Care Home Residents are often some of the frailest patients in our society, carrying significant polypharmacy. Literature searches such as the Care Homes Use of Medication Study often highlight the risk associated with the prescribing, and administration of medications for this cohort of patients as the tablet burden in this cohort is usually higher than average population. There is estimated that 70-80% of care home residents have dementia or suffer from severe memory issues. The Banerjee report highlighted the limited benefit of anti-psychotic medications for use in behavioural and psychological symptoms in dementia (BPSD). Antipsychotic medications are associated with significant adverse effects and using them inappropriately can increase the risk of adverse events such as stroke. Also, hypnotics and anxiolytics may sometimes be prescribed for the short-term to aid in helping with BPSD while anti-psychotic medications reach therapeutic levels.
Across Swansea Bay University Health Board (SBUHB) there are 3,196 available Care Home beds, with 1201 of these being based in Neath Port Talbot locality. An integrated clinical pharmacist role was created between the Medicines Management Team and Cefn Coed Hospital, the main specialist mental health site in SBUHB. The purpose of this role was to undertake clinical medication reviews in the Care Home setting. The focus on these reviews would include reducing inappropriate polypharmacy, assessing anticholinergic effect on cognition and minimising falls risk. The pharmacist also works closely with the Care Home In-Reach Team (CHIRT). This team provides specialist mental health advice, both assessing and reviewing care home residents with mental health related conditions. The team consists of a mental health consultant, nurses, physiotherapists, occupational therapists and health care support workers. Previously no pharmacist has been funded to support the service. By utilising an
integrated post, the pharmacist is able to work with the CHIRT for those residents needing mental health input. They can optimise their mental health related medications and ensure a clear plan and regular review is implemented.
SBUHB are the second highest prescribers of hypnotic and anxiolytic drugs and the fourth highest prescribers of anti-psychotic medications in Wales. These drugs may also carry an anticholinergic burden and contribute to the anticholinergic effect on cognition (AEC) score. Swansea Bay have the fourth highest number of patients with an AEC in Wales. By having a pharmacist integrated across these two teams it allows a pharmacist to identify those care home residents prescribed these drugs that may contribute to AEC scores, as well as other medications that can contribute. They can then identify those residents with a high AEC score and potentially larger risk of falls and complete a medication review with the aim of reducing AEC and inappropriate polypharmacy, ensuring medication is optimised. Where issues arise such as non-compliance they can liaise to rationalise and reduce tablet burden as appropriate and advise on manipulations of medications and ensure correct procedure for covert
medication is in place. By integrating in both the primary and secondary care setting, more seamless care is able to be offered to residents and issues can be resolved more efficiently by ensuring appropriate mental health review and discussions with the CHIRT and also liaising with GP relevant GP and surgery staff to review other medications.
