Background (age, sex, occupation, baseline function)

  • 57-year-old female
  • Nursery manager

History of presentation/reason for review

  • Family and friends have commented on memory problems over last six months, for example, goes to shop and forgets what is needed. Reviewed by psychiatry, short-term memory impairment

Current medical history and relevant co-morbidities

  • Problems with memory for approximately six months
  • Low mood – two years
  • Brain injury due to road traffic accident four years ago

Current medication and drug allergies (include OTC preparation and herbal remedies)

  • Diazepam 5mg one tablet twice daily if needed for anxiety. Ordering 56 tablets every month, but states taking as required. Prescribed for longer than two years
  • Allergies: states ‘bad reaction to fluoxetine’ – unclear symptoms

Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity

  • Ex-smoker
  • Alcohol – approximately 10 units/week

“What matters to me” (patient ideas, concerns and expectations of treatment)

Results e.g., biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

  • All blood tests within normal ranges (U&Es, LFTs, FBC, B12, folate, ferritin, TFTs, bone profile)
  • Mini-Mental State Exam 26/30 – normal cognition
  • Addenbrooke’s Cognitive Examination 96/100 - normal cognition

Most recent relevant consultations

Four months prior to review

  • Attending physiotherapy for neck pain with good effect. Has managed to stop ibuprofen and will aim to reduce diazepam use

 

7 Steps: Person specific issues to address for case study

1.  Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

  • Therapeutic objectives of drug therapy
  • Management of existing health problems
  • Prevention of future health issues, including lifestyle advice
  • Ask individual to complete Patient Reported Outcomes Measures (PROMS) before the review

Person specific actions

  • Wants to improve memory problems
  • Diazepam: minimise actual and potential medication related harms

 

2.  Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice*)

  • Drugs that have essential replacement functions
  • Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific actions

  • None

 

3.  Does the patient take unnecessary drug therapy?

Identify and review the continued need for drugs

  • what is medication for?
  • with temporary indications
  • with higher than usual maintenance doses
  • with limited benefit/evidence for use
  • with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific actions

  • Review need for diazepam – anxiety for more than two years. Takes 10mg daily regularly. Consider need for ongoing treatment and discuss a tapering plan, as may not be suitable to stop immediately

 

4.  Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

  • to achieve symptom control
  • to achieve biochemical/clinical targets
  • to prevent disease progression/exacerbation
  • is there a more appropriate medication to achieve goals?

Person specific actions

  • Discuss non-pharmacological methods to help mood and wellbeing
  • Plan to stop diazepam which may cause/worsen memory impairment

 

5.  Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

  • appropriate individual targets
  • drug-disease interactions
  • drug-drug interactions (see ADR table)
  • monitoring mechanisms for high-risk drugs
  • risk of accidental overdosing

Identify adverse drug effects by checking for

  • specific symptoms/laboratory markers
  • cumulative adverse drug effects (see ADR table)
  • drugs used to treat side effects caused by other drugs 

Medication Sick Day guidance

Person specific actions

  • Diazepam – lack of efficacy? Questionable effects? May be contributing to anxiety, and causing short-term memory impairment

 

6.  Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

  • considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

  • Inhaler use
  • Single use plastics
  • Medicines waste
  • Water pollution 

Person specific actions

  • All medicines are formulary choices
  • Patient advised to dispose of medicines through community pharmacy
  • Advised patient to only order what is needed, do not stockpile medicines

 

7.  Patient centeredness: Is the patient willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

  • Consider teach-back
  • Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

Ensure drug therapy changes are tailored to individual’s preferences. Consider

  • is the medication in a form they can take?
  • is the dosing schedule convenient?
  • what assistance is needed?
  • are they able to take medicines as intended?

Agree and communicate plan

  • discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
  • include lifestyle and holistic management goals
  • inform relevant health and social care providers of changes in treatments across the transitions of care

Ask individual to complete post-review PROMS questions after their review

Agreed plan

  • Go slow and low reduction of diazepam. Planned reduction schedule discussed and agreed
  • Diazepam to reduce by 1mg every four weeks with follow-up reviews as agreed and need
  • Prescription to be supplied as special request (acute) with planned reduction steps recorded in clinical notes

 

Key concepts in this case

  • Diazepam and other benzodiazepines/z-drugs can worsen memory impairment and anxiety symptoms
  • Reducing long-term diazepam use and dose can help to minimize avoidable medicine related harms
  • Long-term diazepam therapy may require a gradual dose reduction prior to stopping

  

Click on the table image to view a PDF version of the full 7 steps table for memory management case study.

Image of table showing details of 7 steps for case study 3