improving medication use in older persons ... - health · chaired by a consultant in public health...

OFFICE OF THE COMMISSIONER

FOR MENTAL HEALTH & OLDER PERSONS

MINISTRY FOR HEALTH ST. LUKE’S SQUARE, GWARDAMANĠA PTA 1010 Email: [email protected] [email protected]

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Improving Medication use in Older Persons Conference

29th October 2013 Westin Dragonara Resort, St Julian’s, Malta

Report

________________________________________________________

Conference multidisciplinary consensus position statement A multidisciplinary care team approach is essential to enable older people to live as long as possible in their own home environments through the delivery of seamless health and social care across the continuum of hospital, primary health and community services and the development of:

o high risk registers for early diagnosis of frail older persons, o medication review, o awareness to adverse drug effects, o the use of non-pharmacological strategies, o appropriate discharge planning, o active follow-up, o out reach services, o support to informal carers, o a comprehensive hospital and community continence service, and o a holistic, accessible, integrated IT system.

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Improving Medication use in Older Persons Conference Report PART A: Technical Report Introduction On 29th October 2013, the Office of the Commissioner for Mental Health and Older Persons held a National Conference entitled “Improving Medication Use in Older Persons”. This full day Conference was held at the Westin Dragonara Resort, St Julian’s between 8.15am and 4.45pm. Nature and aims of conference This multidisciplinary conference was primarily aimed at increasing awareness on issues related to medication use in older persons amongst all health care professionals working with or caring for older persons, whether actively involved in prescribing, dispensing or administering medications or diagnosing, treating or otherwise dealing with the unwanted effects of medication. Secondarily the conference sought to obtain interdisciplinary consensus position statements and to provide recommendations for action in the health and social policy and services areas. Preparation In order to consolidate the necessary professional and technical input and to ensure the best quality output possible in the setting of a large conference, the Office of the Commissioner for Mental Health and Older Persons set up a multidisciplinary Focus Group in October 2012, chaired by a Consultant in Public Health Medicine from the Office. The members on the Focus Group brought with them expertise from geriatrics, clinical medicine, family medicine, public health medicine, medicines regulation, pharmacy, nursing and allied health care. They were further supported by administrative support from the Office. The multidisciplinary Focus Group of 15 members (Annex 1), which eventually became the Conference Organising Committee, met regularly over the year. There were 13 formal meetings of 2 hours each. Further and more intensive work was done over and above formal meeting time. This involved background research, preparatory work for meetings, follow-up work from the meetings, and the myriad of administrative and related tasks to enable the successful organisation of the conference. Most of the members of the Focus Group delivered the presentations at the conference and/or acted as facilitators of workshops. The Focus Group chair was the Chairperson of the conference.




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Conference Organisation The conference was organised in 4 parts. 1) Opening, keynote address and first set of technical presentations 2) Second set of technical presentations 3) Multidisciplinary Parallel Interactive Workshops 4) Concluding session Part 1: Opening, keynote presentation, first set of presentations with some Q&A time In her welcome speech, Dr Miriam Camilleri, Chairperson of the Focus Group on Polypharmacy and Chair of the conference, gave the background context of how and why the Office had decided to focus on the issue of polypharmacy and appropriate use of medicines in older persons. She explained that the conference was the result of one year of planning and hard work by a carefully selected multidisciplinary team supported by Office staff. The opening address was delivered by the Honourable Dr Franco Mercieca, Parliamentary Secretary for Rights of Persons with Disability and Active Ageing. Dr Mercieca recognised that whilst modern medications have contributed to higher life expectancies and significantly improved health, there are also associated increased risks in medication use in later life. He welcomed the initiative taken by the Office of the Commissioner since improved medication use in older persons needs to be achieved by educating not only senior citizens themselves about the proper use of drugs but also by providing appropriate training to healthcare professionals who need to keep abreast with continued advancement of prescription practices, and the adverse effects that may result. Improving medication use in later life is one of the key pre-requisites to achieving independence and dignity with advancing age. The keynote presentation on Adverse Drug Reactions in Older People: Tackling the Quiet Epidemic was delivered by Dr Denis O’Mahony, consultant physician and senior lecturer in the Department of Medicine (Gerontology), at University College Cork Medical School and Cork University Hospital, Cork, Ireland. Dr O’Mahony spoke about adverse drug reaction (ADR) epidemiology, causality, and its association with polypharmacy. He analysed inappropriate prescribing and described the use of tools to detect potentially inappropriate prescribing such as the STOPP (screening tool of older persons’ prescriptions) and START (screening tool to alert to right treatment) criteria. Risk factors for older persons include chronic kidney and liver disease/dysfunction, alcohol dependence and inappropriate medication. His take-home messages were that ADRs in older persons represent a major health problem with incidence increasing in tandem with the increasing numbers of older persons and that comorbid illnesses leading to polypharmacy are the main cause of ADRs in old age. Caution is needed in higher-risk medication such as insulin, anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), neuroleptics and sedatives.




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The first set of 3 technical presentations were: (1) Tales of the not so unexpected by Dr Anthony Fiorini, consultant geriatrician at the Rehabilitation Hospital Karin Grech. Dr Fiorini presented 3 vivid case scenarios which depicted the vicious cycle of exacerbation of symptoms brought about by increasing medication to control the same symptoms. (2) Treating the older person: does a magic ball exist? by Prof Janet Mifsud, from the Department of Clinical Pharmacology and Therapeutics within the Faculty of Medicine and Surgery in the University of Malta. Prof Mifsud showed how knowledge of pharmacokinetics and pharmacodynamics can help us determine more appropriate drug dosages and regimens in order to decrease the risk of adverse drug events whilst improving outcomes in older patients. (3) Attitudes and factors influencing prescribing, dispensing and use of medicines in seven European Countries – a comparative study by Dr Dominic Agius, Research Secretary of the Malta College of Family Doctors who conducted the study on behalf of the Mediterranean Institute for Primary Care. (This project was funded by the Seventh Framework Program (FP7) of the OTC SOCIOMED project, Grant Agreement No: 223654) Dr Agius showed that in Mediterranean countries there was an element of social pressure on prescribing/using medicines, a greater consumption and prescription of medicines and a tendency to provide prescription only medicines without prescription. Part 2: Second set of technical presentations The following 4 presentations were made: (1) Raising awareness: decreasing medicine use in increasing age by Ms Alison Anastasi, Assistant Director at the Central Procurement Supplies Unit. Ms Anastasi provided some statistics on the use of a number of medicines identified from the STOPP criteria. (2) Medication review: why, when and how by Ms Marise Gauci, Principal Pharmacist at the Rehabilitation Hospital Karin Grech. Ms Gauci highlighted the fact that medication review should be conducted at every health encounter with the older person for optimisation of drug therapy using evidence based guidelines and prescribing tools such as the STOPP/START criteria.




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(3) The impact of adverse drug effects on nursing and allied health intervention by Ms Rosanne Scerri, Senior Occupational Therapist at the Rehabilitation Hospital Karin Grech. Ms Scerri delivered this presentation which was the product of a joint collaboration of a team of nursing and allied health professionals. The other members on this team were Ms Alexandra Ameen, an Allied Health Practitioner, Speech Language Pathologist at the Rehabilitation Hospital Karin Grech, Ms Angela Caruana, Practice Development Nurse at St Vincent de Paule Residence, and Ms Ingrid Magro , an Allied health Practitioner Physiotherapist. In this presentation the team highlighted the need for a holistic interdisciplinary approach which focuses on the person, regular medication review, and effective communication amongst health care professionals. (4) For medicines you can trust by Dr Patricia Vella Bonanno, from the Superintendence of Public Health. Dr Vella Bonanno highlighted the interplay between the 4 major stakeholders in the pharmaceutical framework, namely the patients and consumers, the healthcare professionals, the policy makers and regulators, and the pharmaceutical industry, and how this interplay should lead to ensure safe and effective medication use. Following this presentation the Honourable Ms Marie Louise Coleiro, Minister for the Family and Social Solidarity delivered a short speech in which she provided the social policy perspective behind the issues concerning medication use in older persons. She supported the high level input of the many professionals involved in caring for older persons and encouraged all present to continue to explore innovative ways of improving the overall welfare of our senior citizens. Interventions from the floor The participants were invited to make interventions three times: (a) following the keynote address, (2) after the first set of presentations, and (3) after the second set of presentations. Interventions made touched upon issues such as:

• The need to buffer the effect of pharmaceutical company advertising by strengthening medical undergraduate and postgraduate education in relevant clinical pharmacology and therapeutics. A concern was raised that students in Health Care Sciences seemed to be receiving more lectures in the area of pharmacology than medical undergraduates.

• Pharmacist-led medication reviews • Strengthening of the IT entitlement database such as for instance to capture pink form

entitlement in addition to Schedule V entitlement • To allow general practitioners to alter dosage and/or switch to alternative medication

without the need to refer to the Schedule V clinic • To improve hospital discharge letters in content, information to the GP/family doctor,

and timeliness • To give GPs/family doctors the possibility to issue delayed prescriptions • To give GPs/family doctors access to a comprehensive patient management IT system




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Part 3: Multidisciplinary Parallel Interactive Work shops Following the lunch break, the audience broke out into 6 parallel workshops as follows: Workshop 1: Frailty , facilitated by Dr Anthony Fiorini and Ms Joanna Chetcuti. Rapporteur: Ms Victoria Masshala Workshop 2: Continence, facilitated by Dr Mark A Vassallo and Ms Antoinette Zahra. Rapporteur: Ms Charmaine Attard Workshop 3: Adherence to medication, facilitated by Dr Bernard Coleiro and Dr Patricia Vella Bonanno. Rapporteur: Prof Maria Cordina Workshop 4: Behavioural and psychological symptoms of dementia, facilitated by Prof David Mamo and Mr Mark Zammit . Rapportuer: Mr Ian Mifsud Workshop 5: Iatrogenesis, facilitated by Ms Marise Gauci, Dr Antonella Sammut and Ms Alison Anastasi. Rapporteur: Dr Peter Ferry Workshop 6: Mobility , facilitated by Dr Dominic Agius and Prof Janet Mifsud. Rapporteur: Ms Clarissa Captur. Each of these workshops presented a case scenario which was then discussed such that each group could provide a multidisciplinary position statement and come up with specific recommendations for action in the fields of health and social policy and services areas. Part 4: Concluding Session In the Concluding Session the rapporteurs from each workshop provided the main issues/themes discussed in the workshop, the group’s multidisciplinary consensus position statement and the actual recommendations for action in the social and health policy and services fields.




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Main issues/ themes discussed in the workshops Although every workshop departed from different case scenarios, there was significant overlap in the main issues/themes discussed in the different workshops. The following is a collation and integration of the various issues/themes discussed in the six workshops. These are presented in boxes in alphabetical order by the identified primary issue/theme. (Some issues or themes have been listed in more than one box). AGEISM 1. Policies/protocols/interventions have to target the patient’s medical condition and level of functionality and not be directly linked to a cut-off age per se (eg frail person, at risk person) ASSESSMENT & SCREENING 2. Need for a comprehensive geriatric team assessment of older patients/persons 3. Screening of frail elderly at risk persons within the community CARE GIVERS 4. Burden on care giver looking after elderly person with or without dementia at home. This is a major social concern and requires social and health support services for the care giver including timely respite services. CARE PATHWAYS 5. The need for establishing clear care pathways especially for (but not limited to) patients in the community with cognitive and behavioural problems. COMMUNICATION, DOCUMENTATION & SHARED INFORMATION 6. The need for improving communication between:

(a) patients and their family doctors (b) doctors and patients (c) doctors and other healthcare professionals (d) healthcare professionals and patients (e) hospital services and community services

7. Access to clinical documentation by the whole interdisciplinary team which spans primary and secondary care. 8. Importance of quality assurance of documentation including electronic case summary, case notes and GP referral notes.




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EDUCATION 9. Increasing prescriber knowledge through education 10. Education – more information INTERDISCIPLINARY & SERVICE BARRIERS 11. Power struggle between different stakeholders in patient care 12. Fragmentation of services – there is little integration of the interdisciplinary team in the community. INTERDISCIPLINARY TEAM APPROACH & COORDINATION OF C ARE 13. Need for a comprehensive geriatric team assessment of older patients/persons 14. Access to clinical documentation by the whole interdisciplinary team which spans primary and secondary care 15. The need for a focal person to co-ordinate treatment. 16. The patient’s GP could be the focal point of the geriatric team. 17. A co-ordinated and responsive outreach programme/rapid access team especially when dealing with older persons exhibiting behavioural and psychosocial symptoms of dementia. NON-PHARMACOLOGICAL INTERVENTIONS 18. The availability and use of non-pharmacological interventions (especially in older persons with behavioural and psychosocial symptoms of dementia) PRIMARY AND SECONDARY CARE CONTINUUM 19. Access to clinical documentation by the whole interdisciplinary team which spans primary and secondary care. SOCIAL SUPPORT & DOMICILIARY SERVICES 20. Social support and the need to improve domiciliary services – a co-ordinated and responsive outreach programme/rapid access team especially when dealing with older persons exhibiting behavioural and psychosocial symptoms of dementia.




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Multidisciplinary Consensus Position Statements: The following are the 6 consensus statements formulated in each workshop: Frail older people are a vulnerable group who should be on a high risk register and who should be ensured screening and comprehensive co-ordinated services including appropriate discharge planning for a safe and seamless transition of care from hospital back into the community. There needs to be more awareness on the consequences of drug-induced incontinence by prescribers and there should be rapid access to a continence service for the elderly including ultra sound facilities at the A&E/health centres/RHKG to exclude urinary retention and avoid unnecessary admission to MDH. In order to improve adherence to medications, there needs to be appropriate patient follow up, a seamless care model to remove hurdles between hospital and primary care and a need for a multidisciplinary community team to address multifaceted patient issues. Improving community services is essential so that people with dementia can live and receive care in their home environment. The excessive use of antipsychotics can be decreased by the availability of out reach services and the use of non-pharmacological strategies. A holistic, accessible, integrated IT system is fundamental for seamless care between the primary and secondary sectors and will help reduce the effect of iatrogenesis and improve medication use in older persons. This should be accompanied by an extension in the provision of community services. Informal care is imperative for older persons with mobility problems. These statements were organised by the Office into one joint Conference Multidisciplinary Consensus Position Statement which appears on the front page of this document.




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Recommendations for action in Social Policy/Services The following is a collation and integration of the various recommendations for action in Social Policy/Services resulting from the workshops. These are presented in boxes in alphabetical order by the identified primary theme. (Some recommendations have been listed in more than one box and may also be repeated in the recommendations for action in Health Policy/Services since some recommendations will require joint collaboration across the two ministries). AT RISK REGISTERS 1. The establishment and maintenance of a community at risk register which includes frail older people. CARE GIVERS 2. Support services should include care giver education and training in the community. 3. More reduced hours, flexitime, job-sharing and other family friendly measures for carers. CARE PATHWAYS 4. Create clear care pathways. EDUCATION & AWARENESS RAISING 5. Increasing education especially towards the younger elderly age group, targeting medications and their side effects. 6. Encouraging a healthy lifestyle including eating habits to prevent constipation – “behind every full bladder there lies a full rectum” (Bernard Isaacs). 7. Campaign on availability of generic medications which should be appropriately priced. 8. Care giver education and training in the community. 9. Patient education and empowerment regarding access to social and healthcare systems. 10. A media campaign using virtual, social, written, visual and sound messages. INTERDISCIPLINARY TEAM APPROACH & COORDINATION OF C ARE 11. Social workers to coordinate various aspects of care and to liaise with the various professionals. 12. Streamlining of services. 13. Creating a rapid access interdisciplinary team for emergency situations. 14. Every member of the team should feel empowered to intervene with the appropriate professional.




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SOCIAL SUPPORT, DOMICILIARY & COMMUNITY SERVICES 15. More structured and intensive home help services tailored to vulnerability and need. 16. Adequate transport to improve access to services in the community eg day centres. 17. Further development of day centre services. 18. Creation of a buddy system with the young old supporting the old old. 19. A proactive continence service which would help in keeping the elderly active in the community. This service should also be involved in the application and provision of incontinence pads. 20. Streamlining of services. 21. Support services should include care giver education and training in the community. 22. Services should be accessible. 23. More investment in community enablement programmes to help the patient return to a more independent state. 24. Support in the community for patients to comply to medication in a better way. 25. Night shelters. 26. More elderly homes. TAILOR-MADE PRODUCTS 27. Accessibility of appropriate medication packs for older persons.




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Recommendations for action in Health Policy/Services The following is a collation and integration of the various recommendations for action in Health Policy/Services resulting from the workshops and earlier interventions from the floor. These are presented in boxes in alphabetical order by the identified primary theme. (Some recommendations have been listed in more than one box and may also have been included in the recommendations for action in Social Policy/Services since some recommendations will require joint collaboration across the two ministries). AGEISM 1. Remove physical and age barriers for access to services for patient and/or care giver. – Treat and support the family together with the patient. CARE GIVERS 2. Provide care giver education and training in the community. CARE PATHWAYS 3. Create clear care pathways. COMMUNICATION, DOCUMENTATION & SHARED INFORMATION 4. Development of electronic prescriptions made accessible to all the different members of the team including GPs, and the POYC and clinical pharmacists. 5. Access to publicly-held electronic patient databases (such as iSOFT, electronic case summaries, etc) by GPs, community teams and pharmacists. 6. Patient registration with GP to facilitate sharing of information between primary and secondary care and avoid fragmentation of care. 7. Better IT system to determine and clarify entitlement – both primary and secondary care should utilise a unified system. 8. To improve hospital discharge letters in timeliness, content, and information to the GP/family doctor. 9. Give GPs/family doctors access to a comprehensive patient management IT system. 10. Wider use of myHealth by health professionals and the public.




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EDUCATION & AWARENESS RAISING 11. Advertising the 24-hour pharmacy service for health professionals provided at Mater Dei Hospital in order to increase the knowledge of this service amongst health professionals so that they could access it when necessary. 12. Campaign on availability of generic medications which should be appropriately priced. 13. A media campaign using virtual, social, written, visual and sound messages. 14. Patient and care giver education and empowerment regarding access to social and healthcare systems. 15. Education of health care professionals 16. Strengthening medical undergraduate and postgraduate education in clinical pharmacology and therapeutics. INTERDISCIPLINARY TEAM APPROACH & COORDINATION OF C ARE 17. Specialised geriatrics clinics / health teams in the community. 18. Timely interdisciplinary geriatric team involvement. 19. Every member of the team should feel empowered to intervene with the appropriate professional. 20. Access to computerised records / electronic prescriptions by all the different members of the team including GPs, and the POYC and clinical pharmacists. 21. Crucial role of clinical pharmacists and allied health care professionals within the geriatric health team. 22. Clinical pharmacist intervention at critical points of the patient’s journey through the health system. 23. Appoint a key support worker. 24. Team to conduct regular medication review. 25. A collaborative approach between healthcare professionals in order to ensure appropriate prescribing and timely treatment reviews (functional status, target symptoms and severity of symptoms) in people exhibiting behavioural and psychological symptoms of dementia. 26. Create a rapid access interdisciplinary team for emergency situations. MAINTAINING CONTINENCE IN OLDER PERSONS 27. Development of a proactive continence service. 28. Development of standard operating procedures for all health care practitioners to adhere to. 29. The continence service should start from the acute sector where initial assessment is the most important. 30. Continence support in the community.




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MEDICATION REVIEW 31. Regular medication review which should also include pharmacist-led medication reviews. 32. Clinical pharmacist intervention at critical points of the patient’s journey through the health system. 33. Antipsychotic treatment should generally not be used as first-line in older persons exhibiting behavioural and psychological symptoms of dementia. Such therapy is associated with adverse effects which can result in a lower quality of life for both the person suffering from dementia as well as for the care giver. 34. A collaborative approach between healthcare professionals in order to ensure appropriate prescribing and timely treatment reviews (functional status, target symptoms and severity of symptoms). NATIONAL DRUG FORMULARY 35. Review of the drug formulary to include better drugs with less adverse drug reactions especially in the elderly including the newer alpha blockers. PREPARATION OF MEDICINES 36. Preparation of medication in adherence aid boxes on a weekly basis by community pharmacists. 37. Use of pill boxes for safe administration. 38. Accessibility of appropriate medication packs for older persons. 39. Appropriate treatment doses for older persons which requires more public/private partnerships with the pharmaceutical industry and suppliers. PRESCRIBING 40. Prescription clinics should be modified to allow for proper patient evaluation and medication review. 41. Encouraging the practice of evidence-based prescribing. 42. Prescribing guidelines are to be made easily available to health care practitioners. 43. Electronic prescribing with alert systems. 44. Electronic systems to alert about drug interactions. 45. To give GPs/family doctors the possibility to issue delayed prescriptions. 46. Allow general practitioners to alter dosage and/or switch to alternative medication without the need to refer to the Schedule V clinic.




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PRIMARY, SECONDARY AND COMMUNITY CARE CONTINUUM 47. Patient registration with GP to enable sharing of information between primary and secondary care and avoid fragmentation of care. 48. Establishment and maintenance of a community at risk register which includes frail older people. 49. Improvement of primary care. 50. Specialised geriatrics clinics in the community / health teams. 51. Specialised geriatrics ward at the acute hospital. 52. Appropriate discharge planning. 53. Clinical pharmacist intervention at least at the point of patient discharge. 54. Timely interdisciplinary geriatric health team involvement. 55. Regular medication review across the continuum which should also include pharmacist-led medication reviews. 56. Services should be made more easily accessible for older persons and patients. 57. More and better integration and streamlining of services. 58. Creating a rapid access interdisciplinary team. 59. Support services should include care giver education and training in the community. 60. Support in the community for patients to comply to medication in a better way. 61. Night shelters. 62. More elderly homes. 63. Minimise risk in patients exhibiting behavioural and psychological symptoms of dementia in secondary care by ensuring good staffing levels, good communication between staff and dementia sufferer and providing opportunities for activities. 64. Better IT system to determine entitlement – both primary and secondary care utilise a unified system. 65. Strengthening of the IT entitlement database such as for instance to capture pink form entitlement in addition to Schedule V entitlement. 66. Allow general practitioners to alter dosage and/or switch to alternative medication without the need to refer to the Schedule V clinic. 67. To improve hospital discharge letters in content, information to the GP/family doctor, and timeliness. 68. Give GPs/family doctors the possibility to issue delayed prescriptions. 69. Give GPs/family doctors access to a comprehensive patient management IT system TAILOR-MADE PRODUCTS 70. Accessibility of appropriate medication packs for older persons.




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Concluding remarks The conference was officially closed with some general observations made by Dr Denis O’Mahony and Dr John M Cachia, Commissioner for Mental Health and Older Persons. Dr O’Mahony made the following recommendations for future action:

1. Remove duplication of services for example, it should be possible for general practitioners to effect changes of medication within an approved protocol;

2. There should be a stronger shift in emphasis from hospital to general practitioner 3. All essential drugs should be government funded 4. Consider mandatory generic prescribing as for example happens in Sweden 5. Invest in preventive gerontology programmes at community level targeted at

decreasing disability, dependency and ultimately cost. Dr John M Cachia then thanked all members of the organising committee, members of staff as well as all conference participants for their contribution to the huge success of the conference. He remarked that of 300 registered participants more than 95% had actually attended, 66% were present for workshops and more than 50% were present for the concluding session. This testifies to the great interest raised and maintained by the Conference throughout the day and was a certificate of quality by attendees. This encourages the Office to organise further conferences in the future.




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PART B: Organisational and statistical information Target Audience The Focus Group set its target audience at 300 healthcare professionals. Contributors to Conference Organisation 34 persons contributed in one or more ways to the success of the conference as shown in the following table:

Pro

fess

ion

Foc

us

Gro

up

on

Pol

ypha

rmac

y in

O

lder

P

erso

ns

Oth

er

Offi

ce

Sta

ff

Spe

aker

s/

pres

ente

rs (

8 +

3

co-a

utho

rs)

Fac

ilita

tors

(2

pe

r w

orks

hop,

ex

clud

ing

W5

whi

ch h

ad 3

)

Rap

port

eurs

(1

pe

r w

orks

hop)

Doctors 5* 1**** 2 (members on the focus group) + 1 keynote speaker

6 (of whom 4 are members on the focus group)

1

Pharmacists 5 0 4 (all members on the focus group)

5 (all members on the focus group)

3

Nurses 1 0 1 was a co-author

1 1

Occupational Therapists

1 0 1 1 (member on the Focus Group)

0

Physiotherapists 0 0 1 was a co-author

0 1

Communications Officer

1** 0 0 0 0

Speech Language Pathologist

0 0 1 was co-author

0 0

Administrative 2*** 4 0 0 0 * 2 doctors on the Focus Group are also Office Staff. One of them was chair of the

Focus Group and also chaired the conference. ** The Communications Officer on the Focus Group is also Office Staff & a Speech

Language Pathologist *** The 2 administrative officers on the Focus Group are also Office Staff **** The Commissioner




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Registrations There were 303 registrations which included the 34 persons who contributed to the organisation of the conference. The effective expected audience was that of 269 participants. Attendance Only 11 registered participants failed to turn up for the event (7 doctors, 2 nurses, 1 podiatrist and 1 administrative (non-medical)). Thus the total effective audience attending the conference was that of 258 participants representing a 96% effective attendance rate. The total attendance rate rises to 96.4% if the 34 persons who contributed to the conference organisation are included in the statistics. Health Care Professions The following table shows the distribution of the participants (excluding the 34 who were involved in the organisation and/or delivery of the event).

Health Care Profession

Number registered

Percentage of all healthcare professions registered*

Number participating

Percentage of all health care

professions participating*

Nurses 142 53 140 54 Doctors 58 22 51 20 Pharmacists 30 11 30 12 Physiotherapists 9 3 9 4 Podiatrists 7 3 6 2 Administrative (non-medical)

6 2 5 2

Social Workers 5 2 5 2 Speech Language Pathologists

3 1 3 1

Midwives 2 1 2 1 Occupational Therapists

2 1 2 1

Pharmacy Technician 2 1 2 1 Clinical Psychologist 1 <0.5 1 <0.5 Trainee Psychologist 1 <0.5 1 <0.5 Scientific Officer 1 <0.5 1 <0.5 All Professsions 269 258 * rounded off




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Background place of work Annex 2 shows the distribution of registered participants (n=269) by profession and place of work. Annex 3 provides totals for the distribution by institution and department. These tables show that there was a wide variation of the place of work of participants. However Rehabilitation Hospital Karin Grech, Residential Homes for the Elderly, St Vincent de Paule Residence, and other Elderly Services accounted for 133 (49%) of registered participants. These 4 institutions accounted for 94 (66%) of all nurses, 15 (26%) of all doctors and 7 (23%) of all pharmacists registered for the conference respectively. Rehabilitation Hospital Karin Grech 50 9 doctors,

7 pharmacists, 28 nurses, 1 occupational therapist, 2 podiatrists, 2 social workers, 1 administrator

Residential Homes for the Elderly 30 28 nurses 1 physiotherapist 1 administrator

St Vincent de Paule Residence 40 6 doctors 30 nurses 3 podiatrists 1 speech language pathologist

Other Elderly Services (Audit & Management Office, Centru Servizz Anzjan, CommCare Assessment Unit)

13 8 nurses 1 midwife 1 physiotherapist 1 occupational therapist 1 social worker 1 administrator




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The following table shows the background place of work of the 58 doctors registered for the conference. Geriatric wards, MCH 1 Gozo General Hospital 2 Health Centres (Gozo, Gzira, Mosta, Mtarfa, Paola/Cospicua, Qormi/Floriana)

8

Mater Dei Hospital 17 (2 A&E, 2 Anaesthesia, 1 cardiology, 1 ophthalmic, 2 paediatrics, 9 unspecified)

Mental Health Services Crisis Intervention 1 Primary Health Care Department 1 Private Family Medicine/General Practice 4 Private Hospital 1 Public Health Medicine 5 (1 Directorate of Health Information &

Research, 1 Directorate of Environmental Health, 1 Infectious Disease Control Unit, 2 Office of the Chief Medical Officer)

Rehabilitation Hospital Karin Grech 9 Retired 1 St Vincent de Paule Residence 6 SPBH 2 (1 oncology, 1 unspecified) The following table shows the background place of work of the 30 pharmacists registered for the conference. Directorate Health Care Standards 1 Mater Dei Hospital 5 Medicines Authority 2 Central Procurement and Supplies Unit 5 Departmental Contracts Committee 1 Mount Carmel Hospital 1 Medicines Entitlement/Pharmaceutical Affairs Directorate

2

Pharmaceutical Companies 2 Rehabilitation Hospital Karin Grech 7 Retail Pharmacies 2 Sir Paul Boffa Hospital 2




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The following table shows the background place of work of the 142 nurses registered for the conference. Audit & Management Office, Department of Elderly

1

CommCare Assessment Unit 7 Gozo General Hospital 2 Health Centres 3 Mater Dei Hospital 28 Mental Health Services 7 Office of the Superintendent of Public Health 1 Practice Development / CPD Unit, Mtarfa 2 Primary Health Care Department 2 Rehabilitation Hospital Karin Grech 28 Residential Homes for the Elderly 28 St Vincent de Paule Residence 30 Sir Paul Boffa Hospital 3 Workshop Statistics: Workshop Preferences The following table shows the first preferences for workshops at registration stage. Persons from the organising committee who attended the workshop as participants were not included in the statistics. Workshop Number of first preferences Percentage of all effective

participants for the workshops

1. Frailty 23 9% 2. Continence 11 4% 3. Adherence to medication 91 34% 4. Behavioural & Pscyhological Symptoms of Dementia

71

26%

5. Iatrogenesis 45 17% 6. Mobility 28 10% All Workshops 269 As this table shows Workshops 3 and 4 were oversubscribed with Workshops 2, 3 and 6 being grossly unsubscribed. An exercise was therefore conducted to reassign persons from among workshops that were oversubscribed to those that were undersubscribed by noting second preferences and where this did not suffice, third preferences.




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Workshop participation The following table provides some statistics as to workshop participation. Persons from the organising committee who attended the workshop as participants were not included in the statistics.

Wor

ksho

p

No

assi

gned

on

first

pr

efer

ence

s (n

o at

tend

ing

WS

)

No

assi

gned

on

seco

nd o

r th

ird

pref

eren

ces

(no

atte

ndin

g W

S)

Tot

al

num

ber

assi

gned

to

w

orks

hop

(no

atte

ndin

g W

S)

Num

ber

of

thos

e as

sign

ed

atte

ndin

g C

onfe

renc

e

Num

ber

of

thos

e as

sign

ed

atte

ndin

g W

orks

hop

Wor

ksho

p P

artic

ipat

ion

Rat

e*

1. Frailty 23 (12) 29 (13) 52 (25) 48 25 52%

2. Continence 11 (5) 27 (7) 38 (12) 37 12** 32%

3. Adherence to medication

52 (35) 0 52 (35) 50 35 70%

4. Behavioural & Pscyhological Symptoms of Dementia

45 (32) 0 45 (32) 44 32*** 73%

5. Iatrogenesis 45 (37) 0 45 (37) 43 37**** 86%

6. Mobility 27 (16) 10 (7) 37 (23) 36 23 64%

ALL WORKSHOPS

202 (137) 66 (28) 269 (165) 258 164***** 64%

* Workshop participation rate = Number of those attending workshop / Number of those assigned to the workshop who attended the conference, expressed as a percentage ** There were a total of 13 persons attending the Continence Workshop as a person who was assigned to Workshop 1 Frailty as his second preference attended this workshop which was actually his 4th Preference *** There were a total of 33 persons attending the Behaviour Workshop as a person who was assigned to Workshop 1 Frailty as her second preference attended this workshop which was her first preference. **** There were a total of 38 persons attending the Iatrogenesis Workshop as a person who was assigned to Workshop 6 Mobility as her second preference attended this workshop which was actually her sixth preference. ***** This total excludes the 3 persons who attended a Workshop which was not assigned to them.




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Workshop participation by professional background The following table provides the distribution of the 167 workshop participants by professional background.

HE

ALT

H

CA

RE

P

RO

FE

SS

ION

1. F

RA

ILT

Y

2. C

ON

TIN

EN

CE

3. A

DH

ER

EN

CE

4. B

EH

AV

IOU

R

5. IA

TR

OG

EN

ES

IS

6. M

OB

ILIT

Y

ALL

WO

RK

SH

OP

S

Nurses 13 9 22 23** 11*** 8 86(51%) Doctors 3 4* 2 2 14 4 29(17%) Pharmacists 7 7 2 7 6 29(17%) Physiotherapists 1 1 4 6 (4%) Podiatrists 3 1 4 (2%) Administrative (non-medical)

2 2 (1%)

Social Workers 1 1 2 (1%) Speech Language Pathologists

1 2 3 (2%)

Midwives 0 Occupational Therapists

1 1 (<1%)

Pharmacy Technician

2 2 (1%)

Clinical Psychologist

1 1 (<1%)

Trainee Psychologist

1 1 (<1%)

Scientific Officer

1 1 (<1%)

ALL PROFESSIONS

25 13* 35 33** 38*** 23 167

* 1 person chose to attend the Continence Workshop (4th preference) although he had been assigned to Workshop 1 Frailty as his second preference.

* 1 person chose to attend the Behaviour Workshop (1st preference) although she had been assigned to Workshop 1 Frailty as his second preference.

* 1 person chose to attend the Iatrogenesis Workshop (6th preference) although she had been assigned to Workshop 6 Mobility as her second preference.




24

The above table shows that the distribution of professions who remained for the workshops was very similar to that for the attendance of the whole conference. The table below shows the workshop participation rate for each of the professions attending the conference. Health Care Profession Number

participating in Conference

Number participating in

Workshops

Workshop participation rate

(%) Nurses 140 86 61 Doctors 51 29 57 Pharmacists 30 29 97 Physiotherapists 9 6 67 Podiatrists 6 4 67 Administrative (non-medical)

5 2 40

Social Workers 5 2 40 Speech Language Pathologists

3 3 100

Midwives 2 0 0 Occupational Therapists 2 1 50 Pharmacy Technician 2 2 100 Clinical Psychologist 1 1 100 Trainee Psychologist 1 1 100 Scientific Officer 1 1 100 ALL PROFESSIONS 258 167 65% Evaluation The analysis of the feedback provided by participants in the evaluation forms will be made available in a separate report. ____________________________ ___________________________ Dr J M Cachia Dr Miriam Camilleri Commissioner Chair, Mental Health & Older Persons Organising Committee &

Focus Group Polypharmacy in Older Persons

improving medication use in older persons ... - health · chaired by a consultant in public health...

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