Dementia, medication and transitions of care

Abstract

Persons with dementia (PWD) often have complex medication regimens and are at risk of medication problems during the multiple transitions of care experienced as the condition progresses.
To explore medication processes in acute care episodes and care transitions for PWD and to make recommendations to improve practice.
Semi-structured interviews were conducted by two pharmacy researchers from a focused purposive sample of fifty-one participants (carers, health professionals, Alzheimer's Australia staff) from urban and rural Australia. After written consent, the interviews were audio-recorded then transcribed verbatim for face-to-face interviews, or notes were taken during the interview if conducted by telephone. The transcripts were checked for accuracy by the pharmacy researchers. Thematic analysis of the data was undertaken independently by the two researchers to reduce bias and any disagreements were resolved by discussion.
Themes identified were: medication reconciliation; no modified planning for care transitions; underutilization of information technology; multiple prescribers; residential aged care facilities; and medication reviews by pharmacists. Sub themes were: access to appropriate staff; identification of dementia; dose administration aids; and staff training.
Medication management is sub-optimal for PWD during care transitions and may compromise safety. Suggested improvements included: increased involvement of pharmacists in care transitions; outreach or transitional health care professionals; modified planning for care transitions for individuals over 80 years; co-ordinated electronic records; structured communication; and staff training.
Copyright © 2015 Elsevier Inc. All rights reserved.

Full text

Original Research
Dementia, medication and transitions of care
Louise S. Deeks, B.Sc.(Hons.), P.G.Dip.Pharm.Prac.
a,
*,
Gabrielle M. Cooper, Ph.D.
a
, Brian Draper, M.D.
b,c
,
Susan Kurrle, Ph.D.
d,e
, Diane M. Gibson, Ph.D.
f
a
Discipline of Pharmacy, Faculty of Health, University of Canberra, ACT 2601, Australia
b
School of Psychiatry, University of NSW, Sydney, Australia
c
Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Sydney, Australia
d
Faculty of Medicine, University of Sydney, Sydney, Australia
e
Rehabilitation and Aged Care Service, Hornsby Hospital, Sydney, Australia
f
Faculty of Health, University of Canberra, ACT 2601, Australia
Abstract
Background: Persons with dementia (PWD) often have complex medication regimens and are at risk of
medication problems during the multiple transitions of care experienced as the condition progresses.
Objectives: To explore medication processes in acute care episodes and care transitions for PWD and to
make recommendations to improve practice.
Method: Semi-structured interviews were conducted by two pharmacy researchers from a focused
purposive sample of fifty-one participants (carers, health professionals, Alzheimer’s Australia staff) from
urban and rural Australia. After written consent, the interviews were audio-recorded then transcribed
verbatim for face-to-face interviews, or notes were taken during the interview if conducted by telephone.
The transcripts were checked for accuracy by the pharmacy researchers. Thematic analysis of the data was
undertaken independently by the two researchers to reduce bias and any disagreements were resolved by
discussion.
Results: Themes identified were: medication reconciliation; no modified planning for care transitions;
underutilization of information technology; multiple prescribers; residential aged care facilities; and
medication reviews by pharmacists. Sub themes were: access to appropriate staff; identification of
dementia; dose administration aids; and staff training.
Conclusions: Medication management is sub-optimal for PWD during care transitions and may
compromise safety. Suggested improvements included: increased involvement of pharmacists in care
transitions; outreach or transitional health care professionals; modified planning for care transitions for
individuals over 80 years; co-ordinated electronic records; structured communication; and staff training.
Ó2015 Elsevier Inc. All rights reserved.
Keywords: Older people; Dementia; Pharmacy; Transitions of care; Medication
* Corresponding author. Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce ACT 2601,
Australia. Tel.: þ61 2 6201 2254; fax: þ61 2 6201 5727.
E-mail address: louise.deeks@canberra.edu.au (L.S. Deeks).
1551-7411/$ - see front matter Ó2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.sapharm.2015.07.002
Research in Social and
Administrative Pharmacy j(2015) j–j

Introduction
Persons with dementia (PWD) may be pre-
scribed medication for dementia or for their co-
morbidities. Problems with activities of daily
living, a decreased capacity for decision-making,
confusion, disorientation, communication prob-
lems and reliance on carers make managing
medication challenging for PWD.
PWD in Australia is predicted to increase from
266,574 in 2011 to 942,624 in 2050.
1
PWD are
more likely to be admitted to hospital – annually
more than 25% of PWD have hospital admis-
sions, compared to 12% without dementia.
2
The
rise in prevalence of dementia, the associated
risk of hospital admission and the vulnerability
of PWD highlights the importance of understand-
ing hospital admissions and other care transitions
for PWD,
3
particularly as they relate to medica-
tion management.
Care transitions are associated with medication
problems. Research suggests that 12.5% of pa-
tients have a medication-related adverse event
after hospital discharge.
4
Unintentional medica-
tion discrepancies,
5
preventable adverse drug
events,
4
poor selection of medication, no discharge
summary and supply problems
6
have been identi-
fied in care transitions that have not focused on de-
mentia. These problems can be detrimental to
patient safety and thus may lead to hospital read-
missions.
4
As PWD are a vulnerable group of the
population, specific dementia-friendly strategies
for medication management to ensure safe, high
quality transfer of care are therefore important.
To date there has been limited investigation of
this issue, particularly in Australia.
Health care, and the roles of community and
hospital pharmacists in Australia have been
described previously in this journal.
7,8
Briefly,
Australian citizens can obtain free treatment in
public hospitals and free or subsidized general
practitioner (GP) appointments via universal
health insurance, ‘Medicare’.
7
Community phar-
macy in Australia has mainly a supply role with
other services negotiated as part of the Commu-
nity Pharmacy Agreement.
7
Hospital pharmacists
in Australia provide a clinical pharmacy service in
addition to their supply role whereas the role of
the hospital pharmacy technician is usually
limited to supply.
8
This research aims to explore medication pro-
cesses that occur during acute care episodes and in
care transitions for PWD in Australia and to
make recommendations to improve patient care.
Method
In this qualitative study two researchers (LD,
GC) conducted in-depth semi-structured interviews
on topics concerning medications and care transi-
tions for people with a diagnosis of dementia. A set
of seeding questions (see Appendix 1) was used;
however, the conversation was allowedto flow freely
so as to explore issues important to participants.
The participants were a focused purposive
sample of stakeholders from acute and primary
care from four sites, each a region. The fifty-one
participants (#1 to #51) comprised carers, hospital
doctors, nurses (specialist aged care, transitional,
hospital, aged care/respite facilities), pharmacists
(hospital, transitional and community), hospital
occupational therapist, GPs and Alzheimer’s
Australia staff (see Appendix 2). Forty-nine of
the interviews were face-to-face and two were by
telephone. There was one urban site in the Austra-
lian Capital Territory (ACT) (capital city, popula-
tion served 350,000) that recruited 20 participants,
two urban sites in New South Wales (NSW) (ma-
jor city, populations served 313,000 and 205,000)
that recruited 12 and 7 participants and one rural
site in NSW (coastal, population served 35,000)
that recruited 12 participants.
After written consent, the interviews were
audio-recorded then transcribed verbatim for
face-to-face interviews, or notes were taken during
the interview if conducted by telephone. The
transcripts were checked for accuracy by the
researchers (LD, GC) who conducted the inter-
views. LD and GC worked independently on
thematic analysis to reduce any bias. The inter-
view text was read several times by the pharmacist
researchers (LD, GC). The analysis was an
iterative process conducted by reading through
the transcripts, adding codes to the data and then
linking the codes to identify emerging themes that
described the content of the data. Any disagree-
ments were resolved by in-depth discussion and
negotiated consensus.
Human Research Ethics Committee approval
was obtained from: University of Canberra; ACT
Government Health Directorate; and South
Eastern Sydney Local Health District – Northern
Sector (with three Site Specific Assessments).
Results
Thematic analysis identified six themes and
four sub themes (see Table 1). These are described
in the following text with comments italicized.
2Deeks et al. / Research in Social and Administrative Pharmacy j(2015) 1–11

Medication reconciliation
On admission to hospital medication reconcil-
iation (obtaining and verifying a complete and
accurate list of current medication then resolving
discrepancies between the list and medication taken
by the patient)
9
is important for informed clinical
decision making. This is difficult for PWD because
they may lack capacity, their carers may not be pre-
sent, and they may have not brought medication
into hospital. GP medication lists can be used to
obtain a list of current medication but these can
be inaccurate. The reasons for this include: medica-
tion not being updated in the GP database; patients
having multiple GPs; there may be additional
specialist prescribing; and previous inaccurate
discharge information. Regular community phar-
macists were acknowledged as the most reliable
source of a patient’s current medication.
The doctor [GP] will just print off. They don’t do
data cleaning, so it will all come in. And often we
do find things that are charted that really the pa-
tient isn’t on anymore. (#24 hospital pharmacist)
[The Community Pharmacist is] Most accurate,
that’s where I would go. (#4 hospital pharmacist)
Reliance on hospital pharmacists to perform
medication reconciliation, or any task, is compro-
mised by lack of access due to restricted working
hours in our study hospitals (usually Monday to
Friday) and variability of pharmacist services
between hospitals. This leads to nurses and other
allied health care professionals taking on
medication related roles.
Occupational therapists get a bag .[of] the
[discharge] medications, and you’ve got to sort it.
(#10 occupational therapist)
No modified planning for care transitions
Identification of PWD and other cognitive
impairments in the hospital was cited as chal-
lenging, especially where patients were not in
Geriatric Medical Wards. Suggestions included
cognitive screening at admission, more individuals
trained to screen for cognitive impairment, blan-
ket modified planning for older people and using
an above bed symbol to alert staff that there are
cognitive issues.
I suspect in other parts of the hospital [away from
Geriatric Medical Wards] there’s less awareness of
dementia – people more likely to have dementia
that’s either not diagnosed or is really ignored in
terms of prescribing, and people are told things in
the expectation they will remember, whereas they
clearly won’t. (#13, hospital doctor)
There was a symbols project done in a small town
somewhere in New South Wales on a cognitive
symbol above the bed, which didn’t alert the person
.but other staff would go in and go, “right,
okay.” (#16, carer)
After discharge from hospital medication from
hospitals in addition to existing supplies from
community pharmacies can cause misadventure,
especially where generic switching occurs. This
was not a problem in the rural site where
discharge medication was supplied by the pa-
tient’s usual community pharmacy. Other solu-
tions suggested were systems that use ‘green bags’
to transfer medications between care settings,
using patient’s own medication in hospital and
self-administration in hospital.
They come out on a generic medication of every
single medication they were on plus extras and
they end up completely bewildered and over-
whelmed and they go, “I’ll just not take any of
it.” (#11 community pharmacist)
People should start to self medicate in the hospital
especially rehabilitation units. (#3 specialist aged
care nurse)
We want them [medication from home] to get put in
the big, green plastic bags and we’ve just finished
installing all the patient’s own medication cupboards
in all the ward areas, and the idea is it gets trans-
ferred between wards. (#4 hospital pharmacist)
Insufficient quantities of medication supplied
from hospital can cause issues. Problems occur if
the patient isn’t well enough to attend or cannot
get an appointment with the GP or if the GP
hasn’t received the discharge information.
Table 1
Themes and sub themes identified
Themes Sub themes
Medication reconciliation Access to appropriate staff
No modified planning
for care transitions
Identification of dementia
Dose administration aids
Staff training
Access to appropriate staff
Underutilization of
information technology
Multiple prescribers
Residential aged care
facilities
Staff training
Access to appropriate staff
Medication review by
pharmacists
3Deeks et al. / Research in Social and Administrative Pharmacy j(2015) 1–11

3 or 5 day appointment with the GP comes up;
some of them are tired and they cancel it, and so
then what can happen is they revert back [to pre-
admission medication]. (#3 specialist aged care
nurse)
Discharge planning is difficult in public hospi-
tals due short lengths of stay. This leads to
patients not being allocated sufficient counseling
time prior to discharge. It is more challenging
when the discharge is outside of usual working
hours without a carer.
At 5 pm with 3 pages of discharge medications, new
initiations of warfarin .they are actually really
unsafe discharges. (#4 hospital pharmacist)
Problems with the accuracy or appropriateness
of the hospital discharge medication information
provided to GPs were identified. There can be
difficulty establishing whether changes to medica-
tion are intentional. Discharge information can lack
explanations for medication changes causing prob-
lems for ongoing patient care. Respondents linked
this to the responsibility for writing discharge
medicationsusually falling to the most junior person
on the team often with a limited exposure to the
patient and the care aims. In the one rural site fewer
issues were reported and a contributory factor was
thought to be the role hospital pharmacists have
writing discharge medication summaries on that
site. There was support for discharge medication
changes being sent to community pharmacies to
facilitate follow up but this rarely occurs.
The person who knows the patient least well is
writing the instruction manual for further treat-
ment. (#35 general practitioner)
Something has been ceased on the ward, and they
have actually got it on their discharge summary
or vice versa they’ve started it and it hasn’t been
put on. (#39 liaison pharmacist)
A method to facilitate individuals to manage
their own medication or be supported by carers is
using a dose administration aid (DAA). In our
study these were blister pack DAAs containing
tablets or capsules dispensed into a weekly pack
with four dosing times per day. There was support
for DAAs from carers and nurses. DAAs are not
without problems, such as no assessment of ability
to use DAAs occurring, expense, error potential,
ongoing monitoring, and the safety of DAAs from
central packing locations.
She got the pack from Queensland, so it’s got when
to take it and you’ve got the days. As long as you
start on the Monday, it’s a great help for her and a
great help for me too. (#19 carer)
You do need to have a .fairly high degree of
cognition to work out what days, what dates and
then .be able to push the medications [out].
(#10 occupational therapist)
A dementia client, she had a build up of 6. Why
would you keep delivering? (#38 transitional
nurse)
Discharges where the patient will be reliant on
paid carers to monitor medication require more
liaising and planning. This includes assessment of
the need for carers, early notification of expected
date of discharge to enable engagement of services
and alteration of dosing schedules to facilitate
prompting of medication. There were issues
around communication with medication related
care package providers during care transitions for
PWD.
It might take a package provider three days to get
carers back into the home. (#16 carer)
Merge all the meds together so they’re one time a
day, and then you can get a paid carer to go in and
support. (#16 carer)
Good practice centered on individual cham-
pions with good communication networks. These
included workers that supported PWD post hos-
pital discharge, during hospital admission and in
avoiding hospital admissions. Within each hospi-
tal there were clinical nurse consultants to support
PWD. Two of the sites had a community liaison
pharmacist and these can be utilized to support
PWD by conducting medication reviews to ensure
patients receive appropriate medication during
care transitions.
Underutilization of information technology (IT)
Participants expressed frustrations with IT
systems. There are multiple unlinked systems
(for example in emergency departments, mental
health, hospital wards, GPs, pharmacies) leading
to data not being shared. An example where this
causes patient harm is during a medication-related
admission where this information is not trans-
ferred to all hospital systems so is unavailable
leading to the prescribing of this unsuitable
medication again. Restricted access to IT systems
was described. This can mean that some informa-
tion relevant to patients cannot be shared, for
example, their cognitive state or their correct
4Deeks et al. / Research in Social and Administrative Pharmacy j(2015) 1–11

medication. This causes harm where the hospital
pharmacist has agreed a medication change to the
discharge prescription with the ward doctor but
only the doctor can alter the GP discharge
communication. If the ward doctor does not
activate this change, the GP will receive incorrect
information.
If we identify an error in that discharge prescrip-
tion .we say to the doctor, you’ve got to go
back and change the discharge summary .it
probably in reality never happens. (#40 hospital
pharmacist)
Multiple prescribers
Multiple prescribers are associated with prob-
lems during care transitions. It was reported that
little information was shared between private and
public hospitals. Treatment delays have occurred
because the communication method from special-
ists to the GP is a letter. Care coordinating
advocates were suggested as a solution. IT was
cited as an area where improvements could be
made with support for a mandatory electronic
health care record with automatic updating every
time medication changes are made.
If everybody has an electronic record coded to their
Medicare number .every time you as the phar-
macist changes it or me as the doctor changes it,
that automatically quickly alters it. (#12 hospital
doctor)
Residential Aged Care Facilities (RACFs)
Medication problems were identified between
acute care and RACFs. The RACFs require
specific documents to give medication. RACF
staff commented about lacking or inaccurate
information received from hospitals whereas hos-
pital pharmacists had difficulties with the variable
clerical and clinical requirements from different
RACFs. In an urban site, a GRACE CNC
(Geriatric Rapid Acute Care Evaluation Clinical
Nurse Consultant) is employed. One of the
GRACE roles is to ensure that medication infor-
mation is transferred between RACFs and hospi-
tal. There was also support for standardized
information transfer in a ‘yellow envelope’ or bag.
[after hospital discharge] Go through all this .
phoning, faxing, faxing, phoning and then get a de-
livery [of medication]. That’s what holds up the
administration of medication. And it could be 24,
48 hours perhaps longer [before medication can
be administered]. (#42 RACF nurse)
Some information – bowels, aperients, photocopied
medication sheets. In yellow envelope. (#50
specialist aged care nurse)
Training was raised in the context of RACFs
as a proportion of the workforce has limited
training relating to medications. A number of
respondents from RACF commented on negative
attitudes to dementia that may adversely influence
the quality and safety of patient management
generally, and particularly during care transitions.
Training could help to change these attitudes.
I said to the [RACF] staff it’s really important that
he’s having his LasixÔthey weren’t able to demon-
strate that they understood. (#5 chronic care
nurse)
They [GPs] look at aged care and the related
problems, dementia included, as fairly tedious,
boring, a waste of time. (# 42 RACF nurse)
Medication reviews by pharmacists
Pharmacists can interact with GPs with regards
to care transitions within two government-funded
schemes – the Residential Medicines Management
Review (RMMR) and the Home Medicines Review
(HMR). Accredited pharmacists have undertaken
specific training to conduct this enhanced role.
There was support for RMMRs from RACFs.
Issues with HMRs included that the patient is
unknown to the accredited pharmacist so there is
no rapport or knowledge of the patient’s history
compared to the regular community pharmacist or
GP. Older patients may not be receptive to HMRs
because they have more confidence in doctors than
pharmacists.
In hospitals the pharmacists do the reviews, they
then put the pressure on the doctors. In Aged
care we don’t have those professionals. (#41
RACF nurse)
Generationally, they trust their doctors. They
won’t trust a pharmacist to the same degree. (#16
carer)
Discussion
Medication management for PWD is sub-
optimal. Errors in prescribing and administration
compromise safety and therefore will add signif-
icantly to community, hospital and residential
care costs.
10
The lack of an ongoing systematic
approach to achieve a high quality medication
communication process during care transitions
for dementia is a clinical governance issue.
5Deeks et al. / Research in Social and Administrative Pharmacy j(2015) 1–11

Despite the absence of a systematic approach,
there were local examples of specialist transitional
staff such as aged care services in emergency team
(ASET) nurses, dementia clinical nurse consul-
tants and GRACE nurses who were advocating
for PWD, although they may not have been
involved in all care transitions due to cost or
availability.
11
Furthermore, their focus was
broader than medication issues. Utilization of
pharmacists, the health care professional specif-
ically trained in medication, could achieve better
outcomes,
6
but their involvement in care transi-
tions is variable.
12
Pharmacists can support PWD during care
transitions in various ways. These comprise medi-
cation history taking on admission, medication
reconciliation,
6,9,13
assisting with medication
adherence, discharge counseling,
6
information-
sharing with community pharmacies,
5
preparing
interim RACF medication administration charts
14
and conducting post-discharge follow-up such as
telephone calls or visits which may include an
HMR or RMMR.
6,15
There have not been studies
specifically examining HMRs for PWD, but for
older people medication reviews at home in the
post-discharge period reduce the risk of re-
admission to hospital
15,16
so a similar benefit for
PWD can be anticipated. The current study re-
corded reservations about HMRs by carers and
general practitioners so initiatives to adopt post-
discharge HMRs should be accompanied by a me-
dia campaign to promote acceptance amongst the
medical profession and the general public.
The most comprehensive pharmaceutical tran-
sition care model described in the literature is
pharmacist transition co-ordinators.
6
These phar-
macists supply medication-management sum-
maries from hospitals to primary care providers,
complete a comprehensive medication section on
the discharge summary, arrange timely medica-
tion reviews by accredited community pharma-
cists and participate in case conferences with
GPs.
6
Pharmacist transition co-ordinators have
demonstrated that they improve health outcomes
for patients transferred from hospitals to RACF
6
so may be expected to be beneficial for all PWD
in any care transition. The pharmaceutical transi-
tion care model more widely adopted in Australia
however is the community liaison pharmacist.
These pharmacists visit patients at home post-
discharge and have demonstrated that they can
improve continuity of care.
17
Two of the four
sites studied have a community liaison pharma-
cist; we advocate that all public hospitals consider
employing pharmacist transition co-ordinators or
community liaison pharmacists to support PWD.
Using patients’ own medication and self-
administration schemes in hospitals has been
advocated as an initiative to reduce medication
issues following transition from hospital for
PWD. Benefits of using patients’ own medication
include decreased wastage of medicines, more
patient counseling and better continuity of care,
but concerns about risk and increased staff
workload have limited implementation.
18
There
are similar concerns about staff workload and
risk of harm for inpatient self-administration
schemes, but this is offset by evidence that medica-
tion adherence issues can be identified by self-
administration for older patients who were
planning to manage their own medicines post-
discharge.
19,20
Research into the risks and benefits
of such schemes in PWD should be encouraged.
Structured communication for a comprehen-
sive clinical handover with respect to medication
can be achieved by completing care pathways that
are shared in a timely fashion with all care
providers. A standardized patient transfer form
may assist with the communication of advanced
directives and medication lists to identify ceased,
omitted or indicated medications.
21
Recognition of PWD is required for medica-
tion management to be modified appropriately.
Identification and communication of dementia
diagnosis was poor in our study hospitals. Previ-
ous research recorded that dementia was docu-
mented in medical notes for less than half of
admissions in NSW hospitals.
11
Increased
screening for dementia in hospital together with
a positive result triggering an above bed visual
alert may be useful. A visual cognitive impairment
identifier was well received in Victoria as part of a
hospital-wide educational package to identify de-
mentia and modify care accordingly.
22
An alterna-
tive in the interim is that medication management
in hospitals is modified to be dementia friendly for
all individuals over 80 years. This age threshold is
suggested because dementia prevalence increases
with age being above 12% at 80–84 years.
1
Identifying an accurate medication record is a
momentous challenge during care transitions; and
this challenge could be addressed by better use of IT
across the different sectors. At the time of this
study, health services in NSW were in the early
stages of adopting systems such as e-referral and
e-discharge
23
which should eventually facilitate ac-
curate transfer of medication information between
health care providers. Disappointingly the early
6Deeks et al. / Research in Social and Administrative Pharmacy j(2015) 1–11

evidence for improved safety following implemen-
tation of e-discharge
24
and electronic medication
management systems
25
is equivocal. The ease of
use of these systems has been acknowledged to limit
effectiveness
24,25
and further refinements to IT are
required for potential to be realised.
Development of user-friendly electronic sys-
tems that link hospitals with GPs, specialists with
GPs, RACFs with hospitals and community
pharmacies with hospitals are essential to improve
medication management during care transitions.
Electronic summaries (eHealth records) of an
individual patient’s health information, giving
health care providers access to patient informa-
tion such as medications, test results, discharge
summaries and allergies
26
have the potential to
resolve the medication problems. Individuals lack-
ing capacity can nominate an authorized represen-
tative to manage the record on their behalf. To
date, there has been poor uptake of the eHealth
record in Australia by both health care providers
and consumers.
Regulatory bodies and research has identified
that more dementia training is required.
27–30
Various modes of training delivery have been
described that include online,
31
DVDs,
30
didac-
tic
22
and paper-based.
30
Training appeared to
improve job satisfaction,
22
staff knowledge
28,29
and confidence
22,28
but it is unclear whether they
improved clinical outcomes or contained a medi-
cation component. The prospects of success are
surely greater when staff training needs are acces-
sible and inclusive of non-clinical staff.
The inferior health care service provided
outside of normal working hours seems to
contribute to medication management issues dur-
ing care transitions. Limited service by out-of-
hours GPs has been linked to higher hospital
admissions from RACFs in the United
Kingdom.
32
ASET is an NSW initiative that
aims to facilitate better care and management of
older people in ED by referring to appropriate
hospital or primary care services.
11
ASET health
professionals have positive effects on patient care
during care transitions but is limited by part-
time working.
11
The international standard time
frame for medication reconciliation is within
24 hours
33
of admission but many hospitals do
not have 7 day pharmacy services. Although
medication reconciliation should occur after a
transition of care to a RACF,
34
the time frame
is unclear. Specifying that medication reconcilia-
tion should occur within 24 hours of admission
to RACF would necessitate increased health
professional input into RACFs. Increasing service
provision by these key health care professionals in
primary and acute care should improve medica-
tion management for PWD.
Strengths and limitations
This qualitative study recruited a diverse range
of participants from four different sites, including
major urban environments and a rural site. The
results however may not be generalizable because,
although there were four sites, the study was
conducted only in two Australian states. There
may also have been a selection bias, as the partic-
ipants already have a commitment to dementia.
The investigators were concerned that the method
of data collection was not consistent because two of
the interviews were conducted by telephone due to
the unavailability of these participants during the
site visits. This may have affected the responses due
to the different communication dynamic between
the researcher and the participant.
It was disappointing that PWD were not re-
cruited, as ACT law prevents individuals that lack
capacity from participating in research.
35
This rai-
ses complex ethical questions in terms of protecting
vulnerable groups but also the right of vulnerable
groups to have their voices heard in research.
Despite these limitations, this is a compara-
tively large study and is the first to examine
medication processes in acute care episodes and
care transitions with a focus on dementia.
Conclusion
There is scope to improve medication processes
in acute care and care transitions for PWD. It is
suggested here that pharmacists be routinely
involved in care transitions with utilization of
pharmacist transition co-ordinators or community
liaison pharmacists. There should be structured
communication pathways that include routine in-
formation provision to hospitals, general practice,
community pharmacies and RACFs. Modified
planning for all individuals over 80 years can be
implemented in conjunction with adoption of bet-
ter strategies to identify PWD. The results of this
study suggest a need for automatic updating of
medication information whenever changes are
made on an electronic health care record that is
accessible to all relevant practitioners. Addition-
ally, dementia training for staff would be highly
beneficial. These recommendations would help to
achieve safe care transitions rather than the
7Deeks et al. / Research in Social and Administrative Pharmacy j(2015) 1–11

observed reliance on individual champions or
random chance.
Acknowledgment
This project has been funded by the Dementia
Collaborative Research Centre – Assessment and
Better Care, University of New South Wales as
part of an Australian Government Initiative. We
would like to thank all the participants for their
valuable insights into this topic.
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Appendix 1
Semi-structured interview questions for medication management and dementia in the acute care sector and during care
transitions research
Health care professionals:
(a) Can you describe your professional involvement in managing medication for patients with a diagnosis of dementia?
(e.g. policy, direct supervision or identification of harm)
(b) Within your area of practice, can you tell me how information about medicines is provided on transfer to another
setting for patients with dementia?
(c) What systems exist to avoid prescribing medicines that have previously caused harm? Comment on the effectiveness
of this process.
(d) Who is informed of a patient’s hospital discharge in primary care? Who do you think should be informed? And how?
Comment on the effectiveness.
(e) Comment on the processes that inform other members of the health care team in the community about medication
related problems.
(f) Comment how planning around medication changes are shared with primary care providers?
(g) What issues, if any, limit the optimization of medication plans in hospital?
(h) How is information about medication changes given to patients with a diagnosis of dementia? What mechanisms are
there to provide this information to informants (spouse, child, sibling, friend, carer)?
(i) Have you ever recommended a home medicines review by a pharmacist or GP? What prompted you?
(j) Can you identify any systems that work well?
(k) Can you suggest any improvements?
(l) Is there anything else you would like to tell me?
Patients and informant (spouse, child, sibling, friend, carer):
(a) Can you describe how you (or your informant) look after your medicines?
(b) Can you describe any problems that you have had with medicines?
(c) Where do you go to get support and information on medicines?
(d) How are you informed of medication changes or problems by the hospital or your GP?
(e) What was your impression of the system that you encountered of managing medicines in hospital or at discharge?
(f) Do you think that the present systems of managing medicines in hospital and on discharge are helpful?
(g) Have you ever had a home medicines review by a pharmacist or GP? Was it useful?
(h) Can you suggest any improvements?
(i) Is there anything else you would like to tell me?
10 Deeks et al. / Research in Social and Administrative Pharmacy j(2015) 1–11

Appendix 2
Characteristics of the study participants
Job description Urban Rural Total
Aged care facility nurse 2 3 5
Admissions nurse 1 0 1
Specialist aged care nurse
(includes ASET,
a
GRACE,
b
dementia/delirium, old age
psychiatry nurse)
628
Hospital pharmacist 4 4 8
Chronic care nurse 2 0 2
General practitioner 3 1 4
Rehabilitation lead 1 0 1
Occupational therapist 1 0 1
Community pharmacist 1 1 2
Emergency physician 1 0 1
Geriatric physician 4 0 4
Paid carer 3 0 3
Unpaid carer 4 0 4
Hospital nurse manager 0 1 1
Old aged psychiatrist 2 0 2
Liaison pharmacist 2 0 2
Carer support service 1 0 1
Rehabilitation team co-ordinator 1 0 1
a
ASET: Aged care services in emergency team.
b
GRACE: Geriatric rapid acute care evaluation.
11Deeks et al. / Research in Social and Administrative Pharmacy j(2015) 1–11