Medication Management in Homecare Patients

Abstract

In addition to the general practitioner and pharmacist, homecare workers who visit their patients in their homes on a regular basis might be able to facilitate early recognition of potential Drug Related Problems.

First, the beliefs about medicines and factors influencing these beliefs in community-dwelling elderly (n=91) who were using medication were explored. The participants were convinced of the necessity of their medicines, while they did not show concerns regarding overuse and harm.

Next, the medication management capacity of independent living older people (n=95) on polypharmacy in relation to their cognitive- and self-management skills were determined. Almost half of the participants were able to manage their medication by themselves at home. Cognition and self-management ability were related to medication management capacity.

Next, the medication management practices of homecare workers (n=507) were assessed.Homecare nurses’ medication management practices consist of handling over medication, providing information, observing non-adherence and observing ADRs. Almost all homecare workers said they provided information about drugs to their patients although their trust in their medication knowledge was lacking and they said they needed medication education.

Next, knowledge and perspectives of Dutch homecare nurses (n=146) regarding medication frequently used by older people was measured. Although most homecare nurses felt responsible for their older patients’ proper medication use and agreed with the statement that they played a role in preventing older patients’ medication related hospital admissions, their knowledge could be improved.

Next, the association between Prescription Change Frequency (PCF) and hospital admission was assessed (n=17362). The odds ratio (OR) of hospital admission increased with an increase in PCF category. At 3 months before the index date from PCF=1 OR 1.4 [95%CI 1.3-1.5] to PCF=2-3 OR 2.2 [95CI 1.9-2.4] and to PCF ≥ 4 OR 4.1 [95%CI3.1-5.1]. Pharmacists and other healthcare workers should be alert when the frequency of prescription changes increases.

Next, a survey (n=105) was conducted to describe how homecare workers rate their knowledge, monitoring skills and ability to recognize adverse drug reactions and drug interactions of the most commonly used medication in older homecare patients. Homecare registered nurses (RNs) stated to recognize more (OR = 3.84;CI 1.43-10.30) gastrointestinal disorders, diarrhea and nausea and also more (OR = 4.33; CI = 1.09-17.26) confusion, drowsiness and fatigue than lower educated homecare assistants. In general, homecare workers most easily recognize side-effects of confusion, drowsiness and fatigue more easily than gastrointestinal disorders and dizziness.

Finally, to determine whether homecare workers can detect signs and symptoms indicative of potential ADRs in their patients, an observational study (n=115) was conducted. During routine home visits, homecare workers filled in a standardized observation list of signs and symptoms indicative for potential ADRs, namely, gastrointestinal and other bleedings, electrolyte disturbances, renal and heart failure, digoxin intoxication, constipation, disturbances of diabetic control, and falls. The observations were compared against the medications that the patients were using, and their known side effects, by a panel of clinical pharmacology experts. Half (49.6%) of the signs and symptoms were considered drug related. Observed dizziness (64.1%) and drowsiness (53.3%) could be drug related in most cases, as could most cases (71.4%) of fainting spells (indicative of renal or heart failure). Seventeen of 20 observed falls could be drug related. The specificity of the standardized observation list was high, varying from 0.70 (CI: 0.62-0.77) to 0.97 (CI: 0.95-0.98). Signs and symptoms indicative of potential ADRs recorded by homecare workers using a standardized observation list can aid in the early recognition of ADRs in homecare patients.