Managing Medication for those with a dementia

[John Greene]

JPG1 - really useful comments, many thanks

I'll relay your comments to some of the councils I work with. I thought this "we only give from blister packs" stance had mostly disappeared over the last few years (I used to hear this when I first started training care workers 10 years ago).

I'll pick this point up with the councils I work with and include this in the training we give to home care agencies (we provide training for eight councils on the south coast and london). The council who have commissioned this training have recognised that there is a problem, hence they have picked certain agencies to administer (not just prompt) meds for clients with a dementia).

We recommend "DOLOPLUS-2"

http://www.doloplus.com/pdf/3V_DOLOPLUS_GB.pdf

as a pain assessment scale in dementia but there are others out there.

I'll use your 'leaving meds out in plastic pots' as a case study (I'm amazed they even tried it!)

Many thanks for taking the time to write this all up

[jenniferpa]

Just a word of warning, some of the stories you may hear in response to this question may be several years old. My own "3 weeks to get a blister pack filled" lead time occurred in 2006 so this may not be a current problem.

[John Greene]

Point noted - I tend to use these things as discussion points, so that would be okay.

One question - did anyone find that oral syringes were a problem for giving oral liquids? There could be the risk that people think they are about to receive an injection?

[JPG1]

Your “DOLOPLUS-2” would fox the SWs too, let alone the nursing staff in the care home. They just could not handle the language used.

Afterthoughts, and I'll add dates, so as to validate timescales:

Plastic pots: we only found out about it when a plastic pot arrived at the day centre on a day when we visited the day centre too (that would be in 2007); it emerged – and was full of all those other meds that had been “prompted” but not taken. So they’d all been carefully placed into the one pot. There was a little sticker on the top “For you to take later”. Back at the flat, we found a "neatly stored pile of pots" in the bedside cabinet.

The Agency workers that you train may also be the same agency workers who work in care homes too: it was actually the nurses who had a problem with medications (2007-2008).

Oral syringes + aspiration pneumonia. In the care home (2007-2008). Used by nurses to introduce fluids into someone with swallowing difficulties. They have since received training, and the practice has been “banned” in that particular care home, and in every care home in the LA, and under that particular care home provider.

My story is dated 2006 right through to 2008 and then into 2009, from when the problems first emerged to when I became heavily involved in removing some of the ‘unsafe’ customs.

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[John Greene]

Thanks JPG1

We provide training for doloplus-2. You're right, in that it doesn't make alot of sense unless there's some training behind it. It is being used in some of the care homes, but it would be a push to get paid home carers to use it (as they are 'in and out').

That's an interesting point about oral syringes. I've come across them being stoped in care homes due to choking risk. They need to be used with care (max 2mls then wait until someone has swallowed, don't jam into side of cheek). I can see why this might cause problems with a dementia.

I think if there are swallowing difficulties, it's safer to use a spoon (or squirt the syringe onto the spoon - as most people only pour 4mls onto a 5ml spoon as it needs to be a 'heaped' spoon). Speech and langauge therapists often make this point.

Much appreciated

[JPG1]

The care home "nurses" introduced over 1.5 litres of fluids in one 24-hour period, using a syringe. (December 2007)

I did ask whether they had used a bicycle pump, when I read the volume of fluids they had introduced.

Another thought:

I know that it is illegal to test the English-language skills of doctors or nurses or (presumably) support workers, who have come from 'other parts of the world' to work in the health/care services.

Do you think these same untested-for-language-skills people should in fact be in charge of medication prompting/administrating?

I forgot to mention earlier: the small/independent/not-related to a footware company - but still overworked - Pharmacist involved in our case actually delivered the blister packs to the flat. And he worked out the exact time to deliver. Bless him!

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[Izzy]

I talked to a lady from the Princess Royal Trust for Carers yesterday and she mentioned a system called 'NOMAD'. I think it might be a system where the pharmacy sorts the pills out for my mother into morning afternoon evening but I'm not sure about it.

[John Greene]

Izzy - The NOMAD system uses a hard plastic tray with compartments. Your mother will still need to have an awareness of time/day of the week. Also, there may be some meds that couldn't be packed in there (moisture sensitive tablets). However, they can be useful for keeping track of what has been taken (or at least removed from the pack).

[jenniferpa]

Originally Posted by John Greene

Izzy - The NOMAD system uses a hard plastic tray with compartments. Your mother will still need to have an awareness of time/day of the week. Also, there may be some meds that couldn't be packed in there (moisture sensitive tablets). However, they can be useful for keeping track of what has been taken (or at least removed from the pack).

Can I just ask - maybe I'm reading too much into what you said here, but does this mean that moisture sensitive tablets could be packed in the pharmacy prepared blister packs?

[John Greene]

It depends on the drug. The best person to ask is the manufacturer (best to get the Pharmacist to ring on your behalf).

The nomad trays are sealed as are the 'blister pack' versions (these are collectively termed "monitored dosage systems" or MDS packs. Some drugs which we thought couldn't go into an MDS pack, can (even if it's just for 7 days). Some maunfacturers play it safe and say "we've not tested them in an MDS pack, therefore as we've no data we can't recommend this". But recently I'm aware that some manufacturers are starting to be more helpful and give out an opinion or have even done some testing in the MDS packs.

Perhaps ask the pharmacist if they'd be willing to phone the manufacturers again for each drug.

[nellbelles]

Difference..

Carers here can only prompt medication from a Dosette box..

On admittance to hospital, everything must be in the original packaging.

Understand that nurses cannot give medication that they are not certain of, but only one ward would allow me to be responsible for administration of my husbands medication. The other ward was just happy that no medication was given, rather than use their common sense.

Thanks for your interest in this situation

[danny]

Good morning John,I employ around 80 support workers down in cornwall.We have a policy of using blister packs only,this is mainly for the safety of our service users.As you mentioned many councils contract very short sessions of care,if carers are rushing,mistakes will be made.The commissioners are looking at using automated medication reminders!With regards to a training tool for medication support for people with dementia I think is a fantastic idea,when you have completed the work let me know,would you come to cornwall to deliver this course.I think it is worth bearing in mind that support workers have very different educational needs,they are in this role because they care,if they had bundles of qualifications they would be in better paid work.I trained as a nurse many moons ago,we spent months on learning about medication,we expect our carers to learn this in a 2 day workshop!Some carers also may have difficulty reading bottles and packets,another reason why blister packs are safer.Regards,Angela.

[danny]

Forgot to mention,before you deliver any medication training for carers looking after people living with a dementia make sure they have had training in understanding dementia.Believe it or not,many carers have not!NVQs in dementia care are coming next year.

[John Greene]

Helen - This 'carers can only prompt' or 'carers can only give from a dosette pack' attitude is difficult for carers and the agencies. Many of the agencies I work with no longer take this stance and will adminster from original packs. If you pay for the agency yourself (100%) then talk to the manager to see if there is any leeway

If the home care is partly council funded the care agency may just be following the council's medication policy. To be fair on these councils, they don't always get the funding from 'health' to pay for training etc.

In my experience the best avenue for help, is to get in touch with the 'medicines management team' at your local Primary Care Trust (a job I did previously) and talk to them about supporting the council with funding/training (however, I would say that as a training provider!) to allow carers to administer from original packs. In the NHS, we find patient power to be one of the greatest drivers for change.

I would be greatly interested (maybe a separate thread needs to be started) to gather data on those areas of the country where this policy of "we only prompt from dosette (MDS) packs" applies. I could then talk to some at the Alzhiemer's Soc about meeting jointly meeting with the PCTs and doing this work on other's behalf (although I would still say use your own 'patient power' first).

Helen, can I ask? what area of the country you are having these problems?

[John Greene]

Angela - I hear you when you say that blister packs can be safer (although I know of three staff who failed to check the patient name on the pack!). As always it comes down to funding (of which there is little), and the 15min calls you often have imposed on you. Although I would say, that as liquids are often easier to take for some people with a dementia, would that mean that you couldn't adminster them? What if you had some meds in the blister pack and others in orginal packs?

There is a gap between using only blister packs for safety, and the needs of those with dementia (and their non paid carers). I think this gap is caused by a lack of funding and training (and I know that the margins are tight for home care agencies).

I can talk about delivering this training in Cornwall. Before the carers will access this course, they will be getting 2 days training in Dementia from another company using the Skills for Care Knowledge Set for Dementia. Contact me privately (click on my name to send a private message) and we can chat on Monday if needs be.