Five moments to tackle problematic polypharmacy podcasts

Rakhi Aggarwal
Hello and welcome to our on the couch light podcast series from NHS Specialist Pharmacy Service. My name is Rakhi Aggarwal. Today we are here to talk about how we support problematic polypharmacy in the community pharmacy setting. So, what is problematic polypharmacy? Well, it’s sometimes referred to as inappropriate polypharmacy, which may occur when medicines are no longer appropriate, benefits outweigh the risks, combinations cause risk or harm, usage becomes unmanageable or distressing for the patient. 

In today’s podcast, I am joined by Lelly Oboh, Consultant Pharmacist, Care of the Older People. Today we’ll be discussing and being curious about problematic polypharmacy, or overprescribing, in community pharmacy setting. Welcome Lelly, I’m so privileged to be speaking to you today on our virtual couch. 

So, can you tell me the opportunities you see for pharmacy professionals in the community pharmacy setting and how they could support this? 

Lelly Oboh 
Hello, Rakhi and thank you. Well, patients on polypharmacy probably visit the community pharmacy more than any other setting. So, there are many opportunities to identify and to tackle overprescribing or inappropriate polypharmacy. The first opportunity I’d like to talk about is when patients or their carers return medicines. They often bring back unwanted and unused medicines, could be when they collect new prescriptions or sometimes when they have a clear-out. When your patient comes in with that bag of medicines, or even a couple of medicines, that’s the time to get curious and spot the overprescribing. Remember that the most important thing about your conversation with the patient about overprescribing is to ensure that the medicines prescribed are working for them, are appropriate for them, that they feel the medicines are necessary for them in their own circumstances, and also that they want to, and they can take the medicines. So, involving your patients during your conversation is a critical part of spotting and tackling overprescribing in this moment. 

The busy community pharmacy environment may not always lend itself to having these conversations, but you can be curious about what is being returned and proactively seizing the opportunity to find out why, by asking open questions that encourage your patients to engage and to tell you more. 

Rakhi Aggarwal
Thanks, Lelly. So, I’m hearing being curious. What kind of questions should I be asking the patient or carer about the returned medicines?

Lelly Oboh
Let me go through an example of how this might work because it might be a lot easier. So, you or your pharmacy staff spot that Mrs Olders has brought back a bag full of medicines, or maybe just a handful of medicines. You ask her if it’s okay to have a quick chat about her medicines, so you take her to a quiet corner or a less busy part of the pharmacy. Remember, your questions are not to judge or to scare or to make her feel bad, but to encourage her to give you some insight as to why those medicines have been returned. So, it may be as simple as starting with, “I see that you’ve returned three boxes of Laxido and almost a full box of co-codamol; can you tell me a little bit about that?”. The patient might just open up and say to you, “I was prescribed co-codamol for my pain in my shoulder when I went to hospital after having a fall, but now the pain is much better, so I haven’t taken them for a while and I find I’m not as constipated so I haven’t needed the sachets”. So, it could be as simple as that.  

I recently reviewed Mrs Smith who had very bad reflux which was making her bloated, and she found the constant burping uncomfortable and embarrassing. I asked her to explain how she took her medicines to manage her symptoms, and it turned out that she normally takes one omeprazole 20mg, and if that didn’t relieve the symptoms, she’ll take another one, and if that didn’t help, then she would take one teaspoonof Gaviscon, then she would take vitamin B12 tablets PRN as a last resort. So, if she returns that excess vitamin B12 to your pharmacy every month, a quick conversation, you know, like “Mrs Smith, I see you’ve returned this medicine”, and being quiet to hear what she has to say, it might be all you need and that’s a good start. If she says nothing, you might want to dig a little bit deeper and say, “do you remember what these tablets are for?”. She might then say, “it’s for my bloated stomach” or “I don’t know”, but your curiosity would have presented the opportunity for you to then have the conversation about managing that bloated-ness, but also about the overprescribing of cyanocobalamin, which is the vitamin B12. So, let’s be curious about the return medicines in the box rather than just putting them aside or straight in the bin because in there might be the clues that you need to find out if somebody’s being overprescribed a particular medicine. 

Rakhi Aggarwal
Thanks, Lelly. I just wanted to go back in time. I remember working in a community pharmacy as a student and a patient asking me not to tell her GP about the medicines she returned. What’s good in this case? You know, I remember referring at that point, because I was a student, to the community pharmacist, but what reassurance can we provide? 

Lelly Oboh
Thanks, Rakhi for raising, you know, these important issues because the last thing we want to do is to break the good clinician-patient relationship that we have with our patients. As I said, the first thing is that the language and the tone of our questions should not be judgmental. In my own practice, I usually say to patients that we clinicians often prescribe medicines based on what is right for them at the time. As time goes on, their situations may change, and those medicines may no longer be suitable. 

Also, I say that sometimes what is right according to the research may not work as well for their illness as individuals or may not agree with them and cause side effects. So, it’s helpful that they tell us so we can change or stop those medicines accordingly. Sometimes I say if they’re not taking particular medicines, I use this a lot, you know, for patients who are on anti-hypertensives and their clinicians don’t know. If I said to them that if they get admitted to hospital, the prescriber might just look at the dose and assume that the medicine is not working and then give a higher dose or give yet another drug because they hadn’t realised that they’re not being taken. So, that might help the patient feel, or it might just remind the patient that, you know, if the GP or whoever is prescribing the medicine has to know what they’re already taking for them to be able to make a safe and the right prescribing decision for them. So, depending, I might also add that if you return medicines to the pharmacy, it can’t be reused and goes to waste, so it’s better if you’re honest and we don’t prescribe at all in the first place, especially if they know they don’t want to take that medicine and always if they change their mind, they can go back and ask for those medicines to be prescribed. 

Rakhi Aggarwal
Great advice Lelly. So, what should they do with that information? Is this an opportunity to speak to another healthcare provider or refer them for an SMR do you think? 

Lelly Oboh
Well, how you respond and what you do with that information as a community pharmacist depends on what the patient says to you. For example, if you spot that Mr. Brown brings back his unfinished antibiotics, he might say, you know, “I was prescribed these antibiotics for my ear infection, but that they prescribed a new one because it didn’t get better”. In that case, your response may be “thank you very much for returning them” and is a quick advice about finishing antibiotics and all that and to just reinforce that the new antibiotics would need to be finished and whatever it is you need to say about antibiotic stewardship. Or it might require a little more effort, that’s if you’re up for it. So, for example, Miss. Delroy, who had a bag of unused medicines, and you know from your records, she’s unsteady on her feet, even with her stick, and she loves picking up her prescription from the pharmacy as well as shopping on the high street. She has osteoporosis because, you know, she’s taking alendronic acid, and she’s been in and out of hospital from recurrent falls. So, I saw this patient and I was quite curious about the contents of her medicines bag and found that she had six unused boxes of alendronate tablets, she had three half-used boxes of prochlorperazine tablets, she had Viscotears for dry eyes, she had co-amoxiclav antibiotics which were not quite finished, she had Otomize ear spray, she had Waxsol ear drops, and she had expired sodium bicarbonate ear drops. But prochlorperazine caught my eye because it has many prescribing indications including managing dizziness, vertigo and nausea, which, you know, is not surprising considering all the ear preparations that I found in the bag. It also increases her risk of falls and fractures and likely to be causing or worsening her cognition because of its high anticholinergic burden score. The Viscotears was prescribed to relieve dry eyes which is a muscarinic side effect of prochlorperazine and this is known as a prescribing cascade, where one medicine is prescribed, it causes a side effect and a second medicine has to be prescribed to counter that side effect from the first one, and this could also lead to prescribing a third medicine to counter the effect of the second medicine, and so on, and before you know it, that patient is on so many medicines. 

Rakhi Aggarwal
Thanks, Lelly. Using the tips you have given; how do you encourage them to partner in decision making during overprescribing conversations or educate them to optimise their medicines especially the ones that they’re not taking? 

Lelly Oboh 
Right, Rakhi. When patients like Miss. Delroy bring back unused medicines, it might not be practical to discuss every single medicine in the bag. So, asking opening questions or stating what you notice, may prompt the patient to engage or provide the information that you need. For example, you might say, “you’ve been prescribed a few medicines for your ear – tell me more about that”. This might lead to a conversation about prochlorperazine, it’s fall-increasing risk and the related hospital admissions she’s had from falling. Or it might lead to you explaining that the vertigo can be a result of all the ear wax or the ear infection. Similarly, because she’s mobile and at high risk of falls and is having recurrent falls, you may want to ask her to tell you more about the six unused boxes of alendronic acid. When I had that conversation with Miss. Delroy, she said she didn’t know what they were for, and she’d never take the alendronic acid anyway because she’s scared that the acid would upset her tender stomach. So that provided the opportunity for me to explain that the alendronic acid was not an acid as such but was prescribed to reduce the risk of a fracture when she has a fall and this made her think quite differently. So, after the long conversation, she agreed she was gonna take the alendronic acid and we agreed that she would report any new symptoms or any worsening stomach symptoms to her GP and then the GP would review the need for her medicines. 

Rakhi Aggarwal
Wow, just speaking to the patient, you can get some real insight to what they’re thinking and the way they’re thinking. That’s been really helpful, Lelly. So, what’s your one take home message from today? 

Lelly Oboh 
Be curious and look out for the overprescribing clues in the returned medicines. Talk to your patient, listen to what they have to say, then act appropriately in response to what you’ve heard. 

Rakhi Aggarwal
Wonderful, Lelly. Thank you so much. I really appreciate you being on the couch with me today. So, in the next episode Lelly and I will be talking about community pharmacy teams and how they can support patients with discharge medicines from the healthcare setting. What is best for their goals about medicines and reflecting on the plan that works for the patient. 

So that’s all here from us at SPS. Please remember to register on our website and opt in to receive our weekly SPS bulletin. This will make sure you always are informed and get the most up to date with our content and you will receive news on upcoming events. You can also follow us on LinkedIn and search NHS Specialist Pharmacy Service and you will be able to find us.

Rakhi Aggarwal
Hello and welcome to our on the couch light podcast series from NHS Specialist Pharmacy Service. My name is Rakhi Aggarwal. Today we are here to talk about how to support problematic polypharmacy in the community pharmacy setting. So, what is problematic polypharmacy? Well, it is sometimes referred to as inappropriate polypharmacy which may occur when medicines are no longer appropriate, benefits don’t outweigh harms, combinations cause or risk harm, or usage becomes unmanageable or distressing for the patient.

In today’s podcast, I am joined by Lelly Oboh, Consultant Pharmacist Care of the Older People. Welcome Lelly, I’m so privileged to be speaking to you on our virtual couch today.

I’m gonna start by asking you: patients are often discharged from care settings all the time and there’s often significant changes to medicines. What should I be thinking about and what should I be asking as a community pharmacist?

Lelly Oboh
Thank you, Rakhi. You are right, older people, particularly those living with frailty, frequently move between healthcare settings and evidence shows that when they move from hospital to community, for example, 60% of them would have at least three changes to their medicines and 1 in 3 older people will have a medicine related problem post-discharge.

Aside from those who have elective surgery, many older patients go into hospital because they’ve had an acute exacerbation of a chronic condition like COPD, heart failure, or they might have had delirium, they might have had a fall, a stroke, a UTI, or any other infection, and this means that new medicines may be prescribed and current medicines might be changed or stopped. Also, post-discharge, the patient’s circumstances, goals and priorities may be slightly different. So, transitions are a good time to re-look at whether medicines are still indicated for the conditions they are prescribed, they are still appropriate for the patient’s new circumstances, and that they still align with the patient’s goals and perspectives, and also whether the patient wants to carry on taking them and can take them. An example would be one of your regulars, Mrs Brown, who has been waiting a while for a hip replacement and prescribed co-codamol to manage that pain in the interim, may no longer need them some months after she’s had a hip replacement. Unless you bring it to their attention or ask, they might carry on taking those medicines and experience side effects like constipation, drowsiness which could then lead to delirium, falls, fractures, because they are moving post-hip replacement, and all these might lead them back again for unnecessary hospital admission. So, for patients like Mrs Brown, it might be as simple as acknowledging that it’s good to see them back in the pharmacy after a long time and asking how well they’ve been since the surgery to establish rapport. Then moving on to ask if they are still experiencing pain and noting that their co-codamol is still on the repeat list. Depending on how that conversation goes, you might have the opportunity to explain that the risks of adverse effects of co-codamol now outweighs the benefits because the pain has improved with the new hip replacement.

Another common potential overprescribing I see post-discharge is where the dose of a blood pressure tablet, particularly amlodipine, could be increased from 5mg to 10mg in an old person who has been previously stable on 5mg for a long while, and that’s because their blood pressure increased during the admission. Without asking or checking, some of these patients, once they settle back at home, they end up with quite a low blood pressure which could lead to falls, particularly if they are already taking other blood pressure lowering pills, like bisoprolol, ramipril, for maybe other cardiovascular long-term conditions.

Another common one I want to flag up is that PPIs are sometimes started appropriately in hospital for stress-related mucosal problems during the perioperative period and inadvertently continued on repeat prescribing in primary care post-discharge. Just checking or asking if this PPI is intended for long-term use will go a long way to reduce overprescribing of PPIs which then increases the risks of atypical fractures, sometimes it can cause hyponatraemia, or a vitamin B12 deficiency in older patients. That vitamin B12 deficiency may lead to the overprescribing of vitamin B12 supplements in response, which is, like I said before, is a prescribing cascade.

Rakhi Aggarwal
So, what I am hearing is I need to look at the patient’s medicines, think about if they’re still needed, maybe ask the patient why they were on them in the first place, and ask if they are still taking them, like you mentioned with the painkillers.

Lelly Oboh
Exactly Rakhi. I remember as a community pharmacist having many conversations asking my patients about their well-being and what they had been up to before handing out their prescriptions or carrying out any other pharmacy intervention. I hope that even in the busy community pharmacy today, these conversational approach that foster good patient and clinician relationship and trust are still taking place, because they can naturally and easily lead to bringing up discussions about overprescribing in a way that the patient can actually truly engage as equal partners, without feeling judged or threatened.

These conversations are not limited to the transitions from hospital to home, it can also be had when a patient moves from their own home to, for example, a sheltered accommodation or even a care home. So, for example, prior to the care transition some patients might have been unable to cope alone at home with the activities of daily living, so for example, they might not be able to prepare their own food, they might not be able to take, you know manage or take their medicines possibly due to a functional or a cognitive impairment. Then they might have been prescribed maybe oral nutrition supplements, or essential vitamins for them at home because of the poor food intake. Once they’ve settled in their new environment or accommodation, these medicines may no longer be needed because their circumstances have changed. Another example might be a patient who has dementia, and they maybe are prescribed an antipsychotic like risperidone for challenging behaviour at home. Once they are receiving adequate care and attention in maybe a dementia care home, they might not need this medicine. So, unless we ask these questions at that time of transition, particularly where there’s been a significant change, sometimes they just fall off the radar and nobody picks it up.

Rakhi Aggarwal
Thanks, Lelly. So, in a community pharmacy setting, no matter what your role is, take an interest in that patient. It may be your regular patient who you’ve not seen for a while and you notice a change in medicines, but just be curious and ask them the questions about why there’s been change in their medicines.

Lelly Oboh
Absolutely, Rakhi. As the patient’s regular community pharmacy, the staff there often know that patient and the context in which they manage their medicines, perhaps better than other clinicians who might see them just once in a while. Sometimes it might not be the change in the setting but it might be a change in their clinical state, so, for example, they might have a new symptom, they might have worsening of an old symptom, or they might just have uncontrolled symptoms which may be due to an adverse drug effect or even a drug interaction. So, we know that adverse drug effects are more common in older people and those taking many medicines or polypharmacy.

So, when an older person presents with a new symptom, or worsening, or uncontrolled symptoms, especially if they are on optimal doses of their medicines, rather than suggesting yet another medicine, that’s the time to have a conversation with the patient to identify any potential overprescribed medicines that might be causing the problem. You may want to think through a few prompts and then ask the patient the relevant questions to identify if the symptom is caused by a prescribing cascade, like I said. So, a patient might complain about insomnia, or present with a prescription for a benzodiazepine, following on from prescribing sertraline for depression. So, at that point you can begin to ask more questions to see if that new prescription or that new symptom can be linked to the side effects of sertraline.

You might want to check, or just ask yourself, if you know, the symptom is a known drug side effect. So, for example, if a patient comes to you and is asking for urinary incontinence pads due to worsening urinary incontinence from maybe a new prescription for a diuretic, or maybe they’ve increased the dose of furosemide. Similarly, constipation may be worsened by something like ferrous sulphate. So, there are lots of opportunities when you are talking to your patient when they present with all these symptoms for you to just tease out whether there is a chance that they may be drug-related and if that medicine is overprescribed, if it’s no longer appropriate, then that’s a good time to think about stopping the medicine. Or it could even be a drug interaction. So, for example, worsening cognitive impairment may be due to prescribing a combination of drugs with a high anticholinergic burden score. So, for example, oxybutynin with sertraline and amitriptyline. If unchecked, this might lead to a prescribing cascade where the patient is now prescribed memantine or donepezil. So, all these conversations need to be aligned with the patient’s priority, and we need to also think about non-drug options wherever they exist and wherever they are available and easily accessible for the patient.

Rakhi Aggarwal
Thanks, Lelly, some real insights there. So, what would be your one take home message for the community pharmacy team from today’s podcast?

Lelly Oboh
So, Rakhi, I have two take home messages. The first take home message is around the transitions: transitions are a time for reflection and a time to rethink new priorities, new goals.

The second take home message is if the medicine doesn’t work, change the plan, but you don’t have to change the goal; the patient’s goal is still there, but we need to change the plan to fit in with the patient’s goal.

Rakhi Aggarwal
I love it, change the plan to fit in with the patient’s goal – brilliant.

I can’t thank you enough again, Lelly. In the next episode Lelly and I will be talking about how community pharmacy teams can support patients with frailty, how sometimes less is more. We’ll focus on managing issues like falls, mobility, incontinence, and delirium, and how medicines can impact these.

All that’s left for me to say is thank you ever so much Lelly. Thanks from all of us here at SPS on this episode of On the Couch light. Thanks for tuning in and we’ll be back with another episode soon. We’re always keen to hear your suggestions for any resources or events that you want us to cover – our contact details are available on our website. Please remember to register on our website and opt in to receive our weekly SPS bulletin, this will make sure you’re always informed of our most up to date content and you will receive news of upcoming events. You can also stay in touch with us by following us on LinkedIn, search NHS Specialist Pharmacy Service.

Rakhi Aggarwal
Hello and welcome to our on the couch light podcast series from NHS Specialist Pharmacy Service, where we’ll be discussing problematic polypharmacy. My name is Rakhi Aggarwal and on today’s podcast I am joined by Lelly Oboh, Consultant Pharmacist, Care of the Older People. Today we are here to talk about how we support problematic polypharmacy in the community pharmacy setting.

So, what is problematic polypharmacy? Well, it’s sometimes referred to as inappropriate polypharmacy, which may occur when medicines are no longer appropriate, benefits outweigh the harms, combinations cause risk or harm to the patient, or usage becomes unmanageable or distressing for the patient.

In today’s podcast we are focusing on repeat dispensing, the opportunities that open up to start a conversation about medicines as well as adherence, which we discussed on our last podcast. Lelly, let’s start talking about overprescribing conversations in the repeat dispensing and supply process.

Lelly Oboh
Thank you, Rakhi. Right, when to ask? So, we can start at the repeat prescription ordering stage. So, although many people order their repeat prescriptions online and through the NHS app nowadays, a few who are not digitally competent may still contact the community pharmacist to support them through the ordering process. This is a good time to start conversations about overprescribing and the necessity of medicines that they’re ordering.

Once the medicines are ordered, the vast majority of people come into the pharmacy to pick up their medicines and this encounter presents an opportune moment for the pharmacist or pharmacy technician to have a discussion about overprescribing because people are likely to be collecting all or majority of the repeat medicines. Depending on how busy you are and your setup, this may be the time for staff handing out the bagged up repeat medicines to ask the patient if they’re having any side-effects from their medicines, if they have questions about their medicines, or if they wish to discuss their medicines, or have had a recent review of these medicines. But even if you are busy at the time, patients can be signposted to other resources that will inform or support them to reduce overprescribing, for example, by booking a structured medication review appointment at the GP practice. There are useful patient leaflets on the Health Innovation Network website about stopping medicines and the benefits of having structured medication review and how to book one.

Rakhi Aggarwal
Wonderful, thanks Lelly. So, demonstrating actually the wider pharmacy team can be involved, anyone can start overprescribing conversations is what I can hear, what you’re saying. So, are there any key questions that you should be asking the patient when they present at the community pharmacy?

Lelly Oboh
Oh yes, Rakhi, there are some key questions that you might want to use as a conversation starter. So, typically you could just ask the patient, “are your medicines working well for you? Do you feel your medicines are working well for you? Do you feel they are still doing what you would like them to do?”. So, for example, if you have like a regular patient coming in to collect his prescription, the conversation may go like this: “If you have a moment while I have your attention, I’d like to check with you that all the medicines you’ve ordered are still working well for you and you’re still willing to take them”. You can then go on to explain if they’re open to it that once they’ve left the pharmacy, any unwanted medicines brought back will have to be binned and therefore wasted. Whereas if they haven’t taken them out, the item can be crossed off the repeat prescription if they don’t want it, and then we put that back on the shelf and then that can be dispensed for someone else. So, that’s the general question to ask, but also you can ask about specific medicines. For example, there are some medicines where the treatment duration is generally well defined, yet we know in practice that some of those medicines are often prescribed beyond the recommended duration, for example, prescribing omeprazole for a simple peptic ulcer or for a patient who has GORD [Gastro-oesophageal reflux disease] (simple GORD), or sometimes prescribing benzodiazepines for insomnia. So, you might say, “I noticed that you’ve been taking omeprazole for the last six months and I wanted to check if you’re still taking them regularly and if they’re helping for your condition”. If the patient is still listening, you might want to explain that this is because generally they are prescribed for a short period and they need to be reviewed after then and stopped if they are no longer needed so that you don’t get needless side-effects from their long-term use.

Rakhi Aggarwal
Thanks, Lelly. There’s some really good phrases in there. Do you recommend any other questions or phrases? I think these bite-sizes really help just starting that initial conversation.

Lelly Oboh
Yeah. So, I find that sometimes just acknowledging that taking many medicines can be overwhelming can be helpful. So, you might ask “I mean, I noticed that you’re taking all these medicines: how are you feeling about taking them?”, or you could say, “is there something I can help you with?”, you know, or you can say, “do you feel you really need all these medicines?”. Now, this might trigger a response about the patient not being sure about what the medicine is for, or not taking because they’re experiencing a side-effect, or that their symptoms are still poorly controlled in spite of taking their medicine. So this easily leads to an overprescribing conversation while obviously working within your scope, so if it’s something that’s outside your scope, if it’s a drug that sounds a bit complex or that is, you know, it’s not initially obvious what that medicine is for, then you can send a referral to the GP for a structured medication review, you can have the conversation with your GP (depends on the relationship you have), or you can signpost them for an SMR [structured medication review] if appropriate.

For those who are taking many medicines, maybe ten or more, you can be proactive by just sharing one or two key facts about overprescribing, which hopefully should invite further discussion. For example, did you know that taking four or more medicines would increase your risk of a fall? So, this is speaking to, you know, older people. Or even just saying that if people are taking ten or more medicines, they’re about 300 times more likely to have a drug related hospital admission. So vulnerable patients who are taking many medicines can get overwhelmed by the pill burden, not knowing why, what, and how to take them. They may already have old medicines at home, so it’s a good time to check, you know, if they have any medicines at home, to make sure that all the medicines are still required and are still appropriate for what they were prescribed for.

Rakhi Aggarwal
Thanks, Lelly. What I’m hearing is being empathetic actually puts the patient at ease and will actually really engage that patient in that conversation. And so, I guess for me, what is your take home message from today’s podcast?

Lelly Oboh
My take home message for today is coming from a place of improving patient safety, from a place of making sure we’re efficient in our processes, making sure that we are reducing unnecessary drug costs and unnecessary waste. So here it is: there is nothing so useless as doing efficiently that which should not be done at all in the first place. If we invest time and effort to ensure that a drug is prescribed and dispensed safely, and if the patient never needed that drug in the first place, that would have been a waste of all our time and effort.

Rakhi Aggarwal
Great. Thank you so much Lelly for being on the couch with us. In the next episode, Lelly and I will be talking about how community pharmacy teams can support with persistent non-adherence, patients with cognitive impairment, dysphagia, and patients who are needing support to take their medicines. We’re always keen to hear from you about suggestions you have for resources or events that you want us to cover. Our contact details are available on the website. Please remember to register on the website and opt in to receive our weekly SPS bulletin, this will make sure you’re always informed of our most up to date content and you’ll receive news on upcoming events, and you can also stay in touch. You can also follow us on LinkedIn by searching NHS Specialist Pharmacy Service.

Rakhi Aggarwal
Hello and welcome to our on the couch light podcast series from NHS Specialist Pharmacy Service, where we discuss problematic polypharmacy. My name is Rakhi Aggarwal and today I’m joined by Lelly Oboh, Consultant Pharmacist, Care of the Older People. Today we’ll be discussing how to be curious about problematic polypharmacy, overprescribing in the setting of the community pharmacy and how to focus on patients with persistent non-adherence, cognitive impairment, dysphagia, or needing support to take their medicines.

So, what is problematic polypharmacy? Well, it’s sometimes referred to as inappropriate polypharmacy, which may occur when medicines are no longer required, benefits outweigh the risks, combinations cause harm or risk to the patient, and usage becomes unmanageable or distressing for the patient.

Welcome, Lelly, I am so excited to be speaking to you today on my virtual couch. I’m gonna start by asking you, patients come in all the time to see, to look at the medicines, talk about the medicines in community pharmacy. What might be the reason for non-adherence to medicines?

Lelly Oboh
Thank you, Rakhi. There are many reasons why people don’t take their medicines as prescribed or don’t take them at all. Previously, we believed that people are either intentional about not taking their medicines (this is where a patient deliberately doesn’t want to take it) or that they are non-intentional, which is where the patient can’t take their medicines for whatever reasons. More recently research has shown that medicines taking behaviours are determined by a combination of whether they have the capacity to take those medicines, whether they are motivated to take them, or whether there’re opportunities to take their medicines and to take them well.

Non-adherence is individual, specific, and multi-factorial, so can only be addressed when we identify these individual problems and provide the support that they need. Even in the same patient, the reason for non-adherence might change over a period of time. For example, a patient might not be motivated to take their blood pressure tablets because they don’t see it as managing a symptom, yet they wouldn’t forget to take their Gaviscon liquid to manage their indigestion because it’s something tangible where they can see the benefits.

Some patients haven’t got the capacity to take their medicines even when they want to because they might have a sensory, a cognitive, or a physical impairment, or they might have a learning disability; there might be a language barrier, or they might just have low levels of literacy. So, these can manifest in so many ways. So, sometimes they can’t see the instructions if they have a visual impairment; if they have a learning disability or a language barrier they might not be able to read the instructions to take their medicines properly. Sometimes they can’t hear. If they have dementia or sometimes just mild cognitive impairment, they might not be able to remember to take their medicines. Some people who have poor dexterity might not be able to manipulate devices like the insulin pen or the inhaler device. Some older patients or people that have just had a stroke might have dysphagia and not able to swallow certain types of medicines, and some patients just can’t follow the instructions.

Rakhi Aggarwal
So, what I’m hearing is take a patient-centred approach, asking them what’s right for them, and also as a pharmacy professional, not jumping to conclusions to why they’re not taking their medicines, but being curious and asking them.

Lelly Oboh
That’s right Rakhi. People’s knowledge, people’s expectations, their values and their beliefs about their medicines also influence whether they take them or not. For example, a patient might not take a diuretic that’s been prescribed for hypertension because of frequently going to the toilet or the fear of having an accident in a social setting and all these might then be interfering with their social life. Their beliefs are strongly influenced by the people in their lives and clinicians that they trust. So, we’ve all had stories about patients who would not take warfarin because it’s ‘rat poison’. Or people are afraid of being addicted to inhaled corticosteroids because of, you know, all the information in the media around steroids. So, you’re right, Rakhi, rather than making assumptions or conclusions about people’s non-adherence, we need to be curious and ask to find out the specific reason. It’s only then that we can jointly agree the solutions with them that will address their identified needs in the context of their lives. Nevertheless, whatever the reason for non-adherence, it leads to unused or unwanted medicines piling up in the house which may become unsafe or simply wasted, so the identification of non-adherence is a good time to have conversations about overprescribing.

Rakhi Aggarwal
I hadn’t thought about it in that context of actually, other people influencing the decisions, so that’s really interesting. So, what should I be thinking about as a pharmacy professional?

Lelly Oboh
Well, people visit their local community pharmacy all the time to pick up prescriptions, to get everyday items, and to seek health advice for a variety of conditions. There are always moments to ask about adherence and have conversations about overprescribing while they’re there waiting for their prescriptions or when you’re having a one-to-one, you know, conversation with them about, you know, different things they’ve come to discuss, or questions they have to ask, they’ve come to ask you about a particular concern. Also, when relatives or carers come in to pick up prescriptions, you can ask how the patient is getting on with their medicines even though they’re not there. I’ve had several of these, you know, I’ve had several of these conversations with carers and relatives and neighbours, and they would often ask something like “my auntie is not taking some of her pills”, or they might say that she’s getting muddled or confused or getting forgetful about taking her medicines, or they might say there are boxes of unused medicines at home. Sometimes they could tell you about worsening symptoms, new symptoms like increasing drowsiness, difficulty swallowing tablets, or just directly ask for your help, with non-adherence and maybe request the compliance aid. So just remember that your conversations should be structured around whatever is needed at the time. And these are perfect moments to talk about overprescribing to identify and potentially stop medicines that are no longer appropriate. The tendency for us is to jump in quickly with solutions to improve adherence rather than looking at this as an opportunity to find out what medicines related problem the patient is having, check if all the medicines are still appropriate for the patient’s circumstances. Non-adherence is often a symptom of something not being quite right, or just a cry out for people needing support to take their medicines, and so whether we offer that support by changing the formulation, by giving a compliance aid, it’s just as important to seize the opportunity to check if the medicines are still needed and reduce the overall pill burden or overprescribing.

Rakhi Aggarwal
What interventions can I make, and when should I be leaning on my colleagues in general practice?

Lelly Oboh
Your intervention would depend on the patient’s needs identified during that conversation you have with them. Overprescribing is not just about making sure that the medicines prescribed have an indication, but it’s the appropriateness for what currently matters to the patient and the potential to also use a non-drug alternative. People’s circumstances change, so a patient who recent, who is recently discharged from hospital with a stroke, like I said before, might have a swallowing difficulty that requires liquid formulation, which would need your expert advice and guidance as a community pharmacist. You may notice that they’ve been on folic acid for the last two years by which time the levels may already be replete. This is a good one to highlight to GP colleagues to reduce the overall pill burden, so you don’t have to get that extra medicine in a liquid formulation and the carers don’t have to take the time out to give that on top of every other thing that’s going on. It could be asking just to change atorvastatin one at night to the morning because a patient goes to bed quite earlier on and doesn’t get to take the atorvastatin. Or it might be liaising with a GP or a hospital pharmacy colleague about changing a twice a day apixaban to once a day edoxaban in a patient who can only remember to take their medicines once a day. Or it could be as simple as providing a reminder card, a large label, a Haleraid, an eye drop device or just explaining the risk and benefits of medicines to help a patient make that informed choice whether to take it or not.

You could be liaising with carers or relatives to agree a solution that works for their particular, relatives. At the end of the day, the non-adherent patient will likely benefit from reducing the overall pill burden wherever that’s possible.

Rakhi Aggarwal
It’s so important in the community pharmacy setting to be curious especially with non-adherence and actually how family, or carers, or neighbours might actually be able to support in that conversation. It’s been really thought provoking, Lelly, thank you, and it’s been really good to listen to what you’ve been saying. So, what is your one take home message from today?

Lelly Oboh
My message is for pharmacy colleagues to respond and not to react. Let’s take a step back. Let’s ask the right questions. Let’s find out what the real non-adherence problem is. Definitely, let’s think about whether this is a time to potentially stop some of the medicines and then do what we can do and refer to our general practice colleagues or signpost accordingly.

Rakhi Aggarwal
Thank you, Lelly. So, I’ve heard that loud and clear: not to react, and that’s so easily done, to jump in. So, that’s all that’s left with us from here at SPS on this episode. In the next episode Lelly and I will be talking about frailty, focusing on managing issues like falls, mobility, delirium, and how medicines can impact these, understanding what matters most to the patients, especially in our frail patients, alongside common alarm drugs and their effects.

We’re always keen to hear from you about suggestions you have for our resources or events you want us to cover. Our contact details are available on our website. Please remember to register on the website and opt in to receive our weekly SPS bulletin. This way, you’ll always be informed of our most up to date content and you’ll receive news on upcoming events. You can also stay in touch with us by following us on LinkedIn, search NHS Specialist Pharmacy Service.

Rakhi Aggarwal
Hello and welcome to our on the couch light podcast series from NHS Specialist Pharmacy Service. My name is Rakhi Aggarwal and in today’s podcast, we are joined by Lelly Oboh, Consultant Pharmacist, Care of the Older People. Today we are here to talk about how we support problematic polypharmacy in the community pharmacy setting.

So, what is problematic polypharmacy? Well, it’s sometimes referred to as inappropriate polypharmacy which may occur when medicines are no longer appropriate, benefits don’t outweigh harms, combinations cause risk or harm to the patient, usage becomes unmanageable or distressing.

Welcome, Lelly, I’m privileged to be speaking to you today on the virtual couch. Can I start with asking you a question? Could you explain to our audience what is frailty in the context of polypharmacy?

Lelly Oboh
Thank you, Rakhi. You know, frailty hasn’t got a universal definition as such, but the British Geriatric Society define it as a state of health where a minor event can trigger a major change in health from which the patient may fail to return to their previous level of health. So, what this means is once a patient experiences a minor stressor, so for example, that could be an infection, or a fall, or maybe a move to a care home, this would lead to a deterioration in the level of their independence and then this might result in them becoming housebound, you know, they might then have to receive a social care package, or support, or they might have to go into a care home, or even go into hospital for an admission. So, another way to look at frailty is that over the years, people living with frailty have accumulated a lot of deficits that has reduced their resilience and function across multiple organ systems, and this makes them just a bit more vulnerable to adverse health outcomes. So, they’re like a spring without a decent bounce back, and so it takes them longer to recover from minor stresses to their previous level of independence, if at all.

About 10% of people over 65, and up to 50% of people 85 and over live with frailty. They often have multiple long-term conditions and so they take many medicines to manage them. They often would present with what we call the five geriatric syndromes. So, these are falls, immobility, incontinence, delirium, and an increased sensitivity to adverse drug effects. So, as you can imagine, these patients are more likely to experience overprescribing because of the many drugs that they are taking. Also, they are more likely to experience adverse effects from medicines because of the physiological changes in aging that impact on drug handling. Because of prescribing cascades where the effects of one medicine leads to the prescribing of another medicine, which leads to prescribing of another medicine, to counter a side effect. Also, they are more likely to have many drug-drug and drug-disease interactions. And to top it all, the lack of clarity in the research evidence around the risks and benefits of medicines in this patient cohort group adds another layer of challenge.

So, a holistic person-centred cared approach that personalises the evidence base to align with the outcomes that matter most to the patients in their changing circumstances becomes even more important in frailty.

Rakhi Aggarwal
I love the phrase, ‘a spring without a decent bounce back’. That analogy really visualises it for me. So, what should pharmacy teams be looking out for? What questions should they be asking?

Lelly Oboh
Pharmacy colleagues should be able to identify these patients when they present at the pharmacy. They’re typically over 85 and they would usually have one or more of these symptoms: slow walking, self-reported exhaustion, unplanned weight loss, low energy, and a low grip strength. Or perhaps, if you have access to the patient’s record, you might be able to see a frailty score, which is a measure of the level of frailty (usually mild, moderate or severe) and then you would identify that they do have frailty. So, most housebound patients and those in care homes tend to have frailty, a degree of frailty to various extents.

In terms of medicines, we should be looking out for any medicines that aggravate the five syndromes I just talked about, and we should be thinking: is there scope to reduce the dose, to stop them, or to change to something that has a less negative impact? Similarly, any medicines that help to manage them should be encouraged. We should be proactively asking ourselves and just checking with our patients and their carers at various encounters whether all the medicines are still necessary, whether those medicines are causing benefits, or they are causing harms. We should be thinking if there is a chance that medicines might be over-prescribed, as Rakhi defined them at the beginning, are the patients able and willing to take these medicines? Does it align with what matters most to them now in their lives? And these, the things that tend to matter to older patients, for example, has to do with their function and their cognition, anything that helps, you know, their social, community, and family networks, anything that helps them to be more involved and more engaged with them. Anything that, you know, gives them a good cultural experience, anything that aligns with their personal values, dignity, and their general wellbeing.

So, for example, you might notice that 86-year-old Miss Waheed is bruised because she fell over a few days ago. That might be the time to have a discussion about any medicines that she’s prescribed that may be increasing her risk of falls. So, you might start off with, you know, “I noticed you’re on a few medicines that may be causing you to fall, some of which are important to take, but there are a couple that you don’t have to take now because…” so you go on and have that conversation. Or Mrs Adams may come in to ask about the best incontinence pads to buy. This can prompt a discussion about anticholinergic drugs that might be causing or worsening the urinary incontinence.

The opportunities are limitless, if we become curious, and there are various tools to help us to identify these potentially inappropriate medicines, or PIMs, that are prescribed in frailty. Some of these tools can be found on the SPS polypharmacy and overprescribing resource on the website.

Rakhi Aggarwal
Thanks, Lelly. And what should be my focus when I’ve got the patient in front of me? Where should I really be setting my main focus?

Lelly Oboh
Well, here are some tips and examples for focus, Rakhi. The first focus is always on the patient in front of you. Look at them. Ask them what’s most important to them now. Listen to their experience of taking medicines, you know, where are they having benefits? Where are they having adverse effects? What’s the burden it places on them and their carers? What’s the impact on their function, quality of life, you know, and their interests? So, for example, we might be an old man who likes gardening. We might be prescribing medicines that are causing, you know, muscle pain. So again, we might need to have the conversation about, you know, the necessity for that medicine and whether there is a chance to deprescribe them so that he can carry on and enjoy his interest.

The second focus has to be the medicines. So, we need to be familiar with common PIMs, or I sometimes call them alarm drugs to look out for. Drugs that cause drowsiness or dizziness or postural hypertension can lead to falls and fractures, so usually central nervous system or cardiovascular system drugs. The anticholinergic drugs that worsen cognition, so drugs like oxybutynin, antipsychotics, and less commonly known ones like sertraline. You also need to look out for drugs that cause constipation like opiates, clozapine, because if constipation is not addressed, it can lead to confusion and even delirium in frailty. There are also drugs that can cause fatigue and reduce appetite like metformin. And there’s some drugs that cause electrolyte imbalances like hyponatremia, so PPIs and sertraline. When all these drugs are highlighted, it doesn’t mean we need to stop them automatically, but it’s an opportunity to start the conversation with the patient about how we tackle overprescribing and how we optimise their medicines to align with the outcomes that matter to them and reduce the risk of harms or adverse outcomes. Depending on what you identify in your discussions, you might be able to make your own interventions, or you might need to refer them to their general practice for a structured medication review to have an in depth look at the necessity for all these medicines or even signpost them or their relatives to others or resources for further support. This will become more important as we progress to neighbourhood teams and the community pharmacy is well placed to contribute to improving care and outcomes for patients living with frailty.

Rakhi Aggarwal
Wonderful, Lelly. PIMs: potentially inappropriate medicines, that’s a new acronym for me, but a great way to remember. So, what’s your one take home message from today?

Lelly Oboh
Thank, Rakhi. For me frailty marks the point at which disease-based guidelines are no longer the priority so the message is that for patients who are living with frailty, less medicines can be more.

Rakhi Aggarwal
Less is more. That’s wonderful. Thanks so much, Lelly, and that’s all from us here at SPS on the couch. We’re always keen to hear from you about suggestions you have for resources or events you want us to cover. Our contact details are available on our website. Please remember to register on the website and opt in to receive our weekly SPS bulletin. This will make sure you’re always informed of our most up to date resources and content and you’ll receive news on upcoming events. You can also stay in touch with us by following us on LinkedIn, search NHS Specialist Pharmacy Service.