How can we optimise medication in older people on complex medication regimens living in the community?

Problem

Increasing numbers of older people are taking many different medications. The number of older people on five plus medications has increased from 12 to nearly 50% over 20 years. Managing complex regimens can be very challenging for older people, family carers and primary care clinicians. There are key gaps in understanding how, why and for whom complex medication management works and from this, how best to improve practice and outcomes. MEMORABLE (MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation) was funded by the NIHR and aimed to address these gaps (PROSPERO registration: 2016:CRD42016043506). Key aims were:1. To understand causal paths relating to medication management. 2. To develop a framework for an intervention(s) to optimise medication.

Approach

Realism analyses and interprets multiple sources of evidence to understand what works, for whom in what circumstances. As such it is ideal to understand how complex interventions work, or not. Following RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines, MEMORABLE involved three work packages: 1. Realist review: focused on 24 articles on medication management that explore causality; 2. Realist evaluation: 50 realist-informed interviews with older people, family carers and practitioners, exploring and explaining their experiences; and 3. Synthesis and theorising the outputs from 1 and 2.

Findings

Medication management is a complex implementation process that can be mapped onto five separate but linked stages:• Three individual stages where the older person, sometimes with help from a family carer, fits medication into their daily lives, balancing routines, risk and coping with any burden; and• Two interpersonal stages where the older person engages with a practitioner, again sometimes with a family carer, sharing decisions about diagnoses and medications. Using Normalisation Process Theory as an explanatory ‘lens’ we identified four key steps in each stage: 1. Making sense: information, clarification. 2. Taking action: shared decision making. 3. Reflection and monitoring. 4. Building enduring collaborative relationships underpinned by trust. To deepen our understanding of what it means for an older person to take medications, a detailed analysis of the Reviewing/reconciling medications stage was conducted and five burdens that needed addressing identified: ambiguity, fragmentation, unfamiliarity, concealment, exclusion. MEMORABLE established a burden-focused, transferable theoretical framework to explore and explain the complexity of medication management, directly applicable to the experiences of older people, family carers and primary care staff.

Consequences

Older people find managing complex medication regimens a burden. Primary care staff need to work with older people and family carers to reduce the burden from medication. Two interventions that might potentially optimise medication management were identified: a tool to identify older people struggling and individualised information.