Patient Social Care Journey

What are the 2 treatments used for overactive bladder?

• mirabegron - this allows for relaxation of the bladder to increase storage. This is used for urinary incontinence and can be used in combination of oxybutyinin for when symptoms are poorly managed on one therapy. Not anticholinergic, therefore best to keep and deprescribe oxybutynin. If patient is on low dose, consider increasing when discontinuing oxybutynin for symptom control

• oxybutynin - this is antimuscarinic - works to prevent contraction of bladder for urinary incontinence - can cause symptoms of drug mouth and constipation so reasonable to deprescribe to reduce polypharmacy, especially if patient is suffering from constipation or is on other anticholinergic drugs

What is important to prescribe alongside steroids?

Patient on long term corticosteroids due to hypopituritaism - prescribe vitamin D and calcium supplements to prevent osteoporosis as chronic exposure to steroids can lead to osteoporosis.

What is deprescribing?

Deprescribing is part of good prescribing; it is the stopping of medications/ reducing the dose of medicines which are unnecessary or no longer needed. It involved active participation from the patinet

Why is polypharmacy a concern?

Polypharmacy is a concern as it increases the risk of side effect profile, interaction, frailty and falls in the elderly. Polypharmacy in the elderly is particularly a concern due to their rapidly changing physiological states, such as changes in weight, body composition (can affect drug distribution), hepatic function and renal function, cancer etc. Polypharmacy can increase the risk of hospitalisation and non-adherence and also has cost burden on NHS

What are the principles of prescribing in the elderly?

• avoid prescribing prior to diagnosis

• start with low dose and titrate slowly

• avoid starting 2 agents at the same time

• reach therapeutic dose before switching or adding agents

• consider non pharmacological agents

What is social care?

Social care is the care of patients in the community, where patients will receive support at home off carers. This allows patients to stay in their preferred place whilst having help with getting dressed, cleaned, etc. If patients do not receive the appropriate social care they need then they will end up admitted to the hospital

Is medication administration in the community a health or social task?

Everyone has a role for this. Medication administration is a concern for the community where carers will help to support the patient with their medications. However, it becomes a healthcare concern if the medication is taken IV, rectally, PEG etc

What is the preferred way to administer medication in social care and what are the issues with this?

• The preferred way to deliver medicines in social care is by multi-compartment aids (MDS). The disadvantages of this are:

  • Not all medicines are suitable for MDS due to issues with storage/ exposure to air. This means some medicines need to come in their original packaging due to stability issues.

  • Acute prescriptions e.g. if someone has an acute Rx for antibiotics then this will not be included in the MDS so carers would not be able to assisst the patient in taking the medication

  • PRN medicines in MDS may be given when they are not needed - all or nothing.

  • We can’t guarantee all the information is given when in a tray

  • Leaves carers with a false sense of security that this is safe when this is not the case

What is needed for safe medicine support in social care?

• Social workers should not automatically put someone on a system like MDS. Instead, they should: assess the persons ability to manage their medicines and aim for self-administration wherever possible.

• Care staff should be trained so they can give medicines correctly and recognise and handle ADRs and errors

• There should be a contract between agencies and community pharmacies to provide medicine support. Should include a cost element to cover people who fall outside of the Equality Act.

What medicines are considered high risk of falls?

• antihypertensives

• Benzodiazapines

• Zopiclone

• Sedating antihistamines

Essentially anything that leads to sedation, or hypotension increases risk of falls. All patients should have a drug burden review to assess their risk of falls

What can go wrong when a patient is transferring from different places of care e.g. home to hospital, hospital to care home etc.

• unintentional changes - omitted a medication or dose and this is perceived as a change but in fact has just been missed off

• Intentional changes - it is not clear then may lead to re-admission

• Misunderstanding of information

• Inaccuate information

What service helps to ensure consistency in patients’ medicines and confirms they understand their current medications?

Discharge medicine review - Community Pharmacy Reviews discharge to help the patient understand the discharge process.

What medications would we deprescribe?

• antihypertensives

• oral hypoglycaemics/ T2 medicines

• acid-suppressing medications/ anti-ulcer medicines

• bisphosphonates

• primary prevention e.g. aspirin

• DOACs

• Statins/lipid-lowering medicines

• supplements/vitamins - unless you are treating a deficiency, then you would continue, e.g patient has hypopituitarism, so continued due to deficiency

What medications would we keep?

Heart failure medicines e.g. furosemide

corticosteroids are commonly continued

pain killers

What is palliative care?

Palliative care is the improvement of a patient’s symptoms and quality of life when they are dying. It aims to support families and the patient through the dying process by means of early identification and impeccable assessment and treatment of pain and other problems such as psychological, physical, social and spiritual pain.

What are clinical indicators that someone is dying?

Would we be surprised if the patient died in the next 6 months?

• the patient spends over 50% of the day in bed or sat in chair

• The patient has had more than 2 unexpected/ unplanned hospital visits in the past 6 months

• The patient is in a care home or requires assistance at home

• A new diagnosis of a progressive, life-limiting illness

• progressive weight loss in the last 6 months

What symptoms do people get when they are dying and what symptoms do they have?

• Breathlessness - opioids or midazolam

• Agitation/ delirium - haloperidol, midazolam (if associated with anxiety)

• Nausea and vomiting - cyclizine, levopromazine, metoclopramide, haloperidol

• Excessive secretion - glycopyrronium or hyoscine hydrobromide/ butylbromide

• Pain - opioids

• Dry mouth - Biotene toothpaste, frequent sips of water

• pressure sores - pressure-relieving mattress

usually delivered via syringe driver