patient is considered unable to make decisions about disease and treatment they become vulnerable as they rely on others to make decisions for them. In most cases the people involved in the decision-making process have the best interests of the patient at heart. However, occasionally situations occur where patients do not receive the care they require, and they are not in a position to object. Legally a patient should give consent to any treatment given; however, when treating babies and young children, the parent or guardian consents to the treatment on their behalf. As children develop into young adults they acquire more legal rights with regard to consenting to treatment. Decisions can be complex and involve the young person, parents, guardians, the local health authority and courts of law.
Some adults with severe learning difficulties have such reduced mental capacity that they cannot legally consent to treatment; these people are termed ‘incapacitated’ and the consultant in charge of their care makes decisions about their treatment. Occasionally people suffering from mental ill health have no insight into their illness, and they may not realize they need help. In these situations patients can be ‘sectioned’ against their will under the Mental Health Act, to ensure they receive appropriate treatment.
Babies and children rely on adults to feed and care for them. Many vulnerable adults also rely on others for their basic needs. The frail elderly and some with mental or physical disabilities may not have the strength or ability to care for themselves. In these situations people can get support from care services in the community, rely on carers or live in a care home.
In recent years inequalities and failures in the quality of care that vulnerable groups of people receive from the NHS and social services have been highlighted. High-profile public enquiries such as the Victoria Climbie report and the Bristol enquiry have brought these topics into the public domain. In response, the Department of Health has published a number of national service frameworks (NSFs) and guidance documents that aim to increase the quality of care provided, and protect vulnerable groups from abuse and exploitation.
NSFs set national standards for the care that groups of people should receive, and they also provide strategies and measurable time frames for implementation. The purpose of NSFs is to raise standards and decrease inequalities in care. There are now a number of published NSFs; those relevant to vulnerable patients are:
Alongside the NSFs, guidance documents such as ‘Working Together to Safeguard Children’ and ‘The Protection of Vulnerable Adults Scheme’ detail how healthcare professionals can work together to protect the vulnerable from harm and exploitation.
There are many services pharmacists provide that contribute to the care of vulnerable people; these services are referred to throughout the NSFs and include:
Pharmacists also provide enhanced or specialist services to vulnerable patients focusing on the specific care needs of that group. These will be discussed later in the chapter, and services to drug misusers are dealt with in Chapter 49.
All patients benefit from health promotion information (see Ch. 5). However, vulnerable groups may not always receive the information they need. There are a number of health promotion topics that all vulnerable groups benefit from learning about. These include:
A healthy diet is an important component of health and well-being for everyone. When dealing with vulnerable groups of patients it is important to ensure that they receive the correct advice. When considering babies, pharmacists are in an ideal position to promote breastfeeding, give advice on the use of formula milk, and help parents to wean their babies correctly and at an appropriate time. Children have different dietary needs to adults; although children do not require the same volume of food as adults, they may need more energy-releasing foods to support their higher metabolic rate. As children develop in to young adults, pharmacists can advise on what constitutes a healthy diet, promoting the intake of at least five portions of fruit and vegetables a day, with the hope that good eating habits are taken forward into adulthood. Older people may also need advice about healthy diet. Weight loss can have a positive impact on conditions such as hypertension, diabetes and arthritis that develop with age, and ensuring older people eat a diet that provides calcium and vitamin D can help prevent osteoporosis. Some mental health problems, such as bulimia, can present in the pharmacy and pharmacists may be called upon to advise on healthy eating. Care should be taken to refer these patients to specialist services if required.
Many people are confused by health claims related to the use of vitamins, minerals and food supplements. Pharmacists provide a reliable source of information that vulnerable people can turn to. Parents often consult pharmacists for advice about which vitamins are suitable for children. This is an opportunity to discuss what constitutes a healthy diet, and pharmacists can ensure that supplements are used safely. Some people with mental ill health will consult the pharmacist looking for a ‘natural’ cure and again pharmacists can ensure that any supplements are used safely, but should also be able to signpost people to appropriate help if their symptoms appear severe or worsening. Pharmacists need to be aware of potential interactions between prescribed medicines and dietary supplements, especially in the elderly.
Physical activity provides a vast range of health benefits, and there is no reason why vulnerable groups should not partake. Pharmacists may have to advise on what activities are appropriate and signpost people to relevant services. Physical activity is important to children and young people as it can aid learning and development and prevent weight-related diseases later in life. Physical activity and exercise have been shown to mildly reduce anxiety and depression, thus helping those with mental health problems. Exercise is also of benefit to the elderly, where it has been shown to promote higher bone density, increase muscle strength and flexibility, reduce the risk of stroke and improve memory.
Immunizations are an essential method of protecting the public and individuals from disease. Pharmacists can ensure that vulnerable groups receive the immunizations they require. Babies and children receive a number of different immunizations, and parents often have concerns about their use. Pharmacists have a role in educating parents about the safety and importance of immunizations, and they can ensure that they are received at the correct age. Some older vulnerable groups of people require immunizations, and again pharmacists have a role informing people of their necessity. For example, it is recommended that all people over 65, those living in long-term residential care homes and those that care for elderly or disabled people receive an influenza vaccination.
Stopping smoking is the single most important act an individual can do to improve their health. This is particularly important for vulnerable groups where smoking could have a larger impact on their quality of life. When dealing with children and young people, pharmacists have a role in educating about the risks associated with smoking to try and prevent them taking up the habit. However, if they are already smoking then pharmacists are in an ideal position to advise on giving up. Smoking has been linked with mental health problems such as anxiety and depression, so these groups of people may need more support when trying to give up. Smoking contributes to many illnesses experienced later in life such as heart disease, cancer and osteoporosis, therefore older people also need support to help them stop smoking. This may be particularly difficult if it has been a habit for many years. Community pharmacists provide nicotine replacement therapy (NRT) over the counter or via a NHS stop smoking service if appropriate.
Drug and alcohol misuse is often associated with mental ill health, and can exacerbate existing problems. Issues are usually complex, requiring specialist services; however, pharmacists can advise on safe levels of alcohol consumption, and the dangers associated with illegal drug use. Pharmacists providing drug misuse services may be the first to notice deterioration in a patient’s mental state, and can signpost the patient to an appropriate source of help, for example Alcoholics Anonymous or other healthcare professionals involved in their care. As children mature in to young adults they may begin to experiment with alcohol, drugs and volatile substances. Pharmacists have a role in controlling the sale of OTC medicines that are subject to abuse and they can advise against risky behaviours.
Concordance is the agreement between the patient and healthcare professionals about what actions are best taken (see Ch. 46). Often actions involve the use of medicines, therefore pharmacists have an important role to play. Achieving concordance can sometimes be challenging, especially when dealing with vulnerable groups. However, if a patient is able to become involved in their treatment decisions, the chances of treatment being successful are increased.
There are a number of different reasons why patients do not adhere to the advice of healthcare professionals, and vulnerable groups may need more support than others to ensure concordance is achieved. Non-concordance may be intentional, where the patient makes a decision not to comply, or unintentional, where there are barriers to following advice given.
Some vulnerable groups are particularly at risk of intentionally not adhering to the advice of healthcare professionals; however, there are actions that pharmacists can take to try and achieve concordance.
As children mature into young adults they should take more responsibility for their own health. Teenagers may be too embarrassed to take medicines to school, or they may decide that they do not need to follow advice as they assert their own independence. To overcome these problems healthcare professionals should involve the patient in any decisions about their treatment, and pharmacists can help by explaining disease and treatment options to the young person in a way that they will understand. Practical support can be given, such as providing modified-release preparations to avoid school time dosing, or supplying discrete appliances such as insulin pens rather than needles and syringes.
Achieving concordance with treatment regimens for people with mental ill health can be difficult, due to the nature of the illnesses involved and the treatments available.
Stigma is attached to some mental health problems such as anxiety, depression, schizophrenia and mania, which can prevent people accepting they have a problem, leading to non-concordance to treatment programmes. Pharmacists can help overcome these problems by discussing mental health issues sensitively and explaining the use of treatment options.
Patients suffering with schizophrenia or mania may lose contact with reality and suffer delusions, posing problems with concordance. Patients may not believe they need treatment, or they believe that a treatment could harm them. These situations require specialist expertise and there are complicated issues with regard to patient consent. Pharmacists can help by providing advice on medication options or the method of drug delivery such as the use of depot preparations.
Drugs used to treat mental health problems often have unacceptable side-effects for patients, resulting in patients choosing not to take the medication at all, or reducing the dose themselves. Identifying and informing patients of potential side-effects before treatment commences may overcome some of these problems. Pharmacists can give advice on how to manage side-effects if they are experienced.
Mental health issues are often related to drug misuse problems, if a prescribed medicine interacts with alcohol or illicit drugs then the patient may choose to discontinue the prescribed medicine in favour of the other. Pharmacists may be the first healthcare professional to become aware of this type of non-compliance. They should advise the patient against risky activities, and signpost them to specialist services such as the local drug misuse team.
Some vulnerable groups experience physical barriers to taking medicines. The frail elderly and some disabled patients are particularly at risk of experiencing difficulties, for example eyesight problems mean some patients may not be able to read instructions. By supplying large print or talking labels the pharmacist can easily overcome this. Problems with dexterity mean some elderly people are unable to remove tablets from bottles or blister packs and again pharmacists can help by ensuring they provide medicines in the most convenient package for the patient. Some patients with a disability may not be able to swallow tablets; therefore the pharmacist can suggest other routes of administration. People with learning difficulties may be unable to read instructions or patient information leaflets, therefore they do not understand why or how to take their medicines. Pharmacists should take time in these situations to ensure they understand. Older people and some with mental health problems may experience memory loss and just forget to comply with a medication regimen. Supplying a memory card can easily solve this problem. If memory problems are severe, such as those experienced with dementia, the pharmacist can repackage solid dosage forms into blistered monitored dosage systems.
The NSFs detail the role pharmacists can play when supplying OTC medicines for minor ailments. Parents consult the pharmacist for advice about their children and the elderly are one of the biggest users of community pharmacies. Drug misusers often have regular contact with community pharmacists, and those living in care homes may rely on pharmacist visits to receive information about minor ailments.
The NSF for children and young people states that they should receive timely and quality effective care when they are ill. Many illnesses that children suffer from, such as coughs, colds, viruses and skin rashes, can be treated quickly and effectively by community pharmacists; however, care should be taken to signpost parents to more appropriate services when a child appears to be more seriously ill. Only OTC products designed and licensed for use in children should be supplied, as they will have been tested for safety and efficacy in this age group. These products are often pleasant tasting colourful liquids, or melt in the mouth sweets, and are more appealing to children, but parents may have concerns about sugar content, artificial flavourings and colourants. Information should be available to parents to help them make informed choices when treating their children. As these medicines are appealing to children, pharmacists must advise parents about the safe storage of medicines in the home.
Minor ailment schemes can provide timely and effective care. When delivering a minor ailment scheme the pharmacy provides advice and medicines, where appropriate, to those people who would have otherwise gone to their GP for a prescription. This saves a GP appointment, and the patient gets the medicine free or at a discounted NHS charge.
It has been estimated that four out of five people over 75 take at least one prescribed medicine, therefore older people are one of the main users of pharmacy services. Pharmacies are not only places where older people collect their prescriptions; they are a source of advice, OTC medicines and social contact. With this in mind, care should be taken to check for interactions with OTC medicines, and any OTC sales or advice should be recorded in the patient medication record where appropriate. It is important to remember that not all OTC products are suitable for the elderly. For example thrush treatments should not be provided to those over 60 as the incidence of thrush in this group is low and symptoms would require investigation. Vulnerable older people are at risk of becoming socially isolated as family and friends move or pass away. The community pharmacy can become a place of social contact, therefore it should be welcoming, with easy access for those with mobility problems, and pharmacists should take time to talk to people. This gives opportunities to signpost vulnerable people to other services that they may need, and it can give the pharmacist great job satisfaction.
Drug misusers have regular contact with community pharmacies, either as part of a drug treatment programme and a needle exchange service or due to dependence on OTC medication (see Ch. 49). When customers are being treated for opiate addiction they may be taking drugs such as methadone or buprenorphine, and will require advice as to which OTC medicines are suitable. Alcohol dependence can be treated with disulfiram, and patients on this drug need to avoid any alcohol-containing OTC remedies. Customers who use a needle exchange service may be using illicit ‘street’ drugs and it is important to identify the nature of the drugs being used in order to appropriately deal with OTC requests. Dependence on OTC medicines can occur, for example opiate-based painkillers and cough medicines. Pharmacists should be aware of multiple or repeated sales of these products, and refuse their sale if dependence is suspected. These customers should then be signposted to specialist services to obtain help.
When advising on the use of OTC medicines, pharmacists may become aware that a customer is experiencing mental health problems. For example, people requesting St John’s wort or sedating antihistamines may be experiencing anxiety or depression. Customers purchasing large quantities of laxatives could be suffering from an eating disorder. Pharmacists have a duty of care to protect the customer from harm; therefore, if a mental health problem is suspected the customer should be referred to their GP.
When vulnerable patients live in care homes it can be difficult for them to access OTC medicines. If a community pharmacist provides an advisory service to care homes as an enhanced pharmacy service, then they can increase access to OTC advice and treatments. When visiting a care home, the pharmacist can talk to the residents to establish their need for OTC medicines, and then arrange the safe supply. Many care homes keep OTC medicines for residents to use, known as ‘homely medicines’; pharmacists can suggest which are most useful to keep and advise on their safe storage. Most residents in care homes have personalized care plans, and the pharmacist can add in suitable OTC treatments.
The NSFs for vulnerable groups identify that continuity of care is not always achieved between the primary and secondary sectors. The role of the hospital pharmacist is essential for ensuring a smooth transition between hospital, home and community services.
When vulnerable people enter hospital, a detailed medical history needs to be obtained. Pharmacists often take drug histories which contribute to this process, but this can be more challenging when dealing with vulnerable groups. Children may not know what medicines they are taking, and second hand information from the parent or carer may be more reliable. The elderly often take a number of prescribed and OTC medications, therefore a detailed history is required. It has been estimated that up to 17% of hospital admissions in the elderly can be related to adverse drug reactions. When dealing with those with mental ill health, taking a detailed drug history can help identify any medication issues such as non-concordance or ineffective treatment regimens, which could have contributed to the hospital admission.
Upon discharge the pharmacist can help make the transition from secondary to primary care as smooth as possible. Pharmacists should ensure that when children and young people are discharged from hospital they understand when and how to take their medication. Encouraging them to take responsibility themselves aids concordance and eases the burden on the parent or carer. Pharmacists can also give practical support such as liaising with GPs and community pharmacists to ensure a continual supply of medication, arranging dosage regimens compatible with school hours, and arranging adequate supplies if medicines are needed at school.
Older people may find that changes are made to medication regimens while they are in hospital and pharmacists should ensure these changes are understood and any barriers to taking their medicines are removed.
Most people experiencing mental health problems live in the community; however, from time to time patients may stay in secondary care. When planning discharge from hospital, the pharmacist should be involved in developing a care plan ensuring that patients receive only the necessary medicines, in as simple a regimen as possible, to aid concordance. If a patient relies on a carer then they should be fully involved in this process. Practical support such as liaising with GPs to ensure a continual supply of medication, or writing out compliance charts can be helpful.
The use of drugs can be complicated in vulnerable groups as often more than one drug is required to achieve the desired effect, or unusual dosages may be required. The differences in response and pharmacokinetics of vulnerable groups must be taken into consideration, i.e. drug absorption, distribution, metabolism and excretion.
Drug absorption changes throughout life. Neonates and young infants have prolonged gastric emptying, resulting in slower rates of drug absorption. Neonates and the elderly produce less gastric acid, resulting in a higher stomach pH, possibly affecting the absorption of some basic drugs. Older people experience slower intestinal motility, reduced total surface area for absorption and decreased gastric emptying. Although these factors do not usually have a large effect on total drug absorption, they can slow the rate of drug absorption, resulting in a delayed response.
Drug distribution is affected by total body water, adipose tissue and protein binding, three factors which change as a person ages. As children mature, their total body water decreases, therefore neonates and infants may need larger doses of water-soluble drugs. Older people experience a decrease in muscle mass and a gain in adipose tissue. This can sometimes cause problems as lipid-soluble drugs are stored in the adipose tissue, increasing the chances of side-effects and toxicity, therefore lower doses of lipid-soluble drugs should be prescribed.
Neonates have low levels of albumin, therefore less protein binding occurs. This means that lower doses of protein binding drugs are required in this age group. A similar situation occurs in the elderly because as people age, the liver produces less albumin, therefore protein binding drugs such as warfarin and phenytoin may need reduced dosages. In neonates, the protein binding situation is further complicated as they have high levels of bilirubin. Bilirubin attaches to albumin, therefore if a protein binding drug displaces bilirubin from albumin then high circulating levels of bilirubin may result, presenting as jaundice.
Neonates, infants and children have a higher metabolic rate than adults, sometimes resulting in the need for more frequent dosing, or higher doses of drugs on a mg/kg basis. However, care should be taken in neonates as their liver enzyme systems may not be fully mature, and so much lower doses would be required. The elderly experience reduced blood perfusion of the liver, resulting in the slower metabolism of some drugs; lower doses of these would therefore be required.
Renal function does not mature until a baby is 6–8 months old and therefore drugs may accumulate and reduced doses should be given to neonates and infants. The elderly may also require reduced dosages of some drugs as renal filtration becomes slower with age, increasing the chances of drug toxicity occurring.
There are a number of services that pharmacists provide to children and young people. Specialist paediatric pharmacists provide prescribing advice in secondary care, and pharmacists may become involved in advising on sexual health and child protection.
Children suffer from a different range of illnesses to adults, and their bodies react differently to disease states. Ideally drugs used in children will have undergone clinical trials in that age group for the condition that is being treated. However, most drugs are only tested on adults for safety and efficacy, and are therefore unlicensed for use in children. When prescribing decisions are made, pharmacists can provide their expertise by evaluating current clinical evidence. Pharmacists should recommend using a licensed product where possible, or evaluate the safest and most effective unlicensed products available. Parents and carers may be alarmed at the use of unlicensed products, especially if they read an inappropriate patient information leaflet. Explaining the use of the unlicensed medicines to the parent or carer and involving the whole family in any treatment decisions can overcome this. If a drug has not been tested in children, then calculating the dosage can be difficult and the age and weight of the child should be considered. If a high-risk medicine is being used, such as those with a narrow therapeutic range, then the weight of the child and the dose in mg/kg should be stated on all prescriptions to ensure safety. When dosages are being calculated, especially for off-licence medicines, errors may occur and pharmacists have a role in training other healthcare professionals in performing pharmaceutical calculations to ensure correct doses are always given.
Pharmacists are often the first healthcare professional that a young person may encounter for advice on contraception and sexual health. Pharmacists sell condoms, provide emergency contraception, signpost people to family planning clinics, provide Chlamydia screening and treatment programmes, and provide health promotion about sexually transmitted infections. Emergency hormonal contraception (EHC) can be sold to young people over the age of 16 where appropriate, and some pharmacists supply EHC to under-16-year-olds using a patient group direction.
It can sometimes be difficult for pharmacists to know whether a young person has the intellectual competence to make their own treatment decisions. In the 1980s the Gillick court case raised questions about whether a young person under 16 could receive advice about contraception without the parents’ consent. From this court case, the Frazer guidelines were developed to help healthcare professionals make decisions about whether to treat or advise young people without their parents knowing. To provide treatment or advice to an under-16-year-old, the healthcare professional must be satisfied that:
More recently the Sexual Health Act 2003 states that children under the age of 13 are unable to consent to sexual activity, therefore if a young person under this age requests advice on sexual matters, specialist advice must be sought and it may be appropriate to contact the police. Contacting a third party such as the police can be a difficult decision to make as a pharmacist should respect a patient’s confidentiality. Pharmacists must encourage the young person to seek further help if required, or try to get the young person’s consent for the pharmacist to contact a specialist service on their behalf.
Children and young people are considered vulnerable as they may not be able to protect themselves from people who harm or exploit them. Pharmacists may become involved in child protection if they have concerns about the welfare of a child and wish to report them. Pharmacists may be asked to provide information on a child or young person to the police or social services, or pharmacists may be involved in a child protection plan.
All healthcare professionals have a duty to safeguard and support the welfare of children. If a pharmacist suspects that a child or young person is being abused they have a legal duty to act upon their suspicions. Abuse can be physical, emotional, sexual or due to neglect. A pharmacist may suspect physical abuse if a child’s injuries could not be accounted for by an explanation provided by the parent or carer, or a pharmacist may notice that a child or young person often presents in the pharmacy with injuries. Emotional abuse is more difficult to identify; however, pharmacists may have concerns if a child or young person became withdrawn or showed signs of self-harm. Pharmacists may encounter children or young people who are suffering from sexual abuse when they are supplying EHC, or the young person may describe sexual activities that are inappropriate for their age. Signs of neglect include failure to provide adequate shelter, food or clothing, which may become apparent to a pharmacist.
If a pharmacist suspects any form of abuse then they must follow the local child protection procedures. Child protection procedures are overseen by the local primary care organization which designates a child protection officer, usually a doctor or a nurse, to coordinate child protection. It is not recommended that pharmacists investigate any suspicions of abuse themselves, but they should record their concerns and any actions taken.
Pharmacists may be asked to give information to social services if a child protection investigation occurs. It is important for pharmacists to cooperate with the police and social services as all agencies involved in child protection should work together if abuse is suspected.
Pharmacists may be directly involved in a child protection plan. These are plans written by social services to help protect a child from harm. For example, a pharmacist may provide drug misuse services to the parent of an at-risk child. Social services may ask the pharmacist for feedback on whether the parent is accessing the drug misuse service.
In situations such as these, conflicts of confidentiality may arise. However, if disclosure is necessary for the protection of children or to prevent serious injury to a person’s health, then information should be shared.
By 2025, one-quarter of the British population will be over the age of 60. Many older people lead active and independent lives late into old age; however, some older people will become frail and increasingly rely on the NHS and social services.
As people age their bodies undergo a number of changes. This increases the number and range of diseases that older people suffer from and changes their response to drugs that treat disease. Older people may find that as family and friends move or pass away they become more socially isolated and therefore vulnerable.
Pharmacists provide a number of specialist services to help prevent the elderly becoming vulnerable, and to fulfil their needs if they are. These services include medicine management and falls prevention.
The NSF for older people estimates that four out of five people over 75 take at least one prescribed medicine, with 36% taking more than four. Pharmacists have a role in ensuring that older people gain maximum benefit from their medication. Medicines should increase quality and duration of life and not cause harm due to excessive, inappropriate or inadequate use. By providing prescribing advice, medicines use reviews and full medication reviews, pharmacists can ensure that this is achieved.
Pharmacists are often employed as prescribing advisors either in GP surgeries or within the primary care organization. The role of a prescribing advisor is to evaluate current evidence in the use of medicines and to cascade good prescribing practices down to prescribers. Some drugs are of particular benefit to older people and can increase their quality and duration of life. Prescribing advisors ensure that these drugs are made available to patients. For example, pharmacists can promote the use of statins and anti-thrombotics to help reduce the incidence of stroke. As the clinical evidence for drugs changes, prescribing advisors are in a position to reduce the use of drugs that are of doubtful therapeutic value. In the past phenothiazine antipsychotic drugs have been used for dizziness due to postural hypotension, and benzodiazepines have been prescribed for insomnia due to depression, both of which were not appropriate uses and prescribing advisors can ensure a reduction in such inappropriate medication use.
A medicines use review is an advanced pharmacy service in which the pharmacist undertakes a structured concordance-centred discussion about medicine use (see Ch. 47). This usually takes place at the time of dispensing and lasts up to 25 minutes. Medicines use reviews are carried out on patients with multiple medicines, or those with long-term conditions, therefore many older people benefit. It is important to state that medicines use reviews are not full medication reviews, but aim to increase the patient’s understanding of their medicine, identify any problems they have taking their medicines and suggest solutions where possible.
More detailed than a medicines use review is a full medication review. This is an in-depth evaluation of all a patient’s medication, both prescribed and non-prescribed. Full medication reviews are usually carried out at a GP’s surgery and can last up to an hour. GPs have a requirement in their NHS contract to review patients at appropriate times and pharmacists can provide a medication review service for GPs to help achieve this. An appropriate time to carry out a full medication review would be in the following circumstances:
When carrying out a full medication review the pharmacist should first explain the purpose and gain the patient’s consent to the review process. Sometimes the medication review is carried out with a patient’s carer and consent from the patient should be sought if possible. A list of all medications taken by the patient should be compiled which should include OTC remedies, herbal remedies, illicit substances or those borrowed from family or friends. This comprehensive list should then be compared with the GP’s records and any ambiguities corrected. While gathering the information, the patient’s understanding of what each medicine is used for can be checked and if the patient is unsure why they are taking a medicine, the pharmacist can explain its purpose. During the review the pharmacist should confirm that the patient knows how and when to take their medication and should check that the patient is not having any practical issues such as ordering medicines, getting the medicine out of the container or reading the instruction label. Side-effects should be discussed with the patient, and suggestions made to help overcome them. The medication review is also an opportunity to ensure all relevant monitoring tests have been carried out.
When the pharmacist has gained a comprehensive picture of a patient’s drug use, they should evaluate the appropriateness of each medication. Assessing the appropriateness of medication involves checking that the medication is prescribed for an indication listed in the British National Formulary, and identifying any inappropriate drug use or dosages. Any recommendations should then be discussed with the prescriber before appropriate changes are implemented.
Falls in older people have serious consequences and often result in a healthy active older person becoming vulnerable. Falling has been shown to be a major cause of accidental death in older people and many patients who suffer a fracture never live independently again. The fear of falling can limit what older people do in their day-to-day lives.
Older people are at an increased risk of falling as their muscle mass is decreased which results in a loss of physical strength and a reduction in mobility. Medicines have been implicated in causing older patients to fall. Hypnotic drugs such as benzodiazepines can cause drowsiness, and antihypertensives may cause hypotension and dizziness. Particular care should be taken when an older person suffers from osteoporosis as these patients are much more likely to suffer fractures and consequent deterioration in quality of life. The NSF for older people states that if older people can be prevented from falling, they may live longer, healthier lives, not become vulnerable and therefore ease pressures on the NHS. Many pharmacists have undertaken specialist training to become fall prevention pharmacists. The fall prevention pharmacist reviews a patient’s medication, and suggests strategies to withdraw drugs that can predispose a person to falls. They also advise on how to avoid OTC medicines that increase the risk, such as sedating antihistamines or laxatives. Overuse of laxatives can cause dehydration which can result in hypotension.
Fall prevention pharmacists also advise on the prevention of osteoporosis to reduce the risk of fracture. There are some groups of patients that are particularly at risk from osteoporosis and these include those:
The fall prevention pharmacist can identify those at risk of developing osteoporosis and arrange bone density measurements to be taken. If a patient did have osteoporosis, the pharmacist would ensure that corticosteroids were only used when necessary and that preventative measures such as vitamin D and calcium supplementation or bisphosphonates were made available.
Mental ill health is a common problem. At any one time, around one in six people of working age have a mental health condition. The Department of Health has increasingly put an emphasis on caring for those with mental ill health in the community. Medication is a fundamental component in the care of the mentally ill.
Managing medication in those with mental ill health is a specialized area and many pharmacists have undertaken further training to become specialist mental health pharmacists. Specialist mental health pharmacists tend to work in secondary care as part of the multidisciplinary team. Their role is to ensure drug use is clinically effective. This means ensuring that the drug is being used at an optimum dose to achieve symptom relief with minimal side-effects and that drugs are administered in a way that is acceptable to the patient. They are also involved in training other healthcare professionals, contributing to the development of treatment guidelines, and are increasingly becoming supplementary and independent prescribers.
In primary care the pharmacist’s role is more limited. Prescribing advisors can ensure that prescribers follow up-to-date treatment guidelines with regard to antidepressants, benzodiazepines and antipsychotics. There are increasing opportunities for pharmacists to become involved with local community mental health teams to promote communication between all parties responsible for care planning, and there are increasing opportunities to provide mental health support services to those in prison.
Many vulnerable people choose to live in a care home when they can no longer look after themselves or they cannot be adequately cared for by others in their own home. There are a number of different types of care home in the UK which provide different levels of service. Residential care homes provide meals, accommodation, help with personal care such as dressing and bathing and support through short illnesses. This type of home often accommodates the frail elderly or those convalescing after illness. Nursing care homes have a qualified nurse on the premises 24 hours a day and therefore they are often used by those with more severe illness or a disability that requires frequent nursing care. Specialist care homes are available for those who have specific needs or disabilities such as dementia, where specially trained staff or adapted facilities are required. Pharmacists can provide different levels of service to care homes to help them look after their residents.
Ideally residents should have complete control of their medication which includes ordering their medicines, choosing a pharmacy to dispense them and taking responsibility for taking them. If residents are able to do this they should be encouraged to and provided with a lockable cupboard to store their medicines in. Many care homes like to have some control over medication and often vulnerable people need help storing and taking their medicines correctly. If a home takes responsibility for the residents’ medication then a suitably trained person orders the prescriptions from the residents’ prescribers. The home usually has a local agreement with a pharmacy to supply all the medicines, dressings and appliances for the residents in the home. Although this reduces the residents’ choice, it is much more convenient for the care home staff.
Pharmacists can supply medicines in the manufacturer’s original containers or they can put medicines into monitored dosage systems (MDSs). MDSs are a method of repackaging solid dosage forms into individualized blister packs and this is done to help residents or carers in the taking of the medicines. MDSs are time-consuming to prepare; however, they do reduce administration errors as carers and residents can clearly see when to take the medication. Not all solid dosage forms can be repackaged into MDSs. Drugs may deteriorate quickly if not in their original container, and before putting medication into an MDS, the manufacturers should always be consulted.
The way in which the residents receive their medicines depends on the needs of the residents and care home. The care home staff can simply give the resident the manufacturer’s container and leave the resident to take the medication themselves or the care home staff can observe the administration. This may be more necessary in care homes for the mentally ill or if a resident is particularly forgetful. If a home chooses to observe administration, then this is often carried out at meal times. This can cause problems if a drug is affected by food and may require the pharmacist to give suitable directions to care home staff when required.
It is important that adequate records of drug administration are kept, especially in homes with large numbers of staff, frequent shift changes and large numbers of residents. Medication administration record (MAR) charts are official records of the medicines that a resident is taking and should be completed every time a drug is administered. MAR charts are provided with the MDS and are kept up to date to reflect any medication changes.
It is good practice for each resident to have an individual care plan which contains details of prescribed medication.
Even if residents look after their own medicines, there is a requirement to consider the storage of medicines in the care home. Steps must be taken to ensure that medicines are kept securely and appropriate storage conditions are considered. Two main types of storage are used – either medicine cupboards or trolleys. Ideally a cupboard should be specially designed and lockable and the person in charge of the home keeps the key. Medicine trolleys should be stored in a room not normally accessible to residents and fastened to a fixed object when not in use. The storage conditions for medicines must be considered, especially controlled drugs (CDs) which must be kept in a CD cupboard. Some items may need to be stored in a refrigerator. The refrigerator ideally would only be used for medicines, but a mixed use refrigerator can be used as long as medicines are kept separately. The refrigerator must be lockable. The temperature inside cupboards should be checked and trolleys should not be kept near radiators.
Pharmacists need to ensure safe disposal of unwanted medicines (see Ch. 43). If a pharmacy supplies a care home, they are responsible for collection and destruction of unwanted medicines. If a resident dies, medicines should be kept for at least a week in case the coroner requests them. In no circumstances should unwanted medicines be kept by a home for use by other residents.
Pharmacy advisory services help homes reach the standards set by their regulator. The National Care Standards Commission for England, Care Standards Inspectorate for Wales, or the Scottish Commission for the Regulation of Care regulate care homes. Pharmacists receive payment for these services under the NHS contract.
When providing advisory services, the pharmacist makes an initial visit to the home, and then further annual visits to give advice. These visits entail checking that good practices are followed regarding the supply, administration, storage and destruction of medicines. The pharmacist should be aware of the regulatory body requirements and any advice given to the care home should be recorded. Pharmacists should use these opportunities to talk to the residents. These opportunities can be used to give advice about their medicines. Home visits are a good opportunity to carry out full medication reviews with the residents. Any suggestions for changes in treatment could then be fed back to the prescriber or incorporated into the resident’s personal care plan. Pharmacists can use these opportunities to help the home develop safe policies and procedures for drug handling and help train the staff to adopt safe practices, for example helping homes develop protocols for dealing with medication errors. Some pharmacists provide training courses for care workers up to NVQ level, for which extra payment can be claimed from the primary care organization.
While visiting a care home the pharmacist may encounter a scenario where they suspect the residents are at risk of abuse from the care home workers. If a pharmacist becomes concerned that a vulnerable adult may be being harmed, they have a duty to act upon their concerns. Pharmacists should not discuss their concerns with the care home staff, but contact the resident’s GP and social services for advice. Pharmacists have a duty to protect a person’s confidentiality, therefore consent should be sought from the resident. However, if their health or mental capacity renders them incapable of consent or disclosure is necessary to avoid harm then relevant information can be shared.