Medication reviews for people with intellectual disability are a key tool in addressing an access gap in an underserved population, writes Manya Angley
The authors of a recent systematic review examining processes and outcomes of clinical medication review (CMR) in community-settings in Australia concluded that CMRs are effective in optimising a range of clinical outcomes, including disease-specific endpoints and hospitalisations, and highlighted the importance of addressing access gaps in underserved populations. (1)
It is estimated that 2.9% of Australians live with an intellectual disability (ID). (2) People with developmental disabilities (DD) usually have an ID and constitute a population vulnerable to experiencing medication misadventure because of their complex presentations and that they may see a variety of medical practitioners and other health professionals, which can result in multiple medicines being added to their regimens without an overview or review of their medicine-related needs as a whole.
There is evidence that psychotropic medications are commonly used, singly and in combination, in DDs, for example autism spectrum disorder (ASD) and its co-occurring conditions, despite minimal evidence of the effectiveness or appropriateness of psychotropic polypharmacy. (3)
Further, given that conventional medicines are mainly used to address symptoms, and don’t address core issues, complementary and alternative medicine (CAM) products may be used, especially in children with DDs, where rationale for use and /or efficacy is often not established for the condition.
In addition, the potential for CAMs to interact with other medicines exists and the long-term safety and tolerability have not been established. (4, 5)
Since 2010, a key activity within my private consultancy has been to provide medication reviews for people with ID. With respect to optimising medicine use, many medication management issues are the same as for people without disability.
The focus of this piece is to highlight where management differs from the general population.
Pharmacists need to understand how to work with a person with ID to provide quality medication management services.
The Centre for Developmental Disability Health Victoria has produced excellent resources, including a fact sheet that outlines strategies for providing good health care to people with ID. (6) In particular they highlight the importance of being respectful, provide tips on optimising communication and not overlooking health promotion and prevention.
Another valuable resource to support pharmacists conducting medication reviews for this population is the Therapeutic Guidelines: Management Guidelines Developmental Disability. (7)
The referrals I receive for medication reviews in people with ID are usually:
- to determine a current comprehensive medication history (including CAM product use);
- to establish a history of medicine use and reason for discontinuation of agents to inform the client’s GP, psychiatrist and/or other specialist to select future pharmacotherapeutic options; and/or
- difficult and extreme situations where a client’s behaviour presents major challenges to their support workers and/or themselves.
Typically I will peruse progress notes, care plans, comprehensive medical assessments and other documentation to gain a background regarding medical and social history when I may focus on development of behavioural issues.
Wherever possible I engage with the person with ID, their family members and other support people involved in their care which may include staff from non-Government organisations (NGO) and Government disability services.
I will also endeavour to meet with the client’s GP and/or practice nurse to discuss their medication management concerns and obtain relevant laboratory tests and, if necessary, liaise directly with their psychiatrist.
As with medication reviews in the aged care sector, deprescribing can be a focus of medication reviews in people with ID of all ages.
The usual deprescribing process should be followed which include an overall review of medications; identification of potentially inappropriate medications that could be ceased, substituted or reduced; prioritisation of the order in which medication changes should occur; engaging with patients and carers regarding implementation of the deprescribing plan and provision of continuous monitoring, review and support in a manner analogous to medication prescribing. (8)
When undertaking deprescribing, it is important to acknowledge that there are patients who may continue to derive benefits from medications on an ongoing basis and the overarching goal should be always be quality use of medications.
Another focus is to highlight the importance of monitoring physical health and adverse effects when people with ID are prescribed antipsychotics. In these scenarios I direct prescribers to the Women’s and Children’s Health Network (WCHN) antipsychotic monitoring package (9), if patients are children or adolescents, and to the National Prescribing Service antipsychotic monitoring tool (10) if patients are adults.
Recent research by Davis et al. (11) highlights how a medication reviews can also be an opportunity to provide intensive and individualised education to people with ID regarding device use to improve medication-related outcomes.
Davis’ article examined inhaler technique mastery in people with ID with asthma, as well as the educational interaction with a health professional. At baseline none of the 17 participants were able to use their inhalers properly.
However, when standard modules of inhaler technique training were individualised to address the unique cognitive barriers that exist in people with ID, they demonstrated a significant proportion could be trained to mastery.
The authors also concluded that inhaler technique training should also be extended to caregivers of people with ID and/or support persons.
My experiences over the past five years have revealed that pharmacists can make a significant contribution to a multidisciplinary team providing care to people with ID and ultimately optimise a range of clinical and psychosocial outcomes in this underserved population.
Appropriately skilled pharmacists can currently deliver their unique services during a medication review and funded via existing remuneration processes. Alternative models need to be explored such as pharmacists working in a primary care setting where multi-disciplinary care is delivered to people with ID.
There is a dire need for further research exploring this expanded scope of pharmacists’ practice as well as for a specialised training program to be developed and implemented where pharmacists are exposed to working with people with ID and are appropriately mentored.
- Jokanovic N, Tan EC, van den Bosch D, Kirkpatrick CM, Dooley MJ, Bell JS. Clinical medication review in Australia: A systematic review. Research in social & administrative pharmacy : RSAP. 2015 Jul 9. PubMed PMID: 26250049.
- Australian Bureau of Statistics. How many people have intellectaul disability? : Australian Bureau of Statistics; 2014 [cited 2015 November 17]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4433.0.55.003Main%20Features102012?opendocument&tabname=Summary&prodno=4433.0.55.003&issue=2012&num=&view=.
- Spencer D, Marshall J, Post B, Kulakodlu M, Newschaffer C, Dennen T, et al. Psychotropic medication use and polypharmacy in children with autism spectrum disorders. Pediatrics. 2013 Nov;132(5):833-40. PubMed PMID: 24144704. Pubmed Central PMCID: 3813388.
- Semple S, Hewton C, Paterson F, Angley M. Complementary Medicine Products Used in Autism – Evidence for Rationale, . In: Williams T, editor. Autism Spectrum Disorders – From Genes to Environment: Intech; 2011.
- Semple S, Hewton C, Paterson F, Angley M. Complementary Medicine Products Used in Autism – Evidence for Efficacy and Safety. In: Williams T, editor. Autism Spectrum Disorders – From Genes to Environment: Intech; 2011.
- Centre for Developmental Disability Health Victoria. Working with people with intellectual disabilities 2015 [cited 2015 November 17]. Available from: http://www.cddh.monash.org/assets/documents/2015/working-with-people-with-intellectual-disabilities.pdf.
- Therapeutic Guidelines Limited. Management Guidelines for Developmental Disability. Melbourne: Therapeutic Guidelines; 2012.
- Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA internal medicine. 2015 May;175(5):827-34. PubMed PMID: 25798731.
- Ellis D, Angley M. WCHN Antipsychotic Physical Health and Adverse Effect Monitoring Package Adelaide: Women’s and Children’s Health Network; 2015 [updated May 2015; cited 2015 November 17]. Available from: http://www.wch.sa.gov.au/services/az/other/pharmacy/antipsychotic.html.
- National Prescribing Service. Antipsychotic monitoring tool Surry Hills: Natonal Prescribing Service; 2012 [cited 2015 November 17]. Available from: http://www.nps.org.au/__data/assets/pdf_file/0015/130326/NPS_Antipsychotic_Monitoring_Tool.pdf.
- Davis S, Durvasula S, Merhi D, Young P, Traini D, Bosnic-Anticevich S. The ability of people with intellectual disability to use inhalers – an exploratory mixed methods study. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015 Sep 12:1-8. PubMed PMID: 26365005.
Manya Angley is a pharmacist and the director of Manya Angley Research & Consulting.