Supporting special populations

with medicines adherence:

A focus on

Swallowing, Speech, Sight

Nina Barnett. Consultant Pharmacist, Older People

Medicines Use and Safety Team,

NHS Specialist Pharmacy Services

Medicines and the Dysphagia Pathway

Paresh Parmar Lead COE & Stroke Pharmacist1 Mary McFarlane Principal Speech & Language Therapist1 Danielle Thompson Senior Speech & Language Therapist1 Nina Barnett Consultant Pharmacist, Care of Older People1,2 1Northwick Park Hospital, London North West Hospitals Trust 2 Medicines Use and Safety Division, NHS Specialist Pharmacy Services

What is Dysphagia?

Describes a swallowing disorder usually resulting from a neurological or physical impairment of the:

oral (mouth),

pharyngeal (upper throat)

or oesophageal (lower throat) mechanisms.

Why is it a problem?

Common complication of other conditions, occurring in up to

two thirds of patients suffering stroke

two thirds of patients with dementia,

a quarter of patients with Chronic Obstructive Pulmonary Disease

Associated with aspiration pneumonia and this can lead to poor functional outcomes, such as dehydration, malnutrition, increased length of hospital stay, and death

4

How does dysphagia relate to medication?

Patients with dysphagia are unable to take some oral formulations of medication.

Medication administration errors have been found more than three times as frequently in patients with dysphagia than in those without.

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Modified fluids and diet

While pharmacists commonly encounter solid and liquid medication, SLTs have classified food and fluid consistencies to meet swallowing needs. These can be used to support safe oral administration of medicines where simple liquid or solid medication may not be safe.

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Stage 1:

SYRUP

CONSISTENCY

Stage 2:

CUSTARD CONSISTENCY

Stage 3

Follow instructions as per brand of thickener selected to create appropriate consistency eg See Royal College of Speech and Language Therapists (RCSLT) RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN: Dysphagia 2009 (updated 2014) http://www.rcslt.org/speech_and_language_therapy/commissioning/dysphagia_manual_072014

PUDDING

CONSISTENCY

http://www.rcslt.org/speech_and_language_therapy/commissioning/dysphagia_manual_072014

What are food textures?

Texture D Mashed Diet Requires very little chewing eg mashed potato, kitchree, well cooked mashed fish

Texture E Soft Diet Requires gentle chewing. Solids and thick sauces e.g. sponge pudding, fish in sauce, banana, macaroni cheese, potato, cooked carrots, tinned fruit, bread with soft filling.

Texture B Thin blended diet Cannot be eaten with a fork. pours from a spoon rather than drops in a lump e.g. tinned tomato soup, runny yoghurt , thin custard

Texture C

Can be eaten with a fork. Smooth with NO LUMPS no chewing required. e.g. purees, blancmange, smooth fromage frais mousse, whipped double cream.

To crush or not to crush? Knowledge of food textures can allow some tablets or capsules to be administered whole, rather than crushed tablets or opened capsules, within a particular texture of food. This is always preferable from

both legal, pharmaceutical and administration perspective.

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What about the law?

When products are used outside their licence (e.g. crushing non-crushable tablets)

A greater liability rests with the individual prescriber, dispenser and/or person responsible for the provision or administration of the medication

Minimising risk to patients and staff

Liability can be minimized by: Clear documentation of the reason for altering the medicine Following evidence-based, safe, effective practice Obtaining consent from the patient (in England and Wales, doctors

providing consent [in accordance with the Mental Capacity Act 2005]; in Scotland, doctors must act according to requirements of Part 5 of the Adults with Incapacity [Scotland] Act 2000)

Support for this process

Supporting patients with swallowing difficulties: Medicines and dysphagia

https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/ Barnett and Parmar. How to tailor medication formulations for patients with dysphagia 23 AUG 2016 The Pharmaceutical Journal http:// www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.article

https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/http://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.articlehttp://www.pharmaceutical-journal.com/learning/learning-article/how-to-tailor-medication-formulations-for-patients-with-dysphagia/20201498.article

Flow chart for managing medicines in patients with dysphagia

patients with dysphagia

Determine how the patient swallowed food and medication prior to admission

Suggest alternative methods of administration, dosage forms, or therapeutic agents

Prepare instructions on the medication administration that guide the patient, family member or inpatient nurse

Document recommendations in patients notes 14

Helping people with communication difficulties after stroke to understand

warfarin therapy Satinder Bhandal, Consultant Anticoagulation Pharmacist,

Buckinghamshire Healthcare Trust and UK Clinical Pharmacy Association

Nina Barnett Consultant pharmacist, Older People,

Medicines Use and Safety Division, NHS Specialist Pharmacy Service

Katrina Clarkson Principal Speech and Language Therapist,

London North West Healthcare NHS Trust

What is aphasia?

Loss or impairment of language function caused by brain damage

Aphasia is a multimodal disorder:

Difficulties in speaking, understanding, reading, writing

Reduction in capacity to interpret and formulate linguistic elements (e.g. sentences, words, morphemes the smallest grammatical unit in a language)

Murdoch (2010)

Who experiences aphasia?

People who have had a

Stroke

Brain tumour (primary or secondary)

Traumatic head injury

Hypoxic brain injury

Who needs anticoagulation

Stroke - AF

Other reasons Deep Vein Thrombosis

Pulmonary Embolus

Mechanical heart value

Pulmonary hypertension

Severe cardiomyopathy

Which anticoagulant? Warfarin

Advantages of warfarin Tried and tested

well tolerated

easy to monitor adherence

keeps you connected with health system

More experience in reversing and antidote available

Disadvantages of warfarin Complex dosing regimen

Slow onset

Frequent monitoring trips

Drugs and food interaction

What about DOACs (direct oral anticoagulants)? Advantages of DOACs

Simple dosing regimens

fast acting (vs warfarin can take ages to get to an effective level)

less drug and food interaction

less treatment burden (convenience)

Some DOACs can be put in compliance aids

Disavantages DOAC less well tolerated (eg one in five people stop after 2 year, rash, headache, fuzziness, GI side effect (diarrhoea can be disabling)

Other than dabigatran, no licenced antidote

NPSA 2006

Anticoagulant risk assessment

need for doctors to give appropriate time to patients with aphasia to ensure that they

You WILL need extra time to counsel the patient with aphasia

So, a new tool may help........

What do we use now?

Anticoagulation therapy

Patient information booklet

Alert card for patient

Record of INR book

Treatment sheets

What do we need to communicate effectively to patient with aphasia?

Short message

Clear sentences

Easy words

Good layout

Diagrams and pictures

Appropriate font

What did we create

Learning event with pharmacist and speech and language therapist

Agreed on simple, accessible, online tool which can be downloaded for local use

Powerpoint slides using SLT guidance for presentation and pharmacist guidance for content

Yellow book - warfarin doses

Your new tablet is Warfarin

The tablets are different strengths

©Bucks Healthcare & NHS Specialist Pharmacy Service 2015

When will you remember to take it?

Take Warfarin once a day

©Bucks Healthcare & NHS Specialist Pharmacy Service 2015

Yellow book - INR

You will need regular blood tests

It shows how much warfarin you need

If you are ill you need an extra blood test that week

©Bucks Healthcare & NHS Specialist Pharmacy Service 2015

Yellow book dietary interactions

Foods

All foods are okay

Keep what you eat the same each week

©Bucks Healthcare & NHS Specialist Pharmacy Service 2015

Yellow book - alcohol

Do not drink lots of alcohol

Keep what you drink the same each week

©Bucks Healthcare & NHS Specialist Pharmacy Service 2015

Summary for healthcare professionals

Blood tests (INR)

Take Warfarin every day

No big changes to diet

No binge alcohol

If very ill get extra blood test that week

Tell family and health professionals you are on Warfarin

©Bucks Healthcare & NHS Specialist Pharmacy Service 2015

Where can you get a copy?

Tool freely available to download

https://www.sps.nhs.uk/articles/warfarin-consultation-for-patients-with-aphasia/

Now includes DOACs

©Bucks Healthcare & NHS Specialist Pharmacy Service 2015

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Acknowledgements

Satinder Bhandal , Consultant pharmacist Anticoagulation, Buckinghamshire Healthcare NHS. Trust

Frances Akor, Consultant Pharmacist Anticoagulation, Imperial College Healthcare NHS Trust.

Katrina Clarkson, Principal Speech and Language Therapist, Regional Hyperacute Rehabilitation Unit, Northwick Park Hospital,

Clare Cahoon, Highly Specialist Speech and Language Therapist, Regional Hyperacute Rehabilitation Unit, Northwick Park Hospital,

Nina Barnett Consultant Pharmacist, Older People, Medicines Use and Safety Division, NHS Specialist Pharmacy Service and London North West Healthcare NHS Trust

With thanks to the UKCPA HAT group, Estelle Bloom at Making It Clear and the patients of Bucks Healthcare Trust.

©Bucks Healthcare and Medicines Use and Safety Division, NHS Specialist Pharmacy Service 2015

Medicines support for blind and partially sighted people

Nina Barnett

Consultant Pharmacist, Medicines Use and Safety Team, NHS Specialist Pharmacy Service

Hugh Huddy Policy Lead,

Royal National Institute for blind people

How did this come about?

OPNet event November 2015

Identification of gaps

Collaborative thinking

What did we do?

Recognised need to find out what is happening now

Created a survey Feb/March 2017

Surveyed over 200, mostly experienced hospital and community pharmacists

How they identify people needing support

What they currently provide

What did we find?

How important is the label?

How did you know the patient could read the label?