What’s the trouble in medication reviews?
By Nina Fudge
Our study on medication reviews in older adults revealed that despite lengthy consultations, few medication changes occur, with misunderstandings and existential concerns common. These findings highlight the complexity of addressing polypharmacy and the need for better doctor-patient communication.
Recently the Chief Medical Officer in his annual report on health in an ageing society said:
“Improving quality of life in older age sometimes means less medicines, not more. It is essential that all patients, but especially those in later old age are able to have realistic discussions with their doctors”.
We are interested in the potential of medication reviews to help doctors and older people talk about medicines to reduce the problem of polypharmacy.
Polypharmacy, using many medicines, is a global patient safety concern. Over a third of people in England aged 80 – 89 are prescribed at least 8 medicines. The risks of taking multiple prescription medicines increase with age and with the number of medicines prescribed.
In 2021, NHS England introduced a programme to reduce the harms of polypharmacy and unnecessary medicines. This includes inviting patients prescribed 10 or more medicines for a Structured Medication Review (SMR).
The evidence that SMRs can reduce polypharmacy is limited. We don’t know much about what actually happens in a medication review.
We did a linguistic ethnography study of medication reviews in three GP practices. We observed medication reviews as they happened in practice, and examined in detail the conversations and interactions taking place in a medication review. We collected the data just before the pandemic and before the widespread introduction of SMR policy.
We followed 24 older patients who were prescribed 10 or more medicines for up to 2 years with home visits, interviews and telephone calls. We accompanied patients to 29 consultations – 18 of these were video-recorded. We also ran 7 workshops inviting professionals to reflect on the film clips of the consultations.
Most of the consultations were time-consuming yet hardly any medicines were stopped or changed. This raised the question for us:
What does happen in consultations which are typically lengthy but in which little or no change to medication takes place?
Misunderstandings were common. Clinicians and patients were often just not on the same page. Although both parties worked hard to resolve misunderstandings they often failed to reach agreement on matters such as:
- Which medicine are we talking about?
- Why is this medicine prescribed?
The medicines also raised existential concerns such as:
- What are all these medicines for?
- Are the medicines are working?
We witnessed ‘troubles talk’ within the medication reviews. By this we mean the ways participants displayed a sense of trouble through interactional features such as laughter and hesitancies. These features of interaction and communication often point to an underlying concern that is not otherwise expressed.
Both GPs and patients sensitively smoothed over the interactional troubles and maintained respectful relationships. However, they struggled to address polypharmacy more directly.
We identified a tension between the biomedical paradigm, focused on prolonging life, and patients’ lived experiences of growing old and their anticipation of dying.
‘Troubling’ medication reviews in the context of polypharmacy and ageing: A linguistic ethnography by Sarah Pocknell, Nina Fudge, Sarah Collins, Celia Roberts and Deborah Swinglehurst. Social Science and Medicine 2024. You can read the paper in full here – open access and free to read.