Elderly patients with multiple comorbidities and frailty are often hospitalized with the concomitant effects of polypharmacy; side effects, inappropriate prescribing, incorrect administration and problems related to concordance.
Worldwide, medication errors cost an estimated $42 billion annually. It is estimated that the cost to the NHS of people not taking their medicines properly and therefore not getting the full benefits to their health totals more than £500 million a year[1–3].
As part of a quality improvement project at the Royal Wolverhampton NHS Trust, we found that the most common reasons for hospitalization in older people were falls resulting in fractures caused by low blood pressure or confusion, followed by weakness, heart failure, gastrointestinal bleeding and electrolyte disturbance .
The aim of the project was to improve health outcomes, reduce avoidable readmissions, reduce drug burden, discontinue inappropriate drugs, avoid the prescribing cascade, reduce the anticholinergic burden, and minimize prescribing errors.
The project ran from June 2, 2021 to July 8, 2021. A multidisciplinary team (MDT) was involved, including a consultant geriatrician, senior doctor and senior pharmacist specializing in the elderly. If necessary, the first-line teams were also consulted.
The MDT met twice a week to assess patients on five or more medications, within the first 48 hours of admission and before discharge. During this period, 30 patients underwent an MDT assessment. Reviews lasted between 30-60 minutes, so changes in medications were communicated to primary care.
Prescription optimization occurred early in admission and streamlined the clinical management and discharge process.
The STOPP-START tool was used to rationalize medication. Clinical Frailty Score (CFS) and Anticholinergic Burden Score (ACB) were also used. Concerns and expectations of patients and caregivers were discussed, including compliance, formulations, dosage and frequency, leading to a comprehensive patient management plan.
The most common discontinued drugs were antihypertensive drugs, with bisoprolol often discontinued due to bradycardia. Dietary supplements followed, followed by both statins and urinary incontinence drugs, most notably solifenacin. This has a high anticholinergic burden (ACB), which is associated with an increased risk of cognitive impairment, falls and an increased association with mortality.
This project streamlined discharges taking into account patient preferences, reduced the overall drug burden, ACB, and stopped inappropriate and unsafe drug prescriptions.
After the MDT assessment, patients were prescribed an average of three fewer drugs (range 0-10) and more than 50% of patients had a reduction in ACB score.
The total medication savings of all patients in one month was £538.33, with an average saving per patient after MDT assessment in one year of £215.
The project is now being used to support a business case for a committed vulnerable pharmacist to become part of the MDT.
Overall, the project taught me the benefit of MDT assessment for elderly patients with polypharmacy, because skills from different disciplines were harnessed in a timely manner and changes were implemented efficiently. The MDT helped improve medication prescriptions and patient satisfaction was achieved. Valuable communication between first and second line was achieved.
It was satisfying to work on this quality improvement project because I felt we had an impact on patient care and improved the process by which we discharge patients.
We had planned to do this project earlier, but it was postponed due to the COVID-19 pandemic. Interactions with patients’ families and carers were limited, no hospital visits were made, and communication was entirely through telephone conversations. The GP practices were contacted by telephone, which was very time consuming.
Other barriers were to get all members of the MDT together at agreed times, so flexibility was required.
Pharmacy teams should build good working relationships with other healthcare professionals as polypharmacy approaches are efficient and effective when healthcare professionals from different sectors are involved with the aim of improving patient outcomes and discharge processes. Good communication everywhere is imperative, as is being passionate and committed to helping patients get the best care possible.
We are currently re-checking patients on the MDT assessment to assess their length of stay, any hospital readmissions, and whether changes have been made to primary care.
We are also collaborating with another hospital trust to conduct a multicenter research project using the MDT approach to assess polypharmacy in elderly patients.
Misba Janjua is a senior pharmacist for the care of elderly patients and stroke at New Cross Hospital in Wolverhampton, West Midlands