Read Standard 7: Medicines management and review

Ageing and frailty standards
Healthcare Improvement Scotland

Standard statement

Older people living with frailty are prescribed medicines which are safe, effective and person centred.

Rationale

People living with frailty often have multiple long-term health conditions that require medicines. They should be fully informed about what they have been prescribed, including its purpose, benefits and side effects. People can make an informed choice not to take medicines and this should be respected. Where a person without capacity refuses essential medicines, medicines may be given in a disguised or covert form.77 The use of covert medication is governed by the Adults with Incapacity (Scotland) Act 2000. Covert medication must only be used in line with these guidelines.78

People living with multiple long-term health conditions are likely to take multiple medicines. This can increase the likelihood of falls, delirium, bladder and bowel issues and other side effects.79 A seven-step polypharmacy review should be considered where appropriate.

Medicines are associated with risk of falls.80 High risk medicines, including anticholinergics, are associated with adverse outcomes.81 Reviewing and stopping unnecessary medicines may improve a person’s quality of life and reduce anxiety, pain and low mood.82 It can contribute to broader public health goals and reduce waste. Non-pharmacological approaches should be considered where possible.

The principles of Realistic Medicine should be considered when prescribing and stopping medicines. The use of BRAN (benefits, risks, alternatives and what happens if you do nothing) questions can support people to be involved in decisions and reduce harm.83 Medicine reviews should consider a person’s whole circumstances. This includes their choices and preferences.84

Unplanned gaps or suddenly stopping medicines may lead to harm and distress. People should have access to their medicines when moving between health or care settings. People may store more than they need due to confusion or fear of running out. This can result in out-of-date medicines and harmful drug interactions. Medication compliance aids can be valuable for older people with cognitive impairments. However, people using them may experience difficulty when a medicine changes or is prescribed on an 'as required' basis.

Anticipatory or ‘just in case’ medicines can be prescribed in advance for individuals who are likely to die in the next few weeks. These injectable medicines are used to manage symptoms that can happen when someone is dying. Planning ahead when someone is dying avoids delays in managing symptoms especially at night or weekends.

Criteria

7.1

People are involved in conversations about medication options that includes a discussion on:

  • the benefits
  • the risk of side effects or medication-related harm
  • alternatives to medicines
  • the likely outcome of not prescribing the medicine.
7.2

People are supported to:

  • discuss their medicines, including experience of side effects and any concerns they have, with an appropriately trained professional
  • store, manage and administer their medicines in a way that is right for them
  • set targets for pain and chronic disease management, in partnership with healthcare professionals
  • understand the purpose of their medicines
  • take their medicine within the principles of informed choice.
7.3

Unpaid carers and care partners and receive information about:

  • medicines and possible side effects
  • ongoing monitoring
  • alternatives to medicines
  • how to support the person to take their medicine
  • storing medicines and when to use medicine compliance aids
  • any changes to medicines and the reason for the change.
7.4

Organisations have a covert medication policy that is in line with up-to-date guidance and legislation.

7.5

High risk medicines are reviewed regularly and stopped where appropriate.

7.6

Older people with frailty regularly receive a person-centred medicines review led by a pharmacist, with input from a multidisciplinary team where appropriate.

7.7

Staff have the knowledge and skills to:

  • safely stop medicines in line with current guidance
  • refer to specialists for a review of medicines outwith their competence.
7.8

A seven-step polypharmacy review should take place:

  • for people with multiple chronic conditions
  • for people taking multiple medicines
  • when there are significant changes in health status, such as new diagnoses or hospital admission
  • when there are changes to the person’s medicines

whenever the person, or their unpaid carer or care partner, expresses concerns about a medicine or side effects.

7.9
Changes to a person’s medicine is documented and communicated across the multidisciplinary team and with the person and their unpaid carer or care partner.
7.10

During transition between care settings and at time of discharge, organisation ensure people have:

  • medicines in their original packs where appropriate
  • new medicines in the most appropriate quantities
  • at least a seven day supply of their usual medicine.
7.11

When a person is dying, the person and their unpaid carers or care partners are involved in decisions about stopping unnecessary treatments and monitoring.

7.12

When staff recognise a person is dying, anticipatory medicines are prescribed and available, whether the person is being cared for at home, in a care home or in a hospice or hospital.

What does this standard mean for...

What does the standard mean for people?

  • You will be supported to understand what your medicine is for and any side effects you may experience.
  • You will be able to access the correct medicine in the correct form when you need it.
  • Your medicines will be reviewed if there are changes in your health, life or care.
  • You will have the opportunity to discuss the risks and benefits of any medicines.
  • You will be supported to take your medicines.
  • If you are on many different medicines, these will be reviewed to check they are still right for you.
  • The people who care for you will have the information and guidance they need to support you to discuss and take your medicines.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting:

  • prescribe medicines in line with best practice and current guidelines
  • ensure people are able to make informed choices about their medicines and supported to take and store them
  • have an awareness that older people with frailty are more likely to experience side effects from medicines
  • know which medicines may cause withdrawal symptoms if stopped abruptly
  • conduct regular medication reviews using a structured approach.

What does the standard mean for the organisation?

Organisations:

  • demonstrate a good understanding of medicine reconciliation, polypharmacy reviews and a Realistic Medicine approach to prescribing
  • have systems and processes in place to identify, undertake and action recommendations from seven-step polypharmacy reviews
  • provide training and support to staff undertaking medication reviews.

Examples of what meeting this standard might look like

  • Evidence of structured polypharmacy reviews with appropriate documentation and coding.
  • Covert medications policies.
  • Audit on the provision of ‘just in case’ medicines for people who are dying.
  • Evidence of pathways and processes for medicines reconciliation.
  • Use of electronic systems and other systems and processes for example Hospital Electronic Prescribing Medication and Administration, Medication Administration Recording and Requesting.