Welcome []...Patient views Spectrum of dysphagia ‘I don’t have difficulty swallowing every day....
Transcript of Welcome []...Patient views Spectrum of dysphagia ‘I don’t have difficulty swallowing every day....
Welcome
Prescribing medicines for patients with dysphagia
DAVID WRIGHT
PROFESSOR OF PHARMACY PRACTICE
COPYRIGHT UEA 2016
Presentation
Dysphagia aetiology & prevalence (Survey)
Patient & professional opinions (Interviews and focus groups)
Dysphagia & medicines practice (Observation)
Medicines administration in dysphagia (Science bit)
Recommendations (Protocol)
Definitions‘Dysphagia’◦ Physical problem with swallowing
◦ Stroke
◦ Dementia
◦ Parkinson’s disease
◦ Huntingdon’s chorea
◦ Gastro Oesophageal Reflux Disease
◦ Ageing
‘Swallowing difficulty’◦ ‘Dysphagia’
◦ ‘Psychological aversion to swallowing tablets’
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DysphagiaCauses difficulties with◦ Social life
◦ Nutrition & hydration
◦ Medicines administration
Associated with Aspiration Pneumonia
Pneumonia most common cause of death in
◦ Parkinson’s disease
◦ Dementia
National UK survey 2002Regional care home nurse training days
540 nurses response to:
‘Frequency of crushing medicines’
Wright D. Medication administration in nursing homes. Nursing standard 2002; 16(42): 33-8.
Healthcare professional viewsSpectrum of dysphagia
‘Parkinson’s patients and epileptic patients, we know if they don’t get their medication their swallowing is going to get worse’
Medicine formulation
‘I suspect its really the compliance problem with those having great difficulty swallowing their medication probably once they are out of our sight.. don’t!’
Information transfer
‘we don’t know our medication, we don’t have the medical knowledge and the pharmaceutical knowledge to know drug forms and how they can be modified..’
Kelly J, Wright D. A qualitative study of the problems surrounding medicine administration to patients with dysphagia. Dysphagia 2009;24(1):49-56
Patient viewsSpectrum of dysphagia
‘I don’t have difficulty swallowing every day. Sometimes it’s OK..’‘..knowing that this is the last chore before going to sleep..’
Medicine formulation
‘Horrible, they really are!’
‘It’s the chalky texture. If they were all like Gabapentin, and other torpedo-shaped tablets that I take, that would be brilliant’
Information exchange
‘My GP has not asked if I have problems taking my medications… hospital X manages my medicines… they (the GP) just provide repeat prescriptions’
Kelly J, Wright D. A qualitative study of dysphagic patients' experiences of taking medication. Journal of Advanced Nursing. 2009; 66(1), 82–91
Observation of ward rounds4 hospitals, 8 wards
2129 drug administrations observed◦ 817 had an error◦ 313 involved patients with dysphagia
Administration errors◦ Patients with dysphagia 21.1%
◦ Patients without dysphagia 5.9% (p<0.001)
◦ Increases with enteral tubes (p<0.001)
Administrator was last line of defence
Kelly J, Wood J, Wright D. Medication administration errors in secondary care older person’s wards: A multi-centre observationalstudy. Journal of Advanced Nursing: 67(12), 2615–2627.
Wrong preparation 65 preparation errors including:
◦ 2.5mL of Oramorph™ measured using cup
◦ Inappropriate syringes used via enteral tube
◦ Frequent non-flushing of enteral tubes
◦ 26 cases of mixing different medicines together before dispersing
Kelly J, Wright D. An analysis of two incidents of medicine administration to a patient with dysphagia. Journal of Clinical Nursing. September 2010.
Wrong formulation8 patients inappropriately chewing their medicines such as Dipyridamole Modified Release◦ Dysphagia not previously identified
Tablets crushed in 24 cases◦ All without the prescriber’s written authorisation
◦ Seven cases alternative licensed liquid formulation available
◦ 19 cases the tablets could have been more appropriately dispersed in water
Dose omissions due to dispersing medicines and leaving them
Critical Incident analysis 9.30am Nurse W dispersed the sachet of Calfovit D3 in water and added Thick and
EasyTM to produce pudding consistency as prescribed by the dietician.
Added 30 mL of Calogen and administered the mixture to patient.
Nearly finished administering the Calfovit D3 / Calogen mixture, Nurse W added the 20mL of Docusol™ and continued to give it to Patient, who started to refuse to take the medicine as the last mouthful was given.
Whilst still at Patient’s bedside, Nurse W also dispensed the other four due medicines.
Critical Incident analysis Dispensed two ordinary paracetamol tablets into a medicine cup with two Sinemet-110™
tablets and a dispersible aspirin.
A second medicine cup used to measure out 3mL of rivastigmine, before locking the two
medicine cups in the patient’s bedside medicine cupboard.
At 10.10, having completed the rest of the drug round, Nurse W returned to Patient. She
removed the two medicine cups from his locker, added water to the cup containing the
paracetamol, Sinemet-110™ and dispersible aspirin.
When the tablets had dispersed she added Thick and Easy™ to produce a pudding
consistency, poured in the rivastigmine from the other pot, and gave the mixture.
Potential errorsEffect of mixing medicines is unknown,
Effect of adding thickening agents to medicines unknown
Mixing of two licensed medicines, where one is not a vehicle for the administration of the other, is “manufacture”
Dispersing non-dispersible paracetamol tablets
Dispersed Sinemet-110 tablets given over two hours late.
Inaccurate measuring 3mls of rivastigmine with a measuring cup
◦ significant proportion of the drug not being administered as it remained in the cup
Observation in care homes•738 administrations
•166 residents• 38 (22.9%) Dysphagia
•Medication administration error• 57.3% patients with dysphagia
• 30.8% patients with dysphagia
• P<0.001
Serrano Santos M, Wright D, Poland F, Longmore T. Medication administration for residents with dysphagia in care homes: A small scale observational study. International Journal of Pharmaceutics Feb 22, 2016.
Swiss cheese model
Dysphagia prevalent condition in older persons
Frequently not communicated to prescriber
Likelihood of errors significantly increased
oPoor administration practices
oUnstandardised approaches
oNew errors introduced
oIllegal practices
Culture which allows lots of minor errors will result in a major error
Administration of medicines
Dysphagia◦ Aspiration
◦ Asphyxiation
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The swallowing process
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Normal Swallow
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Parkinson’s swallow
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Swallow with aspiration
InterventionsAlternative non-oral formulations◦ Patches, suppositories
Liquid medicines◦ Less likely to block the pharynx
◦ If too runny can cause aspiration
◦ Need to be ‘Gloopy’ in consistency
Crushing or dispersing medicines
Percutaneous Endoscopic Gastrostomy or Jejunostomy tubes (PEG or PEJ)
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Alternative formulations
Alternative routesPatches◦ Pain control, hormones, smoking cessation
Suppositories◦ Pain control, laxatives
Buccal◦ Anti-nausea drugs, angina and migraine treatments
IV Administration◦ Impractical, costly and introduces infections
Liquid medicinesoPalatable
oKnown consistency
oDose standardisation
oStable
oDesigned for dysphagia
Liquid medicine considerationsTexture & taste
Licensed
◦ Long shelf life
◦ Agreed national price
Unlicensed
◦ Quality
◦ Certificate of compliance (Followed formula)
◦ Single supplies
◦ Certificate of analysis (Confirmed contents)
◦ Batch specials
Cost
◦ Tariff & non-tariff
Crushing or dispersing medication
The beautiful tablet
Plus• Enteric coats• Film/Sugar coats• Modified release mechanisms
TabletsIngredients selected to minimise interactions with active ingredient◦ Should not be crushed/dispersed and mixed together
Compressed to control release rate◦ Crushing/dispersing increases peak effects
Unaltered minimal contact of active with tongue◦ Crushed increase surface area of active
Drug Absorption
Modified release absorption
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Modified release crushed
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Enteric coatingsRelease at higher PH◦ To protect stomach
◦ To protect the medicine
◦ To deliver medicine to appropriate location
Remove coating◦ Cause adverse drug reaction
◦ Reduce medicine efficacy
Film or sugar coatings
To mask flavour
◦Quinine
To protect from skin sensitisation
◦Chlorpromazine
To protect from environment during storage
SafetyCrushing or dispersing can expose administrator to harm
◦ Skin sensitisation or rash
◦ Co-danthrusate
◦ Chlorpromazine
◦ Cytotoxics
◦ Methotrexate
◦ Hormonal products
◦ Misoprostol
◦ Finasteride
◦ Tamoxifen
LiabilityCrushing or dispersing medicines outside of license
Prescriber authorised unlicensed medicine use
Liability for harm for any unlicensed medicine lays with prescriber and administrator
Preferable to ◦ Record decisions to administer medicines in unlicensed manner with rationale
◦ Provide some form of written authorisation
Advice before tampering
Ask pharmacist◦ Aware of coatings and their rationale
◦ Aware of alternative options
◦ Able to comment on liquid consistency
Check reference sources◦ Information frequently not evidence based
Obtain authorisation
Record decision making process
Enteral Feed Tubes
Enteral feed tubesDesigned for administration of food and liquid
◦ Foods and liquids designed for feed tubes
Not designed for medicines
◦ Medicines not designed for feed tubes
◦ > 5 medicines 4.8 x risk of blockage
◦ > 13 doses/day 5.3 x
◦ > 10 days 2.6 x
Heineck, I., D. Bueno, and J. Heydrich, Study on the use of drugs in patients with enteral feeding tubes. Pharm World Sci, 2009. 31(2): p. 145-8.
Enteral feed tubesMost administrations unlicensed
◦ Liquid formulations currently being licensed
Primary concerns
◦ Blockage
◦ Feed interactions
◦ Drug stability
Recommendations
RecommendationsIdentify swallowing problem◦ Observe medication administration rounds
◦ Ask about dysphagia & chewing
Review medicines
Consider formulation / route
Tablet crushing/dispersing last resort◦ Introduces unexpected errors
◦ Custom and practice -> errors
Authorise anything process which is unlicensed
Wright D. Swallowing difficulties protocol: Medication administration. Nursing Standard 2002;17(no.s 4-15):43-5.
Further resourceswww.swallowingdifficulties.com
Future learn free access Massive On-line Open Course on ‘Medicines administration in dysphagia’
‘Pharmaquest’ APP for Apple and Android
◦First 25 medicines information cards free
Thanks for listeningANY QUESTIONS?