Search

Healthy ageing is a global priority. Polypharmacy (the use of 5+ medicines) amongst older people is increasing, with over one-third of adults in England, aged 80-89, prescribed at least eight medications. Although sometimes necessary, polypharmacy can be harmful; the risk of harm increases with age and number of medicines prescribed. Medication reviews are recommended as one way of reducing the potential harms of polypharmacy although evidence of clinically significant benefit of medication reviews as currently delivered is limited. What happens in medication reviews in practice is poorly understood. We used a linguistic ethnography approach to explore how medication reviews proceed and what is accomplished during these consultations. We studied 18 video-recorded medication review consultations from three general practices in England. The consultations involved patients aged 65 or older, prescribed 10+ medications ('higher risk' polypharmacy), and primary care clinicians (general practitioner or clinical pharmacist). Video-recordings were gathered as part of a wider ethnographic study investigating practices of polypharmacy in primary care between 2017 and 2021. We conducted microanalysis of consultation data, drawing on our ethnographic knowledge of the organisational, institutional and domestic contexts of polypharmacy to inform our interpretation of these interactions. Consultations were time-consuming and involved lengthy stretches of interactional trouble: non-understandings; misunderstandings; misalignments. These stretches revealed profound uncertainties as to the effectiveness of medicines in the context of multimorbidity and polypharmacy. These uncertainties seeped further into 'troubles talk' concerning patients' existential concerns relating to enduring illness, ageing and mortality. Although these existential concerns were partially articulated, clinicians and patients left such troubles talk unelaborated, unresolved and unfinished. Participants succeeded in smoothing over interactional difficulties and maintaining respectful relationships but often fell short of addressing problematic polypharmacy more directly., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Polypharmacy is a growing and major public health issue. It can be burdensome and risky for patients and costly to healthcare systems. Older adults and those from ethnic minority backgrounds are disproportionately affected by polypharmacy. This study focuses on medication practices among Urdu-speaking Pakistani patients, a significant ethnic group in the UK. Most existing research on medication practices within South-Asian communities centres on adherence, leaving the social and moral dimensions of polypharmacy unpacked. Understanding how British Pakistani patients understand and manage polypharmacy in the context of their daily lives is crucial to avoiding harmful polypharmacy., Methods: In-depth narrative interviews were conducted with 15 first-generation Pakistani patients using the Biographical Narrative Interview Method. Participants were recruited from GP practices in East London. All participants were prescribed ten or more regular medications (a pragmatic marker of 'higher risk' polypharmacy) and were aged over 50. Interviews were conducted with a bilingual researcher at home and were designed to elicit narratives of patients' experiences of polypharmacy in the context of their biographies and daily lives., Results: Polypharmacy is enacted through networks of interpersonal and socio-material relationships. The doctor-patient relationship and the family network held particular significance to study participants. In addition, participants described emotional bonds between themselves and their medicines, identifying them as 'forces for good'-substances which allowed them to maintain their health through the intercession of God. Meanings attributed to medicines and enacted through these social, emotional, and spiritual relationships contributed to emerging and sustaining polypharmacy., Conclusions: Patients make sense of and manage treatments in culturally specific ways. Developing an understanding of how medication practices in different communities are enacted is important for informing meaningful and effective conversations with patients about their medicines. Our findings contribute to enabling the integration of culturally sensitive approaches to prescribing., (© 2023. The Author(s).)

Background: Polypharmacy is an important safety concern. Medication reviews are recommended for patients affected by polypharmacy, but little is known about how they are conducted, nor how clinicians make sense of them. We used video-reflexive ethnography (VRE) to: illuminate how reviews are conducted; elicit professional dialogue and concerns about polypharmacy; invite new transferable understandings of polypharmacy and its management., Methods: We conducted 422 hours of fieldwork (participant observation), filmed 18 consultations between clinicians and patients receiving 10 or more regular items of medication (so-called 'higher risk' polypharmacy) and played short clips of film footage to 34 participants (general practitioners, nurses, clinical pharmacists, practice managers) in seven audio-recorded reflexive workshops. Our analysis focused on 'moments of potentiation' and traced clinicians' shifting understandings of their practices., Results: Participants rarely referenced biomedical aspects of prescribing (eg, drug-drug interactions, 'Numbers Needed to Treat/Harm') focussing instead on polypharmacy as an emotional and relational challenge. Clinicians initially denigrated their medication review work as mundane. Through VRE they reframed their work as complex, identifying polypharmacy as a delicate matter to negotiate. In patients with multimorbidity and polypharmacy it was difficult to disentangle medication review from other aspects of patients' medical care. Such conditions of complexity presented clinicians with competing professional obligations which were difficult to reconcile. Medication review was identified as an ongoing process, rather than a discrete 'one-off' activity. Meaningful progress towards tackling polypharmacy was only possible through small, incremental, carefully supported changes in which both patient and clinician negotiated a sharing of responsibility, best supported by continuity of care., Conclusions: Supporting acceptable, feasible and meaningful progress towards addressing problematic polypharmacy may require shifts in how medication reviews are conceptualised. Responsible decision-making under conditions of such complexity and uncertainty depends crucially on the affective or emotional quality of the clinician-patient relationship., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Polypharmacy is on the rise. It is burdensome for patients and is a common source of error and adverse drug reactions, especially among older adults. Health policy advises clinicians to practice medicines optimisation -a person-centred approach to safe, effective medicines use. There has been little research exploring older patients' perspectives and priorities around medicines-taking or their actual practices of fitting medicines into their daily lives and how these are shaped by the wider context of healthcare., Methods and Analysis: We will conduct an in-depth multisite ethnographic case study. The study is based in seven clinical sites (three general practices and four community pharmacies) and includes longitudinal ethnographic follow-up of older adults, organisational ethnography and participatory methods. Main data sources include field notes of observations in the home and clinical settings; interviews with patients and professionals; cultural probe activities; video recordings of clinical consultations and interprofessional talk; documents. Our analysis will illuminate the everyday practices of polypharmacy from a range of lay and professional perspectives; the institutional contexts within which these practices play out and the sense-making work that sustains-or challenges-these practices. Our research will adopt a 'practice theory' lens, drawing on the sociology of organisational routines and other relevant social theory guided by ongoing iterative data analysis., Ethics Approval: The study has HRA approval and received a favourable ethical opinion from the Leeds West Research Ethics Committee (IRAS project ID: 205517; REC reference 16/YH/0462)., Dissemination: Aside from academic outputs, our findings will inform the development of recommendations for practice and policy including an interactive e-learning resource. We will also work with service users to co-design patient/public engagement resources., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Tackling problematic polypharmacy is a global health safety priority and is likely to require a multifaceted approach. UK health policy hinges around the potential of medication reviews, but deprescribing in medication reviews is uncommon and evidence on how to harness their potential is sparse. Methods: Storytelling Group, a design-led methodology, was used to invite experts-by-experience ('story-creators') to re-imagine the medication review. We facilitated three 2-h workshops with seven story-creators, aged 65+ with experience of polypharmacy and an interest in identifying ways of safely reducing medications. Participants collaboratively built fictive scenarios, creating characters, chronology, contexts and plots, identifying touchpoints and incorporating personal experience. Provocative prompts ('What ifs?') aided story development. Results: Participants created five rich fictional narratives, featuring protagonists affected by polypharmacy and medication reviews involving new and different professionals, roles and contexts. Storytelling Group enabled experts-by-experience to use their knowledge of current medication review practices as their motivation to inspire novel imagined arrangements. This speculative exercise, deliberately crafted to distance participants from current realities, enabled them to share insights and propose new possibilities to address polypharmacy. The process revealed a range of tacit assumptions regarding the roles of healthcare professionals, patients, medications, the health system, and their inter-relationships. Only two of the five narratives they co-constructed involved deprescribing, neither in conventional clinical settings. We then curated a prototype collection of seven fictional short stories ('Let's Talk Differently About Medicines') which we refined through user-experience testing. Conclusions: Our study is an empirical exploration of a design-led methodology which may be adapted for application in healthcare improvement when the phenomenon being addressed is sufficiently complex as to escape easy articulation or resolution. [ABSTRACT FROM AUTHOR]

Contemporary health services are primarily designed around single diseases. People with multimorbidity (multiple long‐term health conditions) often become burdened by accumulated treatments. Through multimodal fieldwork in a socially disadvantaged London borough, we explore how people living with multimorbidity navigate conditions of 'chronic crisis', encompassing ill‐health, overmedicalisation, polypharmacy and social exclusion. Participants in our study frequently experience 'existential stuckness', exacerbated by processes of social exclusion. We argue that diagnoses and treatments should account for people's unique aetiologies, and prioritise the notion of 'flourishing' over 'cure' as the absence of disease is not always achievable. To foster this emphasis on flourishing, we advocate for a dialogical turn in diagnostic processes that better support patients' existential needs in the context of long‐term illness. [ABSTRACT FROM AUTHOR]