Reviewing Medication Regimens

The video is an interesting way to look at the topic you covered in class last time. Just play the video and sing along!

In this blog we are going to look at the topic of reviewing medications. As we have done before this presentation is done on Microsoft Sway. It should just play when you put your mouse in the box a scroll bar will appear and you can just scroll through it. You can click active links and play any video content as you go. You can also launch it using the full screen icon which should appear on the top right of the panel below when you click on it If you do this you adjust how it plays to suit the device you are using.

Hope its useful and remember to stay safe during this Covid-19 lockdown.


Coaching an Education Classroom Session on 11th March 2020

UWS Ayr Campus

Attached is the PowerPoint used for the Coaching & Education Session that took place on the 11th March 2020 at Ayr Campus.

To download the file click the link given below

At the session Scott said he would edit his slides and send them over to Janetta and Constantina. When we have received them we will pass them on to you from the blog.

Note that the next Coaching and Education Sessions are due to take place on the 13th May 2020 between 10am – 4pm and then on the 4th June 2020 again from 10am – 4pm.

Realistic Medicine

Realistic Medicine was a concept first proposed by Scotland’s Chief Medical Officer Cath Calderwood in her annual report for 2014-15 which was published in 2016. Realistic Medicine puts the person receiving care at the centre of decision-making and creates a supported, personalised approach. It aims to reduce harm, waste and unwarranted variation, whilst acknowledging and managing the inherent risks associated with all healthcare. It also champions innovation and improvement. To achieve this, people using healthcare services and their families must feel empowered to discuss their treatment fully with healthcare professionals, in language that they will understand. This should include any possibility that a suggested treatment might come with side effects – or even negative outcomes. Realistic Medicine is an attempt to move away from the “Doctor knows best” approach to shared decision making and the co-production of care.

Realistic Medicine has a particular ethos which involves;

  • Listening to understand patients problems and preferences;
  • Sharing decision making between healthcare professionals and their patients;
  • Ensuring that patients have all the understandable information they need to make an informed choice;
  • Supporting healthcare professionals to be innovative, to pursue continuous quality improvement and to manage risk better;
  • Reducing the harm and waste caused by both over-provision and under-provision of care;
  • Identifying and reducing unwarranted variation in clinical practices.

Realistic Medicine is not about rationing healthcare or saving money. It’s aim is to improve patient care; ensuring that people receive appropriate and beneficial care that is evidence-based and in tune with their personal preferences.

To deliver Realistic Medicine everyone should feel able to ask their healthcare professional why they’ve suggested a test, treatment or procedure, and all decisions about a person’s care should be made jointly between the individual and their healthcare team. One of the early initiatives from Realistic Medicine was to encourage everyone to ask 5 questions

  • Is this test, treatment or procedure really needed?
  • What are the potential benefits and risks?
  • What are the possible side effects?
  • Are there simpler, safer or alternative treatment options?
  • What would happen if I did nothing?

Every healthcare professional should be able to answer these questions for all treatments and procedures they suggest. When people ask these questions they are more likely to receive healthcare suited to their needs that they also be more likely to comply with.

Since its adoption in 2016 the CMO for Scotland has continued to write about Realsitic Medicine and what it involves. Her 2017 report was called Realising Realistic Medicine, the 2018 report was called Practising Realistic Medicine and the most recent 2019 report was called Personalising Realistic Medicine. Last year also saw the introduction of a new comprehensive Realistic Medicine website which you can explore HERE

This video made by Healthcare Improvement Scotland talks to members of the public about realistic medicine and asked them what mattered most to them.

With regards to Fraily

In relation to Realistic Medicine and Frailty, the Director of Public Health for NHS Highland in his Annual Report in 2017 highlighted the following key points:

  • To reduce frailty we need to promote interventions that improve physical functioning by increasing muscle mass and strength, particularly progressive resistance strength training, exercise involving gait, balance, co-ordination, and encourage walking on a daily basis.
  • The effectiveness of dietary interventions are subject to more uncertainty but a healthy diet is important in preventing and addressing frailty.
  • A life-course approach to optimising peak muscle mass and strength in early life, maintaining this in adulthood, and reducing the rate of loss in older adulthood would be a useful strategy for reducing the rate of frailty across our population.
  • For hospitalised patients, better outcomes are associated with care delivered by older people’s multi-disciplinary teams, particularly when these are delivered in designated units or wards.
  • Interventions that reduce hospitalisation include certain types of nurse-led units, tele-health care for long-term conditions, discharge planning from hospital to home, case management in heart failure and integration where more generic case management is utilised would help keep more people in their own homes, where they want to be .
  • We need to maximise the network of support around every frail person so that they have the right support to improve their health, manage their condition and maintain their independence.

Dementia: Some Guidance

Caring for people with dementia in the community is one area which is currently expanding. Recently the Alzheimer Europe calculated that with an increasing, and increasingly ageing, UK population the overall numbers of people with dementia; estimated in 2018 to be 1,031,396 will by 2050 be 1,977,399. A rise from 1.56% of the overall population to 2 .67% in 2050. There is pressure therefore to get this right now ahead of this expansion.

There is no clear way to provide all the people and their carers who require support with what they will need, so new ways to provide effective care need to be considered. This blog will look at 3 existing resources that are already being used in Scotland.

The first resource we suggest that you consider using is the winner of the Scottish Digital Health and Care Award 2020; which was NHS Lanarkshire’s Online Post Diagnostic Support Website which you can access from HERE

Two things to be aware of before you go to the site. It might have been designed for people receiving post diagnostic support but the information and advice is far more extensive than this. It has been tailored to suit Lanarkshire, so some sections discuss services and processes available in Lanarkshire which may or may not be available within the NHS Ayshire and Arran area.

The advantage of using this resource is that the information that it provides is validated and conforms to NHS Scotland standards (the information sources and hwere to get more information are all ij the links given within the site). There is 24/7 access to information which you can return to easily. People living with dementia and their carers can all access it when desired. It can be used to enhance staff knowledge of dementia, post diagnostic support and the services which might be available to improve people’s support and experience.

Topics the resource covers include understanding the illness, Power of Attorney, Driving, Anticipatory Care Planning, support for carers and lots more. Please explore this resource and use as you see fit. Note that the easiest way to find the site is to type “Dementia NHS Lanarkshire” into Google.

The second resource you should consider using is the Social Care Institute for Excellence (SCIE) Dementia Gateway. The Dementia Gateway provides access to information, guidance, resources and training for anyone supporting people with dementia. It is a very extensive resource and worth taking a bit of time to explore. There is so much on it designed to be utilised by health and social care staff in the community both as a resource and as education that you will find something your team can utilise very quickly. A note of caution though. It has been designed for England and Wales which is particularly important when the information given refer to English legislation. You can access the Gateway HERE.

The third resource we suggest that you look at is work done by the “Focus on Dementia” Group who are part of Health Care Improvement Scotland. They are currently working on improving care co-ordination for people with dementia and their carers so that this becomes more integrated.

Their work can be found at https://ihub.scot/improvement-programmes/focus-on-dementia/integrated-care/ They have set about trying to identify the critical success factors for integrated care co-ordination of people with dementia in the community. The focus of their work has been Midlothian. Their overview of the Dementia Care Co-ordination Critical Success Factors is available on the site and is discussed in the video that you will find there. A more detailed report on the critical success factors is due to be published but the list of factors is something you might already be able to use. There is also other work done by Focus on Dementia that you can access from this site.

Delirium in the Community

Delirium is a common and serious medical condition that results in a person experiencing a sudden change in their behaviour. The onset of delirium always indicates the presence of a physical disorder or acute illness.
Any person can get delirium but it is more common when a person is older, has a cognitive or sensory impairment, is very ill, or requires complex treatments.
Of those aged 80 and older living at home, one in 10 people could have delirium at any time. In care home residents, six in 10 could have delirium at any time.
Nurses and nursing assistants working in these settings are well placed to recognise delirium in the people they care for.
It is important to remember that delirium is particularly common in people with dementia – if you see sudden changes in the physical or mental health of a person living with dementia don’t discount delirium. The types of changes to look out for a listed HERE. Early recognition of delirium could help prevent the person falling over, becoming even more unwell and/or being admitted to hospital. In some cases, early recognition of delirium might even prevent their death.

Delirium can be difficult to recognise and sometimes the signs are subtle. That is why any change in a person should trigger the question “Could this person have delirium?” A useful tool to consider using here is called SQiD (the Single Question in Delirium). The single question: ‘Do you think [name of patient] has been more confused lately?’ is usually put to a member of the family or a friend but if you know the person well you may be able to answer the question yourself. Although this seems simple SQiD is almost as good at delirium detection as psychiatric interview and other more sophisticated identification tools. See Sands et al (2010) for example.

It is always better to rule out delirium than miss it completely. Remember, if you identify delirium, it is very likely that the patient has a medical condition that requires assessment and treatment urgently.

Nationally, Scotland has recently adopted its own set of Guidelines regarding the Risk Reduction and Management of Delirium called SIGN Guidleine 157.

Health Improvement Scotland published a patient information booklet to complement Scotland’s first clinical guideline for delirium. These can be used alongside resources produced by @ihubscot to improve delirium care across Scotland: http://bit.ly/37M5vcu

SIGN Guideline 157 asks that health professionals in Scotland adopt a standard assessment tool called the 4AT tool and this should be used for identifying patients with probable delirium in emergency department and acute hospital settings. They go on to suggest that the 4AT tool should also be used in community or other settings for identifying patients with probable delirium. If you are unfamiliar with the 4AT then now would be a good time to adopt it and get your team used to using it.

Identifying delirium is however only part of the issue. It is really important that you and your team create, develop and follow a local escalation plan which provides you and your team with instructions regarding what to do if delirium is suspected. It is worth checking if your organisation has an existing delirium escalation plan in place. If not, you might find the template and the information on this RCN site very useful. https://www.rcn.org.uk/clinical-topics/older-people/delirium/delirium-champion

Exercise and Frailty

Something you might want to try: Assessing strength and balance.

We know that physical activity can help people to maintain their functionality, independence, and quality of life, preventing and delaying some of the diseases which affect people as they age. The illnesses affected range from osteoporosis to cardiovascular disease and cognitive decline, as well as the syndromes which together can be described as frailty. Kidd, Mold, Jones et al, (2019) go further stating that physical activity interventions are the key to maintaining independence in pre-frail and frail older adults.

Older people tend to become less active – with 47% of people aged 75-84 being inactive, and 70% of those over 85 years. Over half of all inactive people across the UK are aged 55 and over.

Increasing physical activity has the potential to improve strength, decrease the risk of reduced bone mass, improve balance and overall fitness. Activity can also be an important way of reducing isolation and increasing well-being for older people. Improving strength and balance is particularly important to reduce falls, which are a common injury for older people and may lead to people no longer living independently at home. For advice about Falls Prevention from NHS Education for Scotland (NES) CLICK HERE

Evidence from NIHR suggests that a range of approaches may be effective in promoting exercise in older people, including both supervised exercise, from walking groups to dance classes, and behavioural approaches such as motivational counselling and tailored activity plans. They suggest that older people are more likely to keep exercising with group classes in a centre than through home-based activity. NIHR also suggest that there is a need for interventions that combine supervised exercise opportunities with an understanding of behavioural change principles as these are the most effective in increasing activity over time.

Increasing inactivity is also more likely in certain groups including women, smokers and those with a longstanding illness, depressive symptoms, arthritis, those who were obese, those with lower starting fitness or have weaker social networks. This suggests a need for more tailored approaches to get those people active. More effort also needs to be directed at these groups as they are the most likely to benefit and least likely to take part.

What Can You do to Promote Increased Activity

Firstly, you have to an awareness of what is available so the first issue to consider is “Are physically active social and group-based opportunities available for older people in your locality? If they are where are they and how do you refer people to go?

Secondly, this is a link to the Age Concern site “Being active as you get older” On the site is a lot of advice and links to other Age Concern resources that are designed to encourage older people to find the best way to keep their bodies moving. You will also find a resource designed for older people with one or more long term conditions called “We are Undefeatable” which is a good place to start. Note that if you follow that link you will also find Age Concern’s Falls Prevention advice.

Finally make use of the following acronym when promoting activity and reducing inactivity. F.I.T.T. This stands for start gently and build up your Frequency (the number of times per week you exercise) or Intensity (how hard you exercise) or Time (go for longer) or Type of exercise (e.g. build up from slow walking to brisk walking). Remember that the target is to get the person to be more active so any increase in activity no matter how it is achieved will be beneficial.

To help, here is something to try. It might not be useful for many people that you would identify as frail but anyone in a Pre-frail group may benefit from using this App. Its called iPrescribe and it creates a 12-week exercise plan based on health information entered by the user. It then sets the duration and intensity of the exercise based on this information. See https://www.nhs.uk/apps-library/iprescribe-exercise/

Some additional reading:

Academy of the Royal Medical Colleges (2015) Exercise: The miracle cure and the role of the doctor in promoting it. Available at: http://www.aomrc.org.uk/wp-content/uploads/2016/05/Exercise_the_Miracle_Cure_0215.pdf

Kidd, T., Mold, F., Jones, C. et al. (2019) What are the most effective interventions to improve physical performance in pre-frail and frail adults? A systematic review of randomised control trials. BMC Geriatrics, 19, 184 doi:10.1186/s12877-019-1196-x

The Value of Social Support

In class yesterday we looked at the value of social support and the damaging effect of loneliness even without the addition of frailty. Social support is the perception and actuality that one is cared for and has assistance available from other people. It requires you to be part of a social network. These supportive resources include

Appraisal support: Information that is useful for self-evaluation; like what should I wear? Should I buy this?

Informational support:  Advice, suggestions, and information

Instrumental support: Tangible aid, for example lending or giving you money, help if you broke your leg, or a service like babysitting for you.

Emotional support: Expressions of empathy, love, trust and caring

Social support can be measured as the perception that one has assistance available, the actual received assistance, or the degree to which a person is integrated into a social network and/or their local community. Support can come from many sources, such as family, friends, pets, neighbours, co-workers or via external organisations.

Below is the Sway that we discussed in class which focuses on tackling loneliness

The BBC Scotland Documentary that was mentioned during the day was called the “Age of Loneliness” and was made in 2016. Its not currently available on the BBC iPlayer but there are many clips from it scattered across the internet. This is the director Sue Bourne discussing making it.

Living Well with Frailty

On the first day of teaching we looked at defining frailty and how you would recognise and screen people for it. What we didn’t discuss was why this is important. To make the effort worthwhile we need to know if frailty is amenable to prevention and treatment. The answer is YES.

Reducing the Likelihood of Frailty

So what can we do to reduce people’s chances of becoming frail? We know that “healthy ageing” reduces the risk of developing frailty. Healthy ageing involves ensuring

  • Good nutrition
  • That you don’t take too much alcohol
  • That you stay physically active
  • That you prevent obesity
  • That you remain engaged in your local community/ avoiding loneliness.
  • That Influenza and pneumococcal pneumonia vaccination is taken up by those identified “at risk”.

NHS England, in partnership with Age UK, Public Health England, and the Chief Fire Officer’s Association and older people themselves, have published “A Practical Guide to Healthy Ageing“. The guide is designed to help people to stay physically and mentally well by providing hints and tips on how to keep fit and independent. It recognises that there is always something that can be done to improve our own health and wellbeing. You can access the guide by clicking HERE

On the same page you will also find “Practical Guide to Healthy Caring“. This guide provides information and advice to carers about staying healthy and identifies the support available to help carers maintain their health and well-being.

What About People With Established Frailty?

The adverse effects of frailty can be mitigated by for example by:

  • Vision and hearing assessment and referral
  • Reducing people’s falls risk
  • Timely medication review can reduce risk of adverse drug reactions, drug interactions and non-compliance.
  • Strength and balance training
  • Assessment of home hazards and then interventions to reduce these
  • Using assistive technology as part of a menu of options in place to help people to effectively self-manage their long-term condition

(NICE, 2019)

A more detailed list of interventions that can be used by both commissioning groups and providers can be found in the NHS England Document “Compassionate care for frail older people using an integrated care pathway” which you can download from

https://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf

The interventions list starts on page 17 of the booklet and finishes on page 21.

You could also look at the information available from NICE onImproving Care and Support for People with Frailty” Click on THIS LINK to view.

Frailty Focus is a test campaign commissioned by NHS North Hampshire Clinical Commissioning Group which has a website for tackling frailty in their local area. There are areas of the website for healthcare professionals, the general public and carers/volunteers all aimed at enabling more of the local population to age well while planning ahead, discussing what matters most and ensuring they get the right care and support now, and into the future.

The Frailty Focus introductory video is below

This is the link to the projects main web page which you should explore and use with your own team

http://www.frailtyfocus.nhs.uk/