Dr Jennifer Stevenson is a Clinical Academic Pharmacist at the Institute of Pharmaceutical Science, King’s College London, and Guy’s and St. Thomas’ NHS Foundation Trust. Dr Stevenson’s work explores - and aims to reduce - medication-related harm in older adults. She tweets @JenMStevenson
This Saturday the England Rugby team will step out onto the pitch at the International Stadium Yokohama, Japan, to compete in the Rugby World Cup Final. In just four years this team has transformed, from a side that failed to qualify from the group stages of the 2015 Rugby World Cup, to one which convincingly defeated the World’s #1 team, the New Zealand All Blacks, last weekend. Head Coach Eddie Jones, along with input from coaching staff, physiotherapists, nutritionists, and psychologists, to name but a few, appears to have tackled the multidimensional challenge facing the England Rugby team and developed “a winning strategy”.
So what does this have to do with geriatrics, and in particular, reducing medication-related harm (MRH)? England Rugby faced a “crisis” (relatively speaking!) in 2015, which they overcame; geriatrics faces its own “crisis” - how to overcome the global public health issue of MRH?
So what can we learn from England Rugby? There are two key points, which are reflected in our recent publication; Medication-related harm: a geriatric syndrome1.
- We must reflect upon our current approaches and recognize the limitations.
- We must become more proactive and overcome the challenges to improve outcomes through a whole system change.
Medicines, including mitigation of MRH, are recognized as a priority point of geriatric expertise, as illustrated through the Geriatric 5Ms. The current approaches focus upon polypharmacy, age-related alterations in drug-handling, medicines appropriateness and transitions of care, but the impact on quality of life, clinical and economic outcomes has been variable and often disappointing. Existing strategies fail to recognize the instability and vulnerability of frail older adults meaning that even “appropriate” medicines can present as a situational challenge and be harmful due to multiple reserve deficits impairing mechanisms to deal with “minor” side-effects. The psychosocial factors which can contribute to MRH through e.g. influence on medicines adherence are also rarely considered.
Viewing MRH through a biopsychosocial lens and promoting it as a geriatric syndrome, as described in our paper, provides a framework for a new integrated approach to reduce MRH1. A whole system change, involving health and social care, which uses a clinician’s judgement to support medicines prioritization based upon patient preference and need, and not driven by guidelines and incentives, is required. To some extent CGA, Choose Wisely and Realistic Medicine offer this, but more work is required on mitigating harm from appropriate medicines which, despite the anticipated risk of adverse effects, are necessary to delay disease progression or alleviate symptoms. Like Eddie Jones, here we are presented with a difficult, but not insurmountable challenge.
Perhaps the proactive identification of MRH is a good place to kick off. MRH should be considered a differential diagnosis in all older adults; after all up to half of older adults discharged from hospital experience MRH. The next phase should include the promotion of MRH as a geriatric syndrome to raise awareness of the multidimensional nature of the problem and send a clear signal from geriatric experts that this is an important issue. The final play may then be the development of a multidimensional assessment with a toolkit of interventions available to generate an individual care plan.
The England Rugby team will know by Saturday mid-morning if their approach is indeed a “winning strategy”; for MRH as a geriatric syndrome we will have a longer wait.
- Stevenson JM, Davies JG, Martin FC. Medication-related harm: a geriatric syndrome. Age and Ageing 2019 https://doi.org/10.1093/ageing/afz121