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Common problems with medication: experiences from domiciliary visits

Medicines management specialist Pippa Scrimshaw has been making domiciliary visits in the Cambridgeshire Primary Care Trust area for almost five years. She shares her thoughts on why patients can struggle with their medicines and her experiences of resolving some of the issues

by Pippa Scrimshaw

Medicines management specialist Pippa Scrimshaw has been making domiciliary visits in the Cambridgeshire Primary Care Trust area for almost five years. She shares her thoughts on why patients can struggle with their medicines and her experiences of resolving some of the issues

 

Some time ago, I was asked by a GP to visit a patient whose blood pressure was still high despite being prescribed three antihypertensive drugs. The patient lived alone and had had numerous GP appointments, as well as hospital visits, with regards to his high blood pressure.

When I saw him, he quickly told me he took all of his prescribed tablets but, after being in his home for a while, I could see he kept only a few of his medicines by his chair in the lounge, so I asked him if he would let me see where he kept his other tablets. Reluctantly, he showed me to a kitchen cupboard crammed full of tablet boxes.

It emerged that he had been ordering all his medicines each month, so his GP thought he had been taking them, but had chosen to take only a few of them, none of which were the antihypertensives. With this knowledge I was able to discuss the situation with the patient’s GP and explain to the patient that he could start treatment again with one antihypertensive, with stepwise addition of other medicines to control his blood pressure only if necessary.

Such instances, where it seems to have been easier to prescribe another drug to alleviate a problem rather than check if the first is being taken or being taken correctly, are not uncommon. Admittedly, without visiting a patient at home, it can be difficult to assess the true picture of medicines use.

Domiciliary visits give an insight into how medicines are stored and, if some are accumulating more than others, can identify patients who:

  • Are not taking their tablets
  • Are taking their tablets but at less than the prescribed dose
  • Are confused about their medicines (for example, believing that aspirin prescribed as an antiplatelet is for headaches and, therefore, only taking it when required)

I have even come across people who order all their medicines, even if they are not used, because they believe it is their entitlement.

The way in which we ask questions can mislead (or lead) patients so I always ask them to show me and explain to me what they do, which makes it less likely for them to tell you what they think you want to hear.

We talk about compliance and concordance and know that concordance is the ideal but sometimes I wonder if we forget the simple basics of whether or not people are physically or mentally capable of taking their medicines.

Most issues people have with their medicines can be linked to five main aspects:

  • Sight
  • Information-overload or lack of information
  • Swallowing
  • Dexterity
  • Memory

Sight

Many patients who have poor sight or who are registered blind have to manage their own medicines. Although each person is different in what they can manage, there are some important factors to consider.

By far, the biggest problem for poor sighted or blind people is the frequent change of outer box and tablet shape. This was highlighted by a patient whose brands of medicine had been changed and this had misled her into thinking what she was doing was correct.

Her round paracetamol tablets had changed to caplets and her previously oval metformin were now round so when I visited, I found she was taking eight metformin tablets and two paracetamol caplets each day. This problem was resolved by ensuring that both tablets were prescribed as generic brands that corresponded to the shapes she had been used to.

The font size used on labels can also cause difficulty, as can the quality of print toner (dark print is easier to read than pale grey print). I ask patients to look at a font size chart to see which size they can read.

“Flagged instructions” (ie, where a large sheet must be attached to a box because normal labels are too small to bear large font sizes) can then be produced to enable patients to identify their tablets more easily.

Too little or too much information

Patients can be given a lot of verbal information during a consultation and often do not remember all they have been told. If they have memory impairment or learning difficulties, the information retained may be even less.

Conversely, patients may be given no information by the prescriber or the pharmacist. Both situations can lead to medication error, especially if a new medicine is prescribed “as directed”.

In the first, the patient may be given so much information that he or she cannot remember the directions for taking the medicine and, in the second, the patient is not told how to use the medicine at all. This is easily resolved by limiting the information given and providing clear instructions, including written instructions.

If a patient is illiterate, picture stickers denoting times of day can be placed on the outer packaging of medicines

If a patient is illiterate, picture stickers denoting times of day can be placed on the outer packaging alongside the printed label to show when tablets should be taken. These work well following simple explanation.

I have worked with a label company to design suitable pictures to show the four main times of the day when medicines are taken (breakfast, lunch, tea time and dinner) and then trialled the stickers for appropriateness.

After a couple of minor alterations the final designs were agreed and the use of these can be classed as a “reasonable adjustment” for patients under the Disability Discrimination Act 2005. They are available to order from Swankee Doodles (tel 01494 862861).

Swallowing

An often an overlooked question is “Do you swallow your medicines easily?”. I learnt early on that a black, toothy smile indicates that a patient is chewing his or her ferrous sulphate tablets and, possibly, his or her other tablets. I ensure that all patients I see are asked about any problems with swallowing and whether they have to chew any of them.

With medicines available in soluble and liquid forms there is often a suitable alternative that can be prescribed. However, the high sodium content of soluble tablets should be borne in mind (in some cases, eight soluble paracetamol tablets can contain 8g of salt, when the Government recommends daily intake should be limited to 6g).

Dexterity

With few tablets now in bottles I seldom see patients with issues over bottles (apart from those where a strip of plastic has to be removed and then the two arrows have to be lined up before prising the lid off).

A simple way to rectify this problem is to repackage the tablets in a bottle with a more suitable cap and, generally, elderly patients are happy to sign a waiver to have plain screw caps on a bottle rather than child-resistant caps.

Patients with arthritic fingers, especially in rheumatoid arthritis, may find wing caps a better option.

There are now several different designs of aids to help patients remove tablets from blister strips (Patterson Medical)

Although the introduction of blister strips has reduced the problems associated with the use of child-resistant caps, a large number of patients also have difficulty getting tablets out of these strips.

I have seen patients try to get the tablets out of them in all manner of ways, for example, using knives, scissors and hat pins.

There are now several different designs of aids to help patients remove tablets from blister strips. My patients tend to favour the Blisterpack pen device because a lot of the other aids still require a fair amount of dexterity. Patients have told me that the Blisterpack pen is easy to hold and grip, and it works on any shape of tablet within a blister strip.

The only disadvantage so far is that if someone picks it up to write with and it does not work, they could throw it away, which has happened to one patient, whose son discarded her “pen”.

Those patients able to use an aid can remain more in control of their medicines. Another option is for the pharmacy to pop all the tablets into a bottle and patients should be given this option.

Another issue that needs consideration is the prescribing of tablets that need to be halved. Even tablets with score lines are not easy to break evenly and before prescribing or dispensing, extra consideration should be given if they are for:

  • Patients with chunky fingers and short nails
  • Patients with diabetes and possible neuropathy
  • Patients who are confused or have dementia

If such tablets must be prescribed, one option would be for the pharmacy to provide them already halved (with explanation to the patient to ensure they know they do not have to halve them again). Another option would be to provide or sell a tablet cutter.

However, giving a tablet cutter to patients with dementia can be dangerous because they can easily forget its purpose and take the whole tablet. One of my patients even cut himself on the sharp blade.

Apart from aids to help with tablets it is worth remembering that aids are available for use with many other medicines, such as eye-drops and inhalers. Rather than asking patients if they use their inhalers, I ask for a demonstration. If he or she cannot depress the inhaler a Haleraid may be useful rather than referring back to the prescriber for a change to an Autohaler or Accuhaler.

If an eyedrop bottle is too small to squeeze a drop from, an aid could be provided. There are several types available, some particularly for arthritic hands, such as Opticare Arthro.

Memory

I have found myself visiting an increasing number of patients with memory problems, from those who wonder “did I take or didn’t I take my tablets?” to those with diagnosed dementias or Alzheimer’s disease. Knowing the extent of a person’s capability, especially if he or she does not have a diagnosis, can be difficult.

This is another area where I believe that visiting patients at home gives me a better insight into how they are managing their medicines — it is often only by spending time with someone that you realise his or her memory is impaired; you can have a good conversation for 25 minutes, where everything makes sense, and then you notice the repeated sentences and drifting of conversation that indicate there may be a problem.

Where poor memory is an issue, I believe we provide blister-packs or other monitored dosage systems far too hastily and other options should be tried. First, I would look at whether or not a patient medication record card, explaining all the medicines to be taken (ie, when they should be taken, how many and what they are for) might help.

On many occasions, such a card can make the difference between a patient being “muddled” and being able to manage. I would also look at where tablets are kept. For example, if morning tablets are forgotten, keeping them by the cereal box might help.

If a patient is still not managing, a tick chart might be suitable. These tend to be useful in patients who are at the “did I or didn’t I take my tablets?”stage. If ticked when tablets are taken, these charts can be a good way of reminding patients that tablets have been taken but they are inappropriate if a patient is unaware of day and time because they become meaningless.

Electronic medicines dispensers audibly and visibly remind patients to take their medicines (PivoTell Ltd)

An alternative aid for these patients is a monitored dosage system that is not day specific. Each day, patients can remove one case to use and can easily see if it is empty or full.

For patients with more pronounced memory issues blister-packing or a monitored dosage system may be suitable, but as with tick charts, patients need to be time and day aware (otherwise they may take tablets at random from the pack).

For patients with poor awareness of the day or time I find it more appropriate to offer an electronic reminder tablet box. My primary care trust has a budget for “assistive telecare technology”, providing equipment to make patients safe, such as fall detectors and seizure sensors.

I work in partnership with the assistive telecare technology team as an assessor, so I am able to assess and lend, free of charge, devices, including electronic medicines dispensers. These audibly and visibly remind patients to take their medicines, which are locked within the device so patients are only able to take medicines at the times the alarm has been set to.

Other reminder devices available include beeping watches and pagers. There is a device to suit everyone.

Outcomes

My role has allowed me to visit many people to discuss their medicines and help them by offering advice and providing written instructions or other aids. It has probably reduced GP and hospital visits and, therefore, benefited patients and decreased costs.

For all patients it is important to consider whether or not all their prescribed medicines are clinically appropriate or if a regimen can be rationalised to aid compliance.

I suspect that not all prescribers and dispensers always ask “how will the patient truly manage this medicine?” and, until they do, I will be kept busy.

Citation: The Pharmaceutical Journal URI: 10037728

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Supplementary images

  • Insights into how medicines are stored can be gained through domiciliary visits (Sandra Cunningham/Dreamstime.com)

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