Working together against Side Effects
Too much, too little or incorrect: As studies prove, the elderly are frequently not getting the right medical treatment. In some cases, the prescribed dose is inaccurate or, in other cases, problems occur because drugs are not taken as prescribed, or different agents interact.
Those affected by the wrong medical treatment are mostly the elderly, such as residents in care or in retirement homes; a fact which became evident in the data collected by the pharmacist Dr. Julia Kruse. In her dissertation she proves that a closer cooperation among physicians, care attendants and pharmacists could eliminate many of the above-mentioned problems. The pharmacist wrote her dissertation in the Clinical Pharmacy study group under the supervision of Prof Georg Hempel of Münster University. The aim of her doctoral thesis was to optimise the current treatment of patients by improving the cooperation between the occupational groups and thus reducing the number of problems caused by the wrong medical treatment.
The results showed that about 53% of all possible drug-induced problems could be avoided by a pharmaceutical intervention, i.e. an examination and, where necessary, an adjustment to the drugs prescribed. These results include cases in which the patients did not show any symptoms but where side effects could be expected. With this improved drug administration, costs could be saved by an average of 30 cents per resident, per day.
For her study, which has been conducted for the first time like this in Germany, the 30-year-old pharmacist examined residents from seven facilities in Münster, 82% of which were women. The constellation of the group Kruse examined was typical for an average German residential home. "The typical care home resident suffers from seven diseases, of which dementia and hypertension were the most frequent diagnoses. On average every patient was receiving just over eight drugs", reports Julia Kruse. She carried out her research as a so-called interventions study. This means that after having established how many drugs a home resident took and which diseases were documented, she examined the medication of each patient in respect of incorrect dosage, prescription without a diagnosis or interactions between drugs. After discussing her observations with the nursing staff, she informed the physician in charge and made suggestions for improvement. Eight weeks later, a follow-up examination was carried out.
"From 209 tested residents I detected 1,323 drug-induced problems", Julia Kruse reports. On average, there were approximately six potential or occurring complications per person. One example is the use of the agent metoclopramide (MCP), which is often prescribed in cases of nausea and vomiting. Around 26% of all residents received the substance as required and 12% even received it as a permanent drug. Since MCP interacts with psychotropic drugs, patients taking both might show symptoms that resemble those of Parkinson's disease, for example motor disorders such as muscular rigidity or tremors. "The problem can be solved by discontinuing MCP. If a drug against nausea or vomiting is required, MCP can be substituted by domperidone. It has the same effect as MCP, but it does not enter the brain and, therefore cannot interact with psychotropic drugs," Julia Kruse explains.
Another problem is that in care homes, drugs are often crushed because the residents have difficulties in swallowing. "However, many pills should not be crushed, as they might be enteric-coated. One resident received crushed pills for months, which were having little or no effect. After consulting the physician, who was not aware of the fact that the pills were being crushed, this drug was replaced by crushable pills, which contained the same agents. By reviewing this case, the care personnel were generally made more aware of this problem," Julia Kruse emphasises. Concerning the willingness for cooperation the young pharmacist has mixed feelings about her results: "Many doctors considered the project to be highly helpful and requested me to examine more patients with regard to medication-induced problems. Others felt offended that their authority was being undermined and communication approved to be very difficult." She underlined that the seven participating care homes were open to her suggestions.
Julia Kruse advocates a general improvement of the communication among physicians, pharmacists and care attendants for the benefit of the residents. Nevertheless, an extensive implementation of the concept is not practicable without further ado. “The pharmacies supplying the homes cannot provide such an extensive pharmaceutical supervision as an additional service to the daily work routine as was provided in the project,” she says. “To my mind, how to finance an improved pharmaceutical care has to be clarified.”
In Australia, for instance, the problem was solved by physicians commissioning pharmacists to monitor the drug therapy, which was paid for by the health insurance. The money from the health insurance companies is generated through abolishing the drugs, which, after being examined, proved to be superfluous.
According to Julia Kruse, it is to be hoped that the improved medication therapy will also result in fewer hospitalizations.
Translated by students from the English Seminar:
Fabian Struckamp
Paula Skosples
Jenny Mertens