Person-Centred Care Including Deprescribing for Older People.

There is concern internationally that many older people are using an inappropriate number of medicines, and that complex combinations of medicines may cause more harm than good. This article discusses how person-centred medicines optimisation for older people can be conducted in clinical practice, including the process of deprescribing. The evidence supports that if clinicians actively include people in decision making, it leads to better outcomes. We share techniques, frameworks, and tools that can be used to deprescribe safely whilst placing the person's views, values, and beliefs about their medicines at the heart of any deprescribing discussions. This includes the person-centred approach to deprescribing (seven steps), which incorporates the identification of the person's priorities and the clinician's priorities in relation to treatment with medication and promotes shared decision making, agreed goals, good communication, and follow up. The authors believe that delivering deprescribing consultations in this manner is effective, as the person is integral to the deprescribing decision-making process, and we illustrate how this approach can be applied in real-life case studies.

Frail older people with multi-morbidities in primary care: a new integrated care clinical pharmacy service.

Background Older people confined to their own homes due to frailty, multiple longterm conditions and/or complex needs, are known to be at risk of medicines-related problems. Whilst a health and social care team approach to supporting these patients is advocated, there is limited evidence regarding how pharmacists can best contribute. Objective To describe a new specialist pharmacy service (called the integrated care clinical pharmacist) in terms of how it works, what it achieves and its policy implications. Setting Patients' own homes in Lambeth, London, UK. Method Community matrons identified patients who were experiencing medicines related problems. These were referred to the integrated care clinical pharmacist who undertook a full medication review and recorded activities, which were independently analysed anonymously. Main outcome measure Medicines-related problems and the associated interventions. Result 143 patients were referred to the service over a 15-month period. A total of 376 medicines-related problems were identified: 28 (7%) supply issues, 107 (29%) compliance issues, 241 (64%) clinical issues. A diverse range of interventions were instigated by the pharmacist, requiring the coordination of community pharmacists, primary and secondary health and social care professionals. Conclusion This project demonstrated that including an integrated care clinical pharmacy service as part of the health and social care team that visits frail, older people in their own homes has benefits. The service operated as part of a wider inter-professional community team. The service also supported current health policy priorities in medicines optimization by identifying and addressing a wide range of medicines related problems for this vulnerable patient group.

Deprescribing and managing polypharmacy in frail older people: a patient-centred approach in the real world.

Polypharmacy is common in people with multiple long-term conditions (LTC) to relieve symptoms and improve quality of life. However, it is also associated with poor outcomes and increased risk of adverse drug events in older people. Older people are seldom involved in therapeutic research, and when the results are applied to those with multiple LTCs, it can increase pill burden and adverse events without necessarily replicating the expected positive outcomes. This article describes a pharmacist-led, patient-centred approach to deprescribing in a 73-year-old diabetic man taking multiple medication, with gastrointestinal (GI) and pain symptoms as well as poor adherence to medicines. The approach considered his perspective and experience of taking his many medicines into account while using the best available research evidence and the clinician's experience. After six visits over 8 weeks, the patient was more involved with self-managing his diabetes, his pain and GI symptoms improved and overall pill burden was reduced.

Patient-centred management of polypharmacy: a process for practice.

Medicines are the most common intervention to improve health. The number of medicines taken by older people in the UK has been steadily increasing for the last three decades. Polypharmacy is a term that refers to either the prescribing or taking many medicines. Concerns about the risks of polypharmacy in primary and secondary care are growing, supported by evidence which associates polypharmacy with increased adverse drug events, hospital admissions, increased healthcare costs and non-adherence. In the UK, this can largely be attributed, over the last 20 years, to the greater availability of evidence-based treatments promoted through therapeutic guidelines which are designed for single conditions, rather than addressing the multimorbidity that affects many older people. There is also currently a paucity of evidence-based national guidance around reducing and stopping medication and incorporating the patient perspective. This paper reviews current UK literature around polypharmacy including a description of four key resources which all make use of international literature and all focus on the medication aspects of polypharmacy from a clinician's perspective. The patient-centred approach combines both clinical health professionals and patient perspective. Developed using existing resources, it is designed to assist with collaborative (patient and clinician based) medication review to inform decisions around deprescribing and address polypharmacy as part of overall strategies to optimise medicines for the patient. Presented as a diagrammatic representation in seven steps, it also includes guidance on points to consider, actions to take and questions to ask in order to reduce polypharmacy and undertake deprescribing safely.