Lost in translation

31 March 2023

Jayne Agnew is a Consultant Pharmacist Older People SHSCT Northern Ireland. She tweets @AgnewJayne. Heather Smith is a Consultant Pharmacist Older People at Leeds Office of West Yorkshire Integrated Care Board She tweets @Heatherspharm. Rosie Marchant is a Frailty Pharmacist at North Bristol NHS Trust.

Polypharmacy, the use of multiple different prescribed medications, has become part of everyday life for many and tends to increase the older we become. Older people are more likely to experience adverse effects from polypharmacy due to pharmacokinetic and pharmacodynamic changes associated with age; that is, changes in how the body processes and responds to specific medications. Whilst medicines can be beneficial, polypharmacy and frailty are independent risk factors for mortality1:  the Newcastle 85+ study observed a 3% increase in mortality for every additional medication prescribed. 2

The NHS has developed recommendations to reduce overprescribing, which is where people are given medicines they do not need or want, or which may do them harm. 3 Responses to overprescribing include medicines optimisation, structured medication reviews and deprescribing.

Sluggett et al found a 4.4% lower risk of mortality over 12 months when a medication review was undertaken for residents within 6-12 months of entry to a care home.4

Health literacy can impact how people understand and contribute to prescribing and deprescribing decisions. It refers to people having the appropriate skills, knowledge, understanding and confidence to access, evaluate, use and navigate health and social care information and services. 5 Health literacy is affected by cultural, social and individual factors and is regularly needed by older people, e.g., when they consult with their GP, use a peak flow meter or take their medicines. The language we use to communicate with older people impacts on shared decision-making around both prescribing and deprescribing, and on the success of these interventions. We need to use helpful language to ensure people understand their treatment and to manage their expectations both now and in the future.

               “I take my levodopa for a few days then stop when I feel better”

We can all help patients by using simple language, avoiding medical terminology and asking the patient to repeat back the information in their own words to make sure they understand. Rather than using the terminology ‘medicines optimisation’ or ‘rationalisation’, we can tell the older person that we are reviewing their medicines to make sure they are getting the most benefit from them.

                       “You’re just trying to save money”

The word ‘deprescribing’ can have negative connotations for people. They can think that the health system is giving up on them or cost-cutting. Instead, explain to the person that it is about gradually reducing the dose of a medication or a trial without a medication. The purpose is to reduce side effects or the number of medicines being taken. Likewise, when starting a medicine, advise the patient that this is a trial with the medicine and if there is no benefit, it will be stopped or changed.

                    “I get on fine with my tablets as far as I know…”

Asking a patient if a medicine actually helps their condition is better than asking them if they are okay on the medication. Not all side effects will be obvious to the patient: e.g., the cognitive effects of anticholinergic drugs.

 “I was told it’s my dog that causes my asthma – I spray it [salbutamol inhaler] on him all the time but it doesn’t seem to help”
Ask patients to show you their medicines and how they use them, especially if you are in their home. This can help identify non-adherence or misunderstandings.
 
Other examples of helpful language include using pain “reliever” rather than “killer”. “Painkiller” suggests all pain will be removed, which is often unrealistic.
  “You’re saying I should stop this but the specialist told me I should take it lifelong…are you giving up on me?”
Similarly, “longer-term” is preferred to “lifelong” when starting long-term treatments, e.g., anticoagulants for AF. This makes subsequent deprescribing conversations easier when the risks of treatment become greater than the potential benefits.

 

We can all make simple changes to our language to help and empower older people.

References

  1. Herr M, Robine J-M, Pinot J, Arvieu J-J and Ankri J. Pharmacoepidemiol Drug Saf. 2015 Jun;24(6):637-46. Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people (doi: 10.1002/pds.3772)

  2. Davies L.E, Kingston A, Todd and Hanratty B. Is polypharmacy associated with mortality in the very old: Findings from the Newcastle 85+ Study. British Journal of Clinical Pharmacology 2022, 88: 2988-2995 (doi: 10.1111/bcp.15211).

  3. Department of Health and Social Care. Good for you, good for us, good for everybody. A plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions. 22 September 2021.

  4. Sluggett JK, Caughey GE, Air T, Moldovan M, Lang C, Martin G, Carter SR, Jackson S, Stafford AC, Wesselingh SL and Inacio MC. Provision of a comprehensive medicines review is associated with lower mortality risk for residents at aged care facilities: a retrospective cohort study. Age and Ageing 2022,51:1-11 (doi:10.1093/ageing/afac149).

  5. Public Health England. Improving health literacy to reduce health inequalities. Practice resource summary: September 201

Comments

Add new comment

CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.