Medication Management for Community-dwelling ... - CSIRO Publishing

Medication Management for Community-dwelling Older People with Dementia and Chronic Illness Debbie Kralik,1 Kate Visentin,1 Geoff March,2 Barbara Anderson,3 Andrew Gilbert3 and Merilyn Boyce4 Research Unit, Royal District Nursing Service, Wayville, South Australia1 School of Pharmacy and Medical Sciences, University of South Australia2 Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute, University of South Australia3 SA Divisions of General Practice Inc.4 The purpose of this paper is to report the findings of an integrative review of the literature on medication management for individuals who live in the community and have both chronic illness and mild to moderate dementia. The aim of the review was to summarise what is known about this topic, evaluate and compare previous research on the topic of medication management for people with dementia, and locate gaps in current work, thus pointing to directions for future research. Dementia is a national health priority for Australia. A significant component of community care for people with dementia is the management and administration of the medications required for other chronic conditions. Medication management is a broad term that encompasses several aspects, such as client-centred medication review, rational prescribing and support, repeat prescribing, client information/education, capacity to communicate with multiple health providers and having access to medicines. Cognitive impairment has been associated with medication management issues so it is important to ensure quality outcomes of medicine use by community-dwelling older people with dementia. The literature revealed a number of issues, such as the importance of person-centred care, the need for the coordination of care, and consumer partnerships in medication management. These are all important considerations in planning primary care services to support people with dementia and chronic illnesses. People with dementia who have chronic illness require coordinated, tailored, and flexible care processes in the community. There exists a range of services and programs such as home medicine reviews to support people living in the community with chronic illness and dementia; however, there is little coordination of care and evaluation of interventions is, at best, inconsistent. Currently, Australia lacks an integrative primary health care (PHC) framework, within which consumer involvement in decision-making and/or care planning is valued and sought. Current services are limited in the degree to which there is collaboration between key partners and Australian PHC initiatives are fragmented and have limited impact on service delivery. Key words: Medication, Dementia, Community health, Home medication review, Chronic illness

Dementia is a national health priority for Australia (Australian Government Department of Health and Ageing [DoHA] 2005). Growth in the prevalence of dementia has been projected in national population statistics and trend figures. During 1995, Australia had a population of 18 million and 130,000 people with dementia. It has been projected that in 2041, Australia will have 25 million people and 460,000 will have dementia (Australian Institute of Health and Welfare [AIHW], 2007). During that time, the Australian population will have increased by 40% but the population with dementia has been projected to increase more than three-fold. The Australian Journal of Primary Health — Vol. 14, No. 1, April 2008

reason for this disproportionate increase is that older people, who are the age group most at risk for dementia, will be the fastest growing segment of the population (AIHW, 2007). The increasing prevalence of dementia presents planning challenges for community health services; however, until very recently there was little public debate about how Australians should manage the increasing prevalence of people with dementia. A significant component of community care for people with dementia is the management and administration of medications required for other chronic conditions. Some of these medicines 25

Debbie Kralik, Kate Visentin, Geoff March, Barbara Anderson, Andrew Gilbert and Merilyn Boyce

will have special administration requirements, associated safety and effectiveness issues and complex regimes, all of which may lead to people being at risk of harm due to medication misadventure. Ensuring that people with dementia are supported by a responsive, interdisciplinary community health team is paramount for effective and safe care. In particular, older people with dementia and living in the community will require interdisciplinary support to ensure the quality use of medicines. While the appropriate use of medication can improve health outcomes, inappropriate or incorrect use may cause harm. It is estimated that more than 140,000 Australians are hospitalised each year as a result of medication-related problems. Of these, approximately 50% of all medication-related hospitalisations were considered preventable (Australian Council for Safety and Quality in Health Care, 2002). Furthermore, in the community setting, there are up to 400,000 adverse drug events managed by general practice each year (Australian Council for Safety and Quality in Health Care). Various factors may contribute to adverse drug events in the community setting. Errors can occur during prescribing by the general practitioner (GP), dispensing by the pharmacist, or misunderstanding by the consumer or carer. Polypharmacy, cognitive status, older age, living alone and cost of medication can all contribute to medication misadventure in the community setting (Ellenbecker, Frazier, & Verney, 2004). Other factors contributing to medication error include inadequate continuity of care and/or multiple health care providers. The financial burden of these adverse drug events has been estimated to be more than $350 million per year (Roughead & Gilbert, 1998). The Quality in Australian Health Care Study estimated that 43% of adverse drug events were preventable (Day, Shenfield, & Smith, 1995). Given these estimates, we must start to ask why adverse drug events are not being prevented. There are a number of funded services to support pharmacists, medical practitioners and nurses in the provision of care to older people in the community. Such services include home medicines reviews, comprehensive care plans and community nursing services. However, these services may be underutilised; supporting and advocating quality use of medicines for older people requires consideration of a multiplicity of factors that influence outcomes 26

and the context within which these occur. The purpose of this paper is to report the findings of an integrative review of the literature on medication management for individuals who live in the community and have both chronic illness and mild to moderate dementia. The aim of the review was to summarise what is known about this topic, compare previous research on the topic of medication management for people with dementia and to locate gaps in current work, thus pointing to directions for future research. Background “Dementia is a progressive and disabling condition that primarily presents in older people. The progression of dementia can be categorised as mild (early stage), moderate (middle stage) and severe or advanced (late stage) at the end of life” (Access Economics, 2003, p. 10). Dementia describes a syndrome associated with a range of diseases that can be characterised by the progressive impairment of brain functioning, including language, memory, perception, personality and cognitive skills. The cognitive, psychiatric and behavioural manifestations of dementia may include memory problems, communication difficulties, confusion, wandering, personality and behaviour changes, depression, delusions, apathy and withdrawal (AIHW, 2004). A variety of medications are used to treat the symptoms of dementia. For example, people with vascular dementia may be treated with aspirin and other blood thinning agents to decrease the risk of stroke (Roman, 2003). Many natural, traditional or alternative treatments are also used with dementia, such as acetylcholine, antioxidants and herbal treatments (Laurin, Maseki, Foley, White, & Launer, 2004; Ernst, 2002; Morena, 2002). The use of prescribed medicines is a common health management approach in Australia. One report identified 10% of the population aged 55 years or more taking six or more medicines, with only a quarter of those aged between 55 and 64 years not taking any prescribed medicine at all (Goldney & Fisher, 2005). The recent introduction of acetylcholinesterase inhibitors has provided a medication management option for delaying the progression of dementia in some people. Trials indicate that use of the anti-dementia drugs delays the progression of symptoms of dementia Australian Journal of Primary Health — Vol. 14, No. 1, April 2008

Medication Management for Community-dwelling Older People with Dementia and Chronic Illness

in the majority of people for nine to 12 months (Lanctot et al., 2003). Improvements may be seen in clarity of thought, carrying out of activities of daily living, mood and behaviour. GPs have used medications to assist with the management of symptoms of dementia for many years at a rate of (AIHW, 2004): • 23.4 per 100 contacts by clients with dementia in 1990–91 • 32.0 per 100 contacts by clients with dementia in 1998–99 • 29.4 per 100 contacts by clients with dementia in 2001–02.

Coincidentally, with the increased level of use of anti-dementia medications, there has been a decrease in the prescription of other drugs such as anti-psychotics, anxiolytics and anti-depressants (AIHW, 2004). Research data has revealed that 96% of the Australian population aged over 65 years who reported dementia also required assistance with self-care, mobility or communication (AIHW, 2004). Although dementia in people aged less than 65 years is less common, this group may have special needs such as employment and financial issues for those unable to work. Furthermore, the disease is thought to progress faster in younger people (Howcroft, 2004). Dementia has broad social and economic impact. Carers of people with dementia have reported detrimental affects on their mental and physical health, in addition to financial hardship (Bruce & Paterson, 2000). In Australia, fifty per cent of people diagnosed with dementia live in the community and are assisted by home-based and community care programs that are funded by Commonwealth and state governments (Access Economics, 2003). Many people with dementia also have one or more chronic illnesses. It is recognised that people with chronic diseases use health services, homebased interventions and medicines frequently and over extended periods of time (Stewart, Pearson, Luke, & Horowitz, 1998; National Health Priority Action Council, 2006). Symptom control of many chronic conditions requires medication and older people are most likely to be taking multiple medications, which increases regimen complexity and risks associated with polypharmacy (Pearson et al., 2006). Furthermore, a number of medications Australian Journal of Primary Health — Vol. 14, No. 1, April 2008

widely used in the older population have been shown to cause short-term cognitive impairment in healthy older people with intact cognition. Such medications include anticholinergics, antipsychotics, medicines for Parkinson’s disease, antidepressants, antiepileptics, benzodiazepines, digoxin and warfarin (Ng, 2006). Thus, it can be assumed that the effect of such medicines on the cognition of older people already experiencing cognitive impairment, such as those with dementia, will be even more pronounced (Ng, 2006). Medication management, however, entails more than an individual merely taking the correct medication at the prescribed dose. Taking medicine is a complex task that places both cognitive and physical demands on older people (Albert et al., 2003; Beckman, Parker, & Thorsland, 2005). Medication management is a broad term that encompasses several aspects, such as client-centred medication review, rational prescribing and support, repeat prescribing, client information/education, capacity to communicate with multiple health providers and having access to medicines (Banning, 2005; Brown, 2003). Cognitive impairment has been associated with medication management problems (Moore & O’Keefe, 1999; Ng, 2006). It is important to ensure quality outcomes of medicine use by older people with dementia living in our community, by services such as home medicines reviews (HMRs). An HMR may assist people living at home in the community to take medicines safely and effectively (DoHA, 2003). The goal of these reviews is to ensure the person has the knowledge and skills to obtain maximum benefit and minimise the risk of harm from their medication regimen. HMRs involve a team approach, including a general practitioner (GP) and an accredited pharmacist. The pharmacist comprehensively reviews the medications in the person’s home and then a report is sent back to the referring GP (DoHA, 2003). The report is used in the development and implementation of an agreed medication management plan. HMRs may also involve other relevant members of the health care team, such as community nurses and carers. Aim The aim was to summarise what is known about medication management for people living in the community with dementia, evaluate and compare 27


previous research on the topic of medication management for people with dementia, and to locate gaps in current work, thus pointing to directions for future research. The questions guiding the review were: • How does cognitive impairment impact upon an individual’s capacity to manage medications? • How effective is the HMR in assisting people with dementia to manage their medication? • What are the gaps?

Method The integrative literature review was undertaken collaboratively by a multi-disciplinary team representing the Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Sansom Institute, University of SA (UniSA), the Royal District Nursing Service of SA Inc. (RDNS) Research Unit and the SA Divisions of General Practice Inc. (SADI). An integrative review of the literature is defined as one in which “past research is summarized by drawing overall conclusions from many studies” (Broome, 2000, p. 47). The purpose of such a review is to define the state of knowledge (Cooper, 1982); it is useful when seeking to identify existing qualitative and quantitative research and information in a number of fields for a specific topic. Integrative reviews infer generalisations about substantive issues from a set of studies directly bearing on those issues (Jackson, 1980). This type of review utilises a team approach, provides outcomes to broad questions and accesses studies that have utilised multiple research methodologies. Team members met at the commencement of the review to determine the guiding questions. Literature relating to primary care in both the international and Australian context was sought, with particular focus on chronic illness, dementia and medication management. Inclusion criteria were: • published in English • relevant to the research questions and topic • research- or project-based • relevant to the Australian context • published between 1996 and 2006.

The focus for the literature search was dementia and medication management. CINAHL and 28

MEDLINE were searched using the following terms: dementia and medication management; dementia and medication administration; dementia and community care; dementia and care planning. A total of 120 references were located using these databases. After careful reading of the abstracts and full text papers, 10 papers were considered directly relevant to this review. The next part of the search focused on home medication reviews (HMRs). Search terms included: home medicine review; medication management and community; community pharmacist and medications; community nursing and medications; medication review. A total of 233 references were found in MEDLINE and 18 were assessed as having met the inclusion criteria. The same search terms were used in CINAHL and 140 references were found. Once replicated papers were excluded, no new relevant papers were identified. The Cochrane Library and The Joanna Briggs Institute database were searched to identify if any relevant systematic reviews had been carried out. One systematic review that examined strategies to reduce medication errors was identified. Reference lists of all publications were scrutinised to identify key texts and authors. A total of eight Australian Government project reports were also sourced. All publications included in this review were researchbased or reporting projects or community programs and services. Analysis, interpretation and synthesis of the literature were undertaken by the team. The intention was to critique the literature in direct response to the questions guiding the review. Results How does cognitive impairment impact upon capacity to manage medications? Theoretical models of cognitive ageing suggest that working memory capacity is affected by the ageing process, thus reducing the person’s ability to comprehend and recall new medical information (Brown & Park, 2003). Despite this, medication regimen can be incorporated into people’s lives through automatic processes as well as environmental cues (Brown & Park). Health professionals need to be aware that people are at most risk of error after changes have been made to their treatments. Dementia causes further disturbances in cognitive abilities and behaviours, and this often referred to as “executive function” Australian Journal of Primary Health — Vol. 14, No. 1, April 2008


(Hayes, May, & Martin, 2006; Maddigan, Farris, Keating, Wiens, & Johnson, 2003). Hence, people with dementia will have limited cognitive resources by which to process information correctly, placing them at high risk of medication misadventure. Instruments have been developed to measure capacity and competence in medication management. Two American studies were identified that specifically targeted people with cognitive impairment. In the first study, Fulmer and Gurland (1997) explored the way in which capacity is influenced by cognition. Using a medication management test (MMT) the authors analysed the discrepancy between capacity for self-medication administration and actual selfadministration behaviour. The study found that there is a higher frequency of MMT errors in the cognitively impaired group (n=51) compared with the normal cognitive group (n=74), which supports the theory that capacity is influenced by cognitive status. In some situations, the person who was cognitively impaired demonstrated adequate capacity using the MMT, but was receiving help with the actual administration. The authors felt this may have related to caregivers becoming hyper-vigilant around medications. The study targeted people with early or intermediate stages of dementia because the authors felt that it is during this period that capacity is most difficult to assess. It is important to point out that current function is different to capacity. The researchers were interested in finding out what the person’s current function was and also what they could achieve as an optimal level of functioning; that is, capacity. Although this was an American study, the MMT may be one way in which the capacity of older people in Australia to manage medications can be assessed in an objective and quantifiable way. The idea of measuring capacity as well as current functioning fits in with the goals of dementia care because it is promoting independence and preserving brain function for as long as possible. In the second study, Albert et al. (2003) examined the association between cognitive deficit and both medication accuracy and consistency with their set schedule. Sixty people with cognitive impairment secondary to HIV infection were randomly selected. There was no control group. The MMT provided a score that correlated with the participant’s ability to interpret the prescription label and medication insert information and to Australian Journal of Primary Health — Vol. 14, No. 1, April 2008

dispense five medications from their bottles. Participants were also asked to recall the times at which they took their medicines over the three days prior to the assessment, which gave an indication of “consistency”. Cognitive status was measured using eight neuropsychological tests. The findings suggested that the more cognitively impaired the person was, the greater likelihood that they reported following a fixed medication regimen. This is important because it can provide direction as to which interventions may help those with cognitive impairment. The study also uncovered health beliefs around potency of medications, which highlights the importance of taking into account prior beliefs and understandings around medication use. For example, clients who viewed medicines as potentially dangerous appeared to be more careful when administering them (Albert et al., 2003). Both these studies used a number of assessment tools in order to quantify the person’s cognitive status and ability to manage medications. Although sample sizes were relatively small, the reliability and validity of the tests had been previously tested in both studies (Fulmer & Gurland, 1997; Albert et al., 2003). Other studies have also looked at capacity for administering medications. A Swedish study used performance tests of hand function, vision, and medication competence to assess the limitations in a sample of older people (Beckman et al., 2005). It used a large population-based sample (n=621) which gives the study greater generalisability and reliability. The medication management test, assessing hand and vision function and medication competence, was measured using case scenarios. The researchers found that 66.2% of the sample could not do at least one of the simple tests. Participants were then asked to self-report their ability to take medications. A large number of participants who did not pass the tests still felt they were able to manage their medications themselves. Participants who did pass took significantly fewer medicines than those who failed the test. This study found that the majority of the older population in Sweden had a physical, visual or cognitive limitation that directly relates to the ability to manage medication. Cognitive limitations were most common. The authors also make the point that having home help is not in itself a predictor of good medication management, because the helper may not have the capacity to 29


provide assistance. Particular attention must be given when changing a regimen as the changes will challenge the cognitive skills most affected by age (Beckman et al.). A different approach to measuring capacity was taken by Maddigan et al. (2003), who argued that using simulated exercises around medication management does not always accurately reflect what that person may actually need to do with their own medicine regimen. Hence, the tool may not provide a valid indication of whether or not that individual is capable of administering their own medications. Instead, these researchers used a retrospective cohort design to assess a self-medication program within a rehabilitation hospital. Of interest for health professionals working in the community was the finding that errors were most likely to occur in the first week of self-administration and that only 26% of the participants (n=302) continued to make errors into the final week. This finding has ramifications for community services providing support for people in their homes, particularly when medication regimens are changed. The study found a relationship between cognitive function and ability to manage medications, but this was also dependent on the complexity of the medication regimen. An Australian study used a pre- /post-test design to investigate the way in which older people (n=113) who were living at home and receiving community nursing care were able to manage their medications (Griffiths, Johnson, Piper, & Langdon, 2004). An outcome of this research was a nursing intervention that included nursing care and referral pathways to GPs for people who might benefit from a GP and/or pharmacist medication review. Each of the 24 clients chosen for the intervention was initially assessed using a medication complexity index and a comprehensive assessment tool to ascertain the ability of the client or carer to administer medications (i.e., problems with directions, vision, hearing, dexterity and knowledge). A medication kit was devised which included prescription labels, child resistant cap on bottle, dosette box with lollies, blister packs with lollies, and coloured wooden beads. Knowledge was ascertained by asking clients to identify all their medications and to describe the function, dose and scheduling of each medication. Selfreported adherence was measured and, where possible, a pill count was done. A number of 30

nursing interventions were carried out, depending on the needs identified. The assessment of the ability of participants to manage their medications highlighted that only 8.3% were able to complete all tasks successfully, with the majority making one or two errors (54.2%). Failing eyesight was also a problem, with 37.5% not being able to differentiate between blue, green and lavender, which may be important if nurses are giving instructions based on colour. Although the sample size is small and may not be representative, the study utilised a number of tools that may be useful for assessing clients with dementia and their carers in regard to their ability to self-manage medications. All cited studies have highlighted the importance of accurate assessment of a client’s situation in order to ascertain their capacity to manage medications. Fulmer and Gurland (1997) contended that tests for capacity to manage medications are usually informal and unstructured in the clinical setting. While nurses, pharmacists or the GP may ask the client to demonstrate a series of tasks related to medication management, the method used is usually highly variable and may not be effective in predicting performance. How effective is the Australian HMR in assisting people with dementia to manage their medication? The Australian Home Medicines Review (HMR) program is one approach designed to address the problem of medication misadventure in the community. The HMR enables a GP and a pharmacist to collaboratively review the use of medications with a person in their own home, and, when required, to develop an agreed medication management plan. This approach is grounded in the necessity of inter-professional collaboration in client care. The GP is ultimately the initiator of the HMR and success depends on acceptance by GP, pharmacist and consumer. To date, there has been an upward trend in the cumulative per capital HMR uptake in Australia, from 167.1 HMR claims per 100,000 population in the September quarter 2003–04 to 560.1 claims in the September quarter 2006–07 (Australian Divisions of General Practice [ADGP], 2006). The Australian HMR program has been externally evaluated. The GP component was evaluated in 2004 and the pharmacy component was evaluated in 2005 (Urbis Keys Young, 2005). Australian Journal of Primary Health — Vol. 14, No. 1, April 2008


The evaluation of the pharmacy component highlighted that, while the HMR clearly addressed genuine and ongoing community needs, HMR referrals to date have been considerably lower than expected. Possible reasons for this are difficulties in incorporating HMR into traditional community pharmacy business models, pressures on general practice, perceptions by GPs that the HMR process is complicated and time-consuming, insufficient numbers of accredited pharmacists, possible GP reluctance to work with pharmacists in the way that HMR requires, dissatisfaction with some aspects of pharmacy HMR services received, and lack of client pressure. Some issues were noted relating to variable levels of contact between GPs and the pharmacist after the HMR report had been delivered. It appears that the pharmacist does not consistently receive a copy of a medication management plan (Urbis Keys Young). The evaluation report by Urbis Keys Young (2005) made recommendations for further quantitative and qualitative research to explore issues around the attitudes of GPs, pharmacists and consumers towards the HMR. Furthermore, the report advocated that national public awareness campaigns are needed so that consumers are more informed about the HMR process. More integration between the GP and pharmacy components is required in terms of planning, implementation and evaluation. The extent to which these recommendations have been implemented is difficult to ascertain. Another area that requires further qualitative and/or survey research is the way in which GPs use the pharmacist’s HMR report and the extent to which they act on its suggestions and recommendations (Urbis Keys Young, 2005). A possible oversight of the report was that there appears to be no formal evaluation of any interventions or the HMR process at the individual client level. It should also be noted that the evaluation did not examine the nurse’s role in medication review, and that within the HMR model the nursing role has not been clearly defined. Some groups in the community have been under-serviced by the HMR, including people from culturally and linguistically diverse backgrounds, Indigenous communities and people living in isolated or sparsely populated areas. Bajramovic Fejzic and Tett (2004) explored the use of HMR for people from the former Yugoslavia who had Australian Journal of Primary Health — Vol. 14, No. 1, April 2008

become Australian residents. Using a convenience sample, 25 clients, recruited through local GPs, were interviewed and counselled in their homes by a registered interpreter, who was also a final year pharmacy student. There were 151 identified interventions in the 25 clients, which clearly demonstrated the extent of medication-related problems. One of the biggest issues was a lack of communication that these consumers had with their community pharmacist, as interpreting services were not available. The authors believed that a teamwork approach with the GP may have averted these problems. A significant number of medication problems are identified during home medication reviews. For example, an Australian study examined the nature and type of medication-related problems that occurred in a large sample of people (n=1000) living in the community and deemed to be at risk of medication misadventure. The findings were that 90% of clients experienced at least one medication-related problem (Roughead, Barratt, & Gilbert, 2004). Prior to the introduction of the HMR in 2001, the Commonwealth Department of Health and Ageing and the Pharmacy Guild of Australia supported a number of Australian studies that were designed to assess the implementation of home medication reviews in a community setting. Of particular relevance was an Adelaide-based study (Gilbert, Roughead, Beilby, Mott, & Barratt, 2002) that utilised a multi-disciplinary team approach from the outset, using a participatory action research design. Researchers worked with participants to design, implement and evaluate the HMR service. Participants included consumers, GPs and pharmacists. A case conference was first held between the GP and the pharmacist. The pharmacist then visited the person’s home to review medication-related issues and prepared a written report. The GP and pharmacist met again to discuss reports and agree on a plan of action. Both the pharmacist and the GP followed up clients in three months’ time. The results from this study revealed that, of the 2764 actions recommended by the pharmacist, 42% were implemented and 81% of these reported were resolved. The study highlighted the need for communication and consumer involvement from the outset. The threemonth follow-up review by both the pharmacist and GP is not part of the current HMR process. 31


Although this model focused on the role of the GP and pharmacist, it could be expanded to include other health professionals, such as community nurses. The role of the nurse in the medicine review process has not been clearly articulated within the HMR documents. Authors agree that community nurses have a responsibility to evaluate the client’s ability for medication self-management (Cox Curry, Walker, Hogstel, & Burns, 2005; Ellenbecker et al., 2004). Griffiths et al. (2004) stated that while the HMR has assisted formalising of links between GPs and pharmacists, there has been less progress in developing formal collaborations involving community nurses. The administration of medications and the monitoring of the effect is an important nursing function, yet there has been little research that explores the effectiveness of community nurses in medication management. Of particular concern was an Australian community nursing project that aimed to develop and test a systems-based approach for community nurse referral for an HMR, and to identify any barriers to their uptake (Kyle & Nissen, 2006). There was a potential client database of 2700 from three different district nursing services, but only five HMR requests were sent to GPs over the seven months of the study. Only two resulted in a completed HMR, which was considered a very disappointing result. The authors suggested that this may, in part, be due to lack of awareness about HMR by consumers, thus making it more difficult for nurses to gain consent. A systematic review conducted during the Urbis Keys Young (2005) evaluation of the HMR program found eight randomised control trials (United Kingdom and Australia) that investigated the benefits of HMRs. Within these studies, there was considerable heterogeneity in the interventions, client populations, processes used, outcomes measured and the duration for follow-up. The main gap highlighted related to the absence of data about the long-term health outcomes for clients who receive HMRs. The literature around home-based medication review highlights the importance of an interdisciplinary service model which is collaborative (Gilbert et al., 2002; Sorensen, Stokes, Purdie, Woodward, & Roberts, 2004). Case conferencing was found to be useful in three studies (Wilkinson et al., 2002; Gilbert et al., 2002; Sorensen et al., 2004). Interventions that focus primarily on one individual within the primary health care team may 32

not have as favourable outcomes when compared with those that had a collaborative team approach (Sorensen, Stokes, Purdie, Woodward, & Roberts, 2005). For example, a UK-based study examined the effect of pharmacist home medication reviews for 872 people aged over 80 who were recently discharged from hospital (Holland et al., 2005). Each person received two home visits by the pharmacist within an eight-week period. The intervention was associated with a significantly higher rate of hospital admissions and did not improve the quality of life or reduce death rates. Similarly, another study used a randomised controlled trial (RCT) to examine pharmacist-led medication reviews for clients over 65 years of age (Krska et al., 2001). They found that the pharmacist intervention increased the number of medication issues resolved, but, again, there was no difference in quality of life between the intervention and control group. What are the gaps in current service delivery? The literature has revealed a number of issues such as the importance of person-centred care, the need for the coordination of care and consumer partnerships in medication management, which are important considerations in planning primary care services to support people with dementia and chronic illnesses. The importance of a person-centred approach is clear within the literature, including the need to redefine problems and understand behaviours of people with dementia; that is, to focus on the person and not just target the behaviours (Access Economics, 2003; National Health Priority Action Council [NHPAC], 2006). An important aspect of providing quality care is effective connection, rather than passive communication between caregivers and the person with dementia. However, it is acknowledged that it does become more difficult as the dementia progresses because the person’s capacity to think about others progressively diminishes (Access Economics). People with dementia who have chronic illness require coordinated, tailored, and flexible care processes in the community. The aim should be to prevent crisis, as opposed to reacting when a crisis occurs (Kumpers, Mer, Maarse, & van Raak, 2005). A comparative qualitative study explored dementia care in England and the Netherlands and found commonalities with service provision Australian Journal of Primary Health — Vol. 14, No. 1, April 2008


(Kumpers et al., 2005). Both English and Dutch mainstream services were found to be lacking in terms of supporting clients and carers, as well as a lack of integrative service provision. Powell Davies et al. (2006) concluded that Australia lacks a coherent national approach to PHC. Furthermore, there is no single authority or common accountability for the health of defined populations, which is also acknowledged within the National Chronic Disease Strategy. It states that PHC networks exist informally throughout the system and that there is a lack of population-level data that monitors risk factors and health status (National Health Priority Action Council, 2006). A study conducted by the Centre for GP Integration Studies assessed the effectiveness of government initiatives that were aimed at strengthening general practice and improving links with the rest of the PHC sector (Powell Davies et al., 2006). They found that, although there were a significant number of programs, most focused on individual care and there was little evidence of integration across programs. It is recognised that consumers of medications are an integral part of the PHC team. Between February 1998 and August 2000, the Pharmaceutical Health and Rational use of Medicines (PHARM) Consumer Sub-Committee conducted a series of consultations that highlighted a number of factors that made it difficult for consumers to be active partners in the use of their medicines. These factors were: difficulty in timely access to important information when it is needed; inadequate communication between consumers and pharmacists; difficulty managing regimes of multiple medicines; and accessing help to overcome that difficulty (PHARM, 2001). Carers reported having problems accessing information about their family members’ medicines due to privacy concerns. Within the PHARM consultations, consumers were asked for suggestions for improving current systems. It was recognised that carers needed more information and support when they are responsible for another person’s medicine management (PHARM, 2001). Consumer groups reported language barriers between non-English speaking consumers and their doctors and pharmacists. In addition, there was difficulty in obtaining information about prescription medicines in other languages. Interpreters were not used when needed, meaning that limited information about medicines was provided. Consumers also claimed that doctors Australian Journal of Primary Health — Vol. 14, No. 1, April 2008

were not attuned to cultural differences related to medicines (PHARM, 2001). Limitations The primary studies included in this review gathered data from people in diverse situations, circumstances and environments, using diverse analytical approaches and theoretical perspectives. Integrating studies that have used diverse methods and sample sizes into a coherent whole has involved the drawing of inferences by the authors. Clearly a tension exists between the integrative review and the analytical, systematic approach required to conduct a literature review in which the intention is to undertake a secondary synthesis of knowledge, taking into consideration the diversity of method, human circumstance and experience of research participants. Conclusion This paper has summarised what is known about medication management for people in the community with dementia, evaluated and compared the available research and located gaps in order to make recommendations for future research. The review has revealed that there exists a range of services and programs to support people living in the community with chronic illness and dementia, such as HMRs; however, there is little coordination of care and evaluation of interventions is at best inconsistent. Current services are limited in the degree to which there is collaboration between key partners and Australian PHC initiatives are fragmented and have limited impact on service delivery. At this time, Australia lacks an integrative PHC framework within which consumer involvement in decision-making and/or care planning is valued and sought. The prevalence of dementia is expected to increase in the future; hence, it is imperative that effective integrative models of care are developed to enable people with dementia and chronic illness (and their carers) to remain safely in their own homes for as long as their situation allows. To develop such models, collaborative action research approaches are called for, in order to explore the feasibility of active engagement of people with dementia, their carers and other community support groups and health professionals in improving medication management and client safety. 33


Acknowledgments The project and development of this paper was funded by the National Health and Medical Research Council Project Grant Development Scheme, at the University of South Australia and the Foundation of the Royal District Nursing Service, South Australia. References Access Economics. (2003). The Dementia Epidemic: Economic Impact and Positive Solutions for Australia. Alzheimer’s Australia. Albert, S. M., Flater, S. R., Clouse, R., Todak, G., Stern, Y. & Marder, K. (2003). Medication Management Skill in HIV: I. Evidence for Adaptation of Medication management Strategies in People with Cognitive Impairment. AIDS and Behavior, 7(3), 329-339. Australian Council for Safety and Quality in Health Care. (2002). Second National Report on Patient Safety: Improving medication safety. Canberra, Australia. Australian Government Department of Health and Ageing. (DoHA). (2005). Dementia - a national priority. 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Debbie Kralik Research Unit Royal District Nursing Service Wayville South Australia 3054 AUSTRALIA Email: [email protected]

Barbara Anderson Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute University of South Australia Adelaide South Australia 5000 AUSTRALIA

Kate Visentin Royal District Nursing Service Research Unit Wayville South Australia 3054 AUSTRALIA

Andrew Gilbert Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences University of South Australia Adelaide South Australia 5000 AUSTRALIA

Geoff March School of Pharmacy University of South Australia Adelaide South Australia 5000 AUSTRALIA

Merilyn Boyce SA Divisions of General Practice Inc. 66 Greenhill Road Wayville South Australia 5034 AUSTRALIA

Correspondence to Debbie Kralik

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