Polypharmacy 1

Question 1

Sources of information for drug history of a patient in rehab community hospital

Answer 1

• Letter from GP
• SystemOne - see GP records and what medications their on
• Summary care record on the spine - check repeat meds, allergy information
• Northamptonshire care record - similar to summary care record
• D/C letter from hospital
• Copy of drug chart
• Repeat prescription slip
• Actual medication from home
• Ask patient/carer

Question 2

What do make sure you document?

Answer 2

• Indication for anticoagulant drugs
• Reason for stopping medications
• Reaction to allergies
• Document if on warfarin - on seperate chart

Question 3

Writing doses on prescription

Answer 3

• Can use g or mg
• But must write microgram, nanogram, units

Question 4

Prescribing times per day

Answer 4

• If prescribe QDS ensure circle 4 times in the aministration time column

Question 5

How to cancel prescription

Answer 5

Cross through on L side
Cross through on R hand side where nurses sign

Question 6

What can you do with dose in PRN?

Answer 6

Can do dose range eg 15-30mg

Question 7

What does community hospital have?

Answer 7

• List of medications that can be signed by doctor if patient needs them
• Basic things like paracetamol, lactulose, gaviscon

Question 8

Prescribing insulin

Answer 8

• Prescribe by brand name and type (eg humulin M3)
• Prescribe concentration too eg 100 units/ml
• Can prescribe rapid acting novorapid PRN if at risk of hyperglycaemia

Question 9

What to think re creatinine clearance?

Answer 9

Decreases 8mls/decade after age 30

Question 10

Measuring renal function in patients

Answer 10

• U&E - gives eGFR - rough estimate based on age, gender and creatinine level - doesn’t take into account size of patient
• Cockcroft-Gault equation - calculates creatinine clearance (estimates eGFR) (use for age 75 and over if dosing for DOACs, nephrotoxic, meds cleared renally with narrow TI)

Question 11

Key meds to be aware of risk in older patients

Answer 11

• NSAIDs - sodium, renal impairement, GI bleeding (need PPI at least), use topical ibuprofen/diclofenac instead
• Hypoglycaemics - gliclazide
• Antidepressants - hyponatraemia, postural hypotension (withdraw gradually). Max daily dose citalopram for over 65s is less
• Z drugs and benzodiazepines - falls, confusion, cognitive impairement
• Anticoagulants - indication, are they on correct dose for indication? weight? renal function? age?
• Opioids - good for acute/palliative care pain, not good for long term pain - confusion, constipation

Question 12

Problem with polypharmacy

Answer 12

• 10 or more medicines =. 300% more likely to be admitted to hospital
• Can cause admissions to hospital - adverse reactions

Question 13

What to first check if new symptoms of person?

Answer 13

Could it be side effect of new medication prescribed - CHECK THIS FIRST before prescribing anything

Question 14

Guidance for polypharmacy to look at

Answer 14

• STOPP/START
• BNF - area for elderly and if part of STOPP/START says guidance
• Specialist pharmacy service website - webinars, switching antidepressant tool, pregnancy and medications
• Wales polypharmacy guide

Question 15

Opioid awareness - risks of these

Answer 15

• Opioid awareness in non-chronic and cancer pain - royal college of anaesthetics

Question 16

How to de-prescribe

Answer 16

• One thing at a time
• Antidepressants, gabapentin or baclofen should be reduced gradually
• Ensure patients are aware why this happening
• Document why
• If struggling with withdrawal/side effects - contact and can modify regime

Question 17

Solutions for managing complex medication regimes for older people

Answer 17

• Self administration regimes on ward - nurses support to select medications and take + reminder chart (what is it, what for and time of day)
• Tick chart - tick off as taken
• Phone apps or program alarms for different times of day
• Refillable medicines tray at home (own dossett)
• Blister packs - pharmacy fill and seal - not all meds can go in, not for carers
• Carousel/pivotel device - program and gives reminders for 30 mins, turns and expose dose in window. Can be connected to lifeline system if don’t take.
• Large print labels if struggling to read
• Talking labels - record message what medication is
• Devices that help get meds out of packaging - or break foil with teaspoon
• Aerosol inhalers - spacer (5 breathes in and out, one press)
• Powder inhalers - need quite hard inspiration to get drug, switch to different type
• Eye drop device - opticare - large device to squash, allows, or if arm can’t get high enough there is another device