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Care Homes News

Medicines Management Team

Edition: 3 | July 2021

In This Issue:

Hydration in Care homes
COVID-19 – Important guidance links for care homes
Drug Safety Update – Polyethylene glycol (PEG) laxatives and starch-based thickeners
Herbal and homeopathic medicines: vigilance with regards to Yellow Card Scheme reporting
Managing Distress and ‘Behaviours That Challenge’ in Residents with Dementia

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Hydration in Care Homes

We are well into the summer months now, but with this may come some challenges, especially if we have very hot weather and rising temperatures. Extreme heat can be dangerous to everyone, but more so for older people and those living in care homes.
People of all ages should have more fluid in hotter weather, but for some this may be more challenging e.g. those with dementia, memory problems, mobility issues, communication problems, reduced feeling of thirst as you get older and swallowing problems. Sometimes people may cut down on fluid to avoid having to visit the toilet or reduce the risk of any ‘accidents’.
Not drinking enough fluids can lead to dehydration in the body.
Signs of dehydration can be:
• Headaches
• Tiredness
• Dry mouth or feeling thirsty
• Confusion or feeling muddled
• Dizziness or feeling light-headed
• Constipation
• Dark, smelly urine
• Dry lips and skin

Dehydration may lead to more urine infections and incontinence. It also increases the risk of constipation, falls (due to dizziness, low blood pressure or infection), pressure sores and hospital admissions.

Drinking enough fluids has positive benefits to your physical and mental health and, also keeps your skin healthy.
Please can we ask all staff to be extra vigilant during hot weather conditions.
Below are some tips from the ‘Drink Well Team’ on how staff can ensure their residents remain hydrated and well. We have also attached with this newsletter some resources from the ‘Drink Well Team’ – this includes posters with ‘Summer Hydration tips’, Guidance for staff, A-Z of Hydration activities and the UTI Symptom Flow sheet for people with a suspected UTI.

Hydration tips

  • Encourage residents (and staff!) to aim to drink between six to eight drinks per day.
  • Ensure residents have fresh water within reach, in a cup they are able to drink from. Also remember to make sure the water is palatable – cooler water tends to be favourable and is refreshing in the heat so replace drinks regularly.
  • If a resident is unable to take a drink themselves increase the frequency you offer them assistance with drinking.
  • Provide a variety of drinks to suit individuals’ likes and dislikes. Water, tea, milk, fruit juice, and coffee all count towards this total. Alcohol does not count as it can make you more dehydrated.
  • Ensure residents have a full glass of water with any medication.
  • Place prominent signs, encouraging hydration, around the home as a reminder
  • Make it as easy as possible for residents to drink e.g. making a wide variety drinks easily available, brightly coloured cups to draw attention, drinking aids and adapted cups, straws, structured drinks rounds.
  • Use foods with high water content such as ice lollies, ice creams and jelly. Most fruits boast a high-water content and veggies too! Some of the best include; watermelon, melon, oranges, cucumber, tomatoes, broccoli, spinach and apples.
  • Make hydration an event! People are sometimes more likely to drink if other people around them are doing so. Ideas can include a mocktail session, tasting sessions (e.g. smoothies), afternoon tea or just sitting down and having a drink and a chat with a resident (then you stay hydrated as well!)
  • Keep residents cool to reduce fluid loss from sweating.

We have also attached with this newsletter the Public Health England ‘Beat the Heat’ poster on how to keep residents safe and well during COVID-19.

Protection from sunburn
• If a resident is sitting outside or will be going out for the day, you can advise they stay in the shade as much as possible, especially between 11am and 3pm which is when the sun is at its peak.
• Advise the resident to cover up as much as possible and to apply enough sunscreen to ensure they do not burn.
• Make sure that the resident wears suitable clothing (e.g. light and loose fitting) if going out in direct sunshine.
• The resident can use sunglasses to protect their eyes.
• They could be advised to wear a wide brimmed hat to protect the head and neck.

We all want you to enjoy the summer and being out in the sunshine but in a safe way!
References used:
Central Bedfordshire Care Provider Bulletin – Edition 181 24 June 2021
Bedfordshire CCG, Drink Well Leaflet
Drink Well Team – NHS Bedfordshire hospitals

COVID-19 - Important guidance links for care homes

During these challenging times we are conscious that guidance is constantly changing and you may be receiving a lot of information from various sources. For this reason we have produced links (below) to a few of the key guidance documents:

Coronovirus (COVID-19): admission and care of people in care homes
COVID-19: Managing the COVID-19 pandemic in care homes | British Geriatrics Society (bgs.org.uk)
COVID-19: infection prevention and control (IPC) – GOV.UK (www.gov.uk)
Coronavirus (COVID-19): getting tested
COVID-19: how to work safely in care homes
Coronavirus (COVID-19): adult social care action plan
COVID 19 Vaccination: guide for older adults
COVID 19 Vaccination: guide for healthcare workers
Safeguarding adults in care homes – NICE Guidance

Drug Safety Update - Polyethylene glycol (PEG) laxatives and starch-based thickeners

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning that there is a potentially harmful interaction between polyethylene glycol (PEG) laxatives (e.g. macrogol, Movicol®, Cosmocol®, Laxido®) and starch-based thickeners (e.g Nutilis® Powder, Resource Thicken Up® ,Thick & Easy®).
Addition of a PEG laxative to a liquid that has been thickened with a starch-based thickener may counteract the thickening action and can produce a mixture that is thin and watery undoing the intended act of thickening. Patients with dysphagia who swallow the thinner liquid are potentially at a greater risk of aspiration.
Constipation and dysphagia coexist more commonly in the elderly and in people with disabilities that affect swallowing. These populations may be of particular risk if a PEG laxative is added to liquid thickened with starch. Therefore, patients and carers are advised to avoid directly mixing together PEG laxatives and starch-based thickeners.
If a PEG laxative is required to be thickened, Xanthan gum-based thickening agents may be used as they do not appear to affect the viscosity. Examples of Xanthan gum-based thickeners include Nutilis Clear®, Resource Thicken Up Clear® and Thick & Easy Clear®.
If you are concerned that a resident may be on a PEG laxative and starch-based thickener (as mentioned above), please contact your aligned GP practice/PCN in the first instance.
Please see the Drug Safety Update 27 April 2021 for further information.
Further resources on the use of Thickening Agents with medicines can be found at:
PrescQIPP Care Home bulletin – Assisting people with swallowing difficulties
CQC guidance – Dysphagia and thickeners
SPS Thickening agents and interactions – Q&A for NHS healthcare professionals

Herbal and homeopathic medicines: vigilance with regards to Yellow Card Scheme reporting

The Yellow Card scheme is vital in helping the MHRA to monitor the safety of all medicines in the UK, including herbal and homeopathic medicines.
Herbal and homeopathic medicines are available from outlets such as pharmacies, retail stores, online shops or supplied by herbal or homeopathic practitioners and only some of these are licensed by the MHRA. These are not prescribed medicines but you may have residents in your care homes that already purchase or may wish to purchase herbal or homeopathic medicines for self care.
Important advice for herbal or homeopathic medicines:
• Ensure the product has been licensed by the MHRA and meets the required standards of quality, safety and patient information.
• Always read the patient information provided with a herbal or homeopathic medicine to ensure that it is suitable and how to use it safely.
• Remember – herbal and homeopathic medicines may interact with other medicines so check whether it is safe for use with a pharmacist.
• If an adverse reaction to a herbal or homeopathic medicine is suspected, this can be reported to the MHRA’s Yellow Card Scheme.
For full details of this safety alert please visit: https://www.gov.uk/drug-safety-update/herbal-and-homeopathic-medicines-reminder-to-be-vigilant-for-suspected-adverse-reactions-and-to-report-them-to-the-yellow-card-scheme

Managing Distress and ‘Behaviours That Challenge’ in Residents with Dementia

Dementia is the collective term for a range of symptoms caused by diseases affecting areas of the brain, such as Alzheimer’s Disease and vascular dementia. Whereas many symptoms of dementia vary depending on the part of the brain affected by the underlying disease, distress and challenging behaviours are common with all types of dementia.
It is important to exclude alternative causes of these behaviours, which could include physical health issues (e.g. infection, delirium) or side effects of medication. It is especially important to rule out delirium in care home residents. Delirium is an acute, confusional state that may occur when a resident is ill. Delirium can present itself in a variety of ways: hyperactive (patients may become restless, agitated, and/or aggressive), hypoactive (patients may become withdrawn, quiet and/or sleepy) or a mix. The symptoms of delirium can be mistaken for challenging behaviour or a progression in the person’s dementia. However, unlike a progression in dementia severity, delirium presents as a sudden change over the course of a few hours/days. If you suspect a resident has delirium, seek medical attention immediately. (Also see: Recognising & Preventing Delirium – A Quick Guide for Care Homes)

Non-Pharmacological Management (see chart below)
Type and severity of behaviours varies so there is no management plan or single strategy that will be suitable for all. The principles of person-centred care underpin good practice in dementia care and all interventions should be personalised.
Non-pharmacological interventions should always be first line in the management of distress or challenging behaviours. Often residents displaying signs of distress have an unmet need – if we can identify and meet this need, it will help to alleviate the resident’s distress and any behaviours that challenge.

Pharmacological Management
Medication is rarely effective in reducing the behaviour and can have serious side effects such as increasing the risk of chest infections, falls, strokes and death. Medicines such as antidepressants, benzodiazepines or hypnotics should only be used if essential and discontinued as soon as clinically appropriate, under the guidance of a suitable clinician.
Antipsychotic medication can be used to help people manage severe symptoms of mental health conditions such as psychosis and schizophrenia. However, antipsychotic medication should not be routinely used for treatment of agitation and aggression in people with dementia. Antipsychotics should only be considered if the patient is at serious risk of harming themselves/others OR when experiencing agitation, hallucinations, delusions which are causing severe distress and should be used in tandem with non-pharmacological methods of support.
For people with dementia, antipsychotic medication can have serious adverse effects including an increased risk of stroke and death if taken for long periods of time (months rather than weeks). NICE recommends that antipsychotic medication should only be used at as low a dose and for as short a time as possible. Furthermore, the use of antipsychotic medication should be reviewed regularly by a clinician (with guidance suggesting a review at least every six weeks, if possible) and should be discontinued if it is not achieving the intended outcome.
Older people, including those living with dementia, often have multiple conditions and require several medications to treat them. With this increased risk of polypharmacy there is an increased risk of adverse effects and potential for harm. Regular structured medication reviews (SMRs), involving the resident (and family where appropriate), and the appropriate MDT members, are essential to assess the risks and benefits of medicines, with the aim of reducing inappropriate polypharmacy.
The weekly ‘home rounds’, as well as MDT meetings conducted with your aligned Primary Care Network (PCN) are an ideal forum to raise any issues or concerns care homes are experiencing with individual residents, including reviews of antipsychotic medication. However, medical attention should be sought without delay for any acute concerns which cannot wait until the next ‘home round’.
Resources
https://www.nice.org.uk/guidance/ng97/resources/dementia-assessment-management-and-support-for-people-living-with-dementia-and-their-carers-pdf-1837760199109
http://www.oxfordhealthformulary.nhs.uk/docs/OHFT%20BPSD%20Guideline%20May%202019.pdf
https://www.southeastclinicalnetworks.nhs.uk/wp-content/uploads/2021/03/Dementia-OPMH-Guidance-for-PCNs-and-Care-Homes.pdf

Care Homes newsletter July 2021 - attachments

Summer Hydration Tips

Drink Well for Good Health Staff Guidance

A-Z_hydration activities

People with suspected UTI – symptom flow sheet

PHE Beat the Heat flier

Contact Us

If you would like to get in touch with us, please contact the Medicines Management Team:
bedccg.bedsmeds@nhs.net or 01525 624 375

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