Dr Ian Maidment is the Primary Investigator in the ‘Medication Management in Older people: REalist Approaches BAsed on Literature and Evaluation (MEMORABLE) project’
The MEMORABLE project is designed to develop a framework for a novel multi-disciplinary, multi-agency intervention(s) to improve medication management in community-dwelling older people on complex medication regimens using a realist approach. This research was profiled on BBC Breakfast on the 21st June.
This project is building on previous research by Dr Maidment that was funded by Pharmacy Research UK (PRUK), which looked at medication management in people with dementia living in the community and the potential role of the Community Pharmacist.
Hi Ian, this study has been described as methodologically novel – why would you say a study of this kind is needed?
I think it’s needed because medications management is such a challenge with older people on complex regimes. There’s been a big growth in the number of old people taking lots of meds. That’s why the study’s needed. Its novel because it’s the first time, certainly in the UK, that realism has been applied to this particular problem. Realism is a very up and coming research technique, and as far as I’m aware it’s only been applied worldwide once to med management problems, in Canada but for a very different question, looking at a very specific issue. It’s never been applied, as far as I’m aware, to this type of problem.
So following on from that what do you think the wider impact could be?
This has been an ongoing problem for many years. Even when I qualified 30 years ago medication management was a challenge. We’re obviously struggling to get solutions, so hopefully by using a novel, innovative technique, we can develop a well-theorised intervention, which will work in the real world. Realism is designed to find solutions based on real world experience and evidence; that’s what we’re hoping to find.
How do you think this can help pharmacists and other healthcare professionals improve patient care?
This research project involves developing an intervention for future trial. As we develop an intervention we will hopefully find out what the challenges are, and then from that pharmacists will get an idea of what they should be doing and how they should be working; and equally importantly what they should not be doing.
So you’re identifying where all the biggest problems are with medications management in older people rather than coming up with a solution for them?
We are coming up with a solution as well. You can’t find out what works until you find out what the problems really are. The idea is that we will find out what works for who in what circumstances. Once we understand what is likely to work, we can test it in a trial.
You mentioned in the BBC interview the technological advances that have come in this field, what sort of impact do you see those technological advances having on medications management?
So you’re talking about things like apps, I guess, is that what you’re referring to?
Potentially apps will offer a solution. However, I’m yet to be aware of a situation where they have had a significant impact. Any app that is likely to be effective needs to be designed using the end users; not IT working in isolation.
One of my colleagues at Aston, Dr Jo Lumsden, is doing novel work on designing apps where you involve the end user; however such a rigorous approach is time-consuming and therefore more costly.
Although plans are underway to kite mark apps there is a lot less control on apps compared to medication. Potentially an app which gives incorrect information is equally as risky as a medication.
So you’d say it’s a very risky route to go down at this point?
Well, I think apps can be just as risky as the medication itself; for example if an app tells someone to take a medication once a day when it should be once a week. Various companies are producing apps for medication management; it is not always clear how much these apps are marketing tools or how much they are clinical tools. I’m not saying apps don’t have a place, they definitely have got a place, but they need to be developed rigorously bearing in mind the risks. Because if you get an app wrong, it’s just as dangerous as getting a medication wrong.
And it also brings security issues, doesn’t it?
There’s also security issues as well, personal security data and stuff like that. But for me, that’s a lower risk than someone taking the wrong drug. People focus on security but, if for example, there’s a glitch in the program and the app tells you to take a medication four times a day rather than once a day… It’s an extreme example but shows the potential risk. Or if the instructions aren’t quite clear to the patient and they take the medication incorrectly.
That could be very dangerous.
Yes, it could be very dangerous, and it’s not talked about. There’s very little conversation about the risks of apps. My concern is people won’t seriously consider this until after people have experienced harm due to an app. Measures need to be put in place before any potential event. I’m not an expert on apps but we need proper development of apps; specifically involving the end user (in particular older people, who may not be familiar with technology).
The dementia project mentioned the difficulty in getting BME participants in the study, sometimes due to cultural differences, what kind of steps have you taken in this study to ensure a diverse sample population?
We’re trying to learn from what we used in the Pharmacy Research UK study. And that’s by using a gatekeeper from the BME community, using a member of the same community, who has got trust there who we can work through. We’re using a diverse strategy, going through gatekeepers who are part of the communities themselves, and trying a number of gatekeepers.
The dementia project talked about the need for community pharmacists to work outside the ‘four walls’ and to work without boundaries, how do you think community pharmacists can best achieve this with regards to medications management?
I mean I think ultimately they probably need to be working in the patient’s homes and in the GP practice. There’s a need to get out of the pharmacy; obviously I’m aware there’s all sorts of legal and financial problems and the need for incentives. However, you won’t really understand what’s going on in a patient’s home until you’re in that environment and you won’t understand the challenges with prescribing, from the GP viewpoint, until you’re working very closely with a GP. Practice based pharmacist posts are being established, but they are still going need to work with community pharmacists, who are going to be dispensing the medication.
The dementia project suggested that public policy should enable community pharmacists to support people with dementia and their informal carers. What steps have been taken to influence public policy and what more needs to be done?
Obviously there’s been a move to change the funding models for community pharmacists from dispensing based to more clinical based activity specifically funding for Medicines Use Reviews (MURs) and New Medicines Service. I know these services are being reviewed at the moment, but they need to be targeted for the most appropriate groups. They are a clinical service and shouldn’t be viewed as a target. Also there needs to be some sort of model to enable these to be conducted outside the physical premises of a community pharmacy.