Important Information for Candidates

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Important Information for Candidates
Tips for the case study assessment (updated 03/03/14)
1. Asking the right Questions
2. Addressing medication management in the case study assessment
3. Demonstrating an advanced level of pharmaceutical & therapeutic knowledge
4. Identification of medication related problems
5. Critical evaluation of the literature
6. Presentation of Submissions
7. Reference resources for RMMRs
8. Reference resources for Pain Management
9. Clinical Guidelines
10. GP report – use of SOAP
11. Prioritisation in the FP report
12. Taking a medication history
13. References for the treatment of Type 2 Diabetes
14. Medication problems and the prescribing cascade
#1. Asking the right Questions
Question 1 of the case studies asks ‘What further information would assist in making your
assessment of this patient. Explain reasons for obtaining this information. Who/where would you
obtain this information from?’
Here are some tips:
• Read the case closely – is there information missing about medication management? To
assess compliance – would a dispensing history help?
• Consider the sources of information that might be available to you, such as the patient, their
partner/carer, the community pharmacy and the GP surgery.
• You should demonstrate that you have an understanding of which sources can provide
which information.
• The marker will be looking to see that you have sought information that is specific to the
patient in the case.
• Consider each presenting symptom shown by the patient. Can you determine the possible
causes? Formulate the questions you ask based on what additional information might be
required to help ascertain the most likely cause/s.
• Consider each of the medical conditions listed in the case. Are they adequately and
appropriately managed?
• Consider each of the medications (prescribed and non-prescribed). What questions should
you be asking to determine whether or not they are appropriate and effective?
• Include specific questions which relate to the patients conditions and presenting problems
and avoid using a list of ‘generic questions’
• The use of headings can be useful, such as ‘Pain management’ ‘Falls and dizziness’
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 Think about the reasons why you are asking particular questions and list these reasons in
your answer e.g. ‘How often do your experience difficulty breathing/shortness of breath and
what is its impact on your quality of life?’(to assess the need for additional medication/s in
patient with COPD)
• Does the patient have any concerns/issues that are not being managed or that might be
related to medicines?
• Is there some information which is missing which would assist in the management of specific
conditions e.g. poor co-ordination in patient using inhalers, swallowing ability in a patient
who has had a stroke?
• Do you have all the relevant information to decide if the patient’s medical conditions are
being well managed?
• If you feel that recent laboratory test results would be useful, you should be specific about
which results you need and the reasons you need them.
• Remember that not all of a patient’s medical conditions may be listed on a HMR referral.
#2. Addressing medication management in the case study assessment
Information acquired during a patient interview on adherence and medication management is likely
to be of great interest to GPs. A patient’s GP may be unaware of adherence issues and wrongly
assume that a patient is not responding adequately to a prescribed treatment/s. Non adherence
must be identified so that patients can achieve optimum health outcomes. Accredited pharmacists
are ideally placed to identify issues relating to adherence and medication management during a
HMR.
It is therefore important for candidates to demonstrate that they understand the questions which
need to be asked and issues discussed during a patient interview. Relevant information relating to
adherence and medication management needs to be included in the report to the GP (the answer to
question three of the case study assessment)
GPs will appreciate learning information about their patients which indicates that they are adherent
to their medicines. If patient non-adherence to medicines is suspected, it is important for it to be
confirmed, if possible during the interview.
Candidates should consider addressing the following:

Patent Adherence
Patient knowledge of their medicines

Storage
Actual ability to manage medication administration

Checking how well patients manage their medicines is vitally important, e.g.


Swallowing difficulties may adversely affect adherence
Breaking of tablets may prove to be difficult. If ‘half’ a tablet has been prescribed, does the
patient have a pill cutter? How is the remaining half a tablet stored?
Can the patient open the tablet box or bottle? Can the tablets be accessed from the foil
wrapping? Can the patient use their inhaler correctly?
What is the patient’s level of manual dexterity? Do they suffer from arthritis or other
conditions which can affect their ability to perform tasks with their hands?
Does the patient suffer from any other conditions which may affect their ability to take their
medicines as prescribed such as depression or dementia?

When addressing adherence and medication management issues in their answer to question three
of the case study assessment, (the GP report) candidates should assume that the patient is managing
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their medicines well unless the alternative is clearly stated in the case study information provided.
Some examples are:

Mrs Smith is managing her medicines well and does not describe any difficulties with
opening containers. All medicines, including insulin, are stored appropriately.

 Mr Smith advised that he does not encounter any difficulties in swallowing any of his
medicines. We discussed management of his warfarin dosing and I suggested that he keep a
diary or calendar to keep track of his daily doses. A dose administration aid may also assist.
Mr Smith’s knowledge of warfarin management was good.
#3. Demonstrating an advanced level of pharmaceutical & therapeutic knowledge
Question Two of the case study assessment asks: Based on the information provided, identify
potential and actual medication-related and disease related problems, and patient concerns. Suggest
how these could be addressed and/or monitored.
You need to be able to demonstrate that you possess an advanced level of pharmaceutical and
therapeutic knowledge. In your answer to question two you should consider whether or not
medication use is indicated, appropriate safe and effective.
You are required to show the marker that you can apply your knowledge and make critical
judgments on the medication used by the patient in the case study. When writing your answers to
Question Two, you need to clearly and carefully articulate your opinions based on your knowledge
and relevant, up to date evidence. You should avoid quoting from a limited range of reference texts
and, instead, use appropriate references to support your statements where required.
Your answers should be aiming to demonstrate advanced knowledge, with an answer that is written
in a clear and logical manner. A structured answer with relevant headings will enable the marker to
see how well you understand all the drug related problems in the case study. All factors which are
impacting (or have the potential to impact) on optimum medication management in the patient
should be considered.
When writing your answers to Question Two, you should express your own opinions, providing the
marker with sufficient detail to demonstrate that you possess the ability to carry out medication
reviews. The markers do not make assumptions when they are assessing case study submissions, so
it’s up to you to demonstrate your knowledge by submitting an answer which demonstrates
advanced pharmaceutical and therapeutic knowledge, and understanding, of the issues applying to
the patient in the case. For example, the issues which pertain in a HMR for a 50 year old lady with
type 2 diabetes may be different to those to be considered in a RMMR for a frail 85 year old with the
same condition.
#4. Identification of medication related problems
One of the goals of medication review is to reduce medication-related problems. In their answer to
question two of the case study assessment, candidates need to be able to demonstrate that they can
identify clinically significant potential or actual medication related problems in the patient’s current
medication treatment.
For the assessment process, candidates are required to discuss all actual, suspected or potential
medication related issues relevant to the patient. Issues should be discussed in sufficient detail to
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demonstrate an understanding of the problems. The use of a systematic approach is useful, as
answers need to be comprehensive to demonstrate competence.
Candidates should initially consider focusing on describing the medication-related
issue/problem/concern that they have identified in the patient. The next step is to write a detailed
and comprehensive summary to show that consideration has been given to all possible solutions.
This information needs to be communicated logically and critically. The clinical relevance of any
medication-related problems should be assessed, evaluated and prioritised in the context of the
patient’s overall health status. The most appropriate course of action should then be selected as the
recommendation to the GP in the answer to question three, the GP report.
Consideration should be given to the patient’s symptoms. Could any of these possibly be related to
their medications? Are all of the prescribed medications indicated? Are all of the currently
prescribed medications effective? What are the therapeutic options for the GP to consider if the
medication is not effective?
The APF has an excellent section on ‘Medication Review’ which may assist candidates in the
systematic identification of medication-related problems. The PSA’s
‘Guidelines for pharmacists providing Home Medicines Review (HMR) services’ lists several
prescribing indicator tools that are designed to identify potentially inappropriate medicine
prescribing, especially in patients over the age of 65 years.
Such tools can form an important part of the medication review process and may also be useful to
candidates as they complete their case studies.
The NO TEARS tool may also be useful and it can be found at
http://www.bmj.com/highwire/filestream/382551/field_highwire_article_pdf/0.pdf
#5. Critical evaluation of the literature
When formulating your response to question two, consider how knowledge can be applied to the
patient who is the subject of the case study. An ability to critically evaluate and interpret the
relevant literature is vitally important.
Knowledge and understanding of current evidence based references sources will enable a thorough
discussion and will demonstrate an understanding of the pharmacological and therapeutic basis for
medication use in the patient concerned.
For example, knowledge of the Heart Foundation’s ‘Guide to management of Hypertension’ may
provide information regarding the appropriate choice of an antihypertensive for a patient with other
morbidities such as diabetes.
http://www.heartfoundation.org.au/SiteCollectionDocuments/HypertensionGuidelines2008to2010U
pdate.pdf
#6. Presentation of Submissions
Candidates should remember that the answer to question 3 of the submission is the designed to
reflect the actual look and content of a letter written from an accredited pharmacist to a general
practitioner.
The format should be one that you feel comfortable using, and once accredited, should be the one
that you and the referring GP find most useful. Whichever format is used, the letter should be clear
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and concise. The language used should be tactful and appropriate. Submissions should reflect the
standard of communication which is expected in written professional communication between
health professionals.
Prior to uploading their case studies for assessment, candidates should ensure that they have
checked their submissions, including their answer to question three. Candidates should re-read
their submissions prior to uploading to ensure that spelling and grammatical errors are corrected.
Sentences should be complete. The use of capital letters for drug names should be reviewed. Only
drug trade names should commence with a capital letter. Drug names should be spelt correctly.
If necessary, a dictionary can be used to check both the meanings and spellings of words of which
you are uncertain. Spell-checkers in word-processing software packages can be useful, but
remember that they will recognise only misspellings; they cannot help you if you type, say, “causal”
for “casual”.
Any reasonably large (i.e. more than 1000 pages), reasonably recent dictionary will be useful to you.
Good quality Australian dictionaries include:


The Macquarie Dictionary, rev. 3rd edn (Sydney: Macquarie Library, 2001).
The Australian Concise Oxford Dictionary, 4th edn (Melbourne: Oxford University Press,
2003).

#7. Reference resources for Aged Care
References specific to Aged Care: When working on the Residential Medication Management
Review (RMMR) case studies for assessment, candidates should note that there are several
reference sources that may be particularly useful to them.
AMH Drug Choice Companion: Aged Care: The revised and updated Third Edition of the AMH Drug
Choice Companion: Aged Care is a widely-accepted aid to Quality Use of Medicines in Aged Care in
Australia. An on-line web-based version is also available for desktop, laptop and tablet computers
with internet access.
Both versions contain information on more than 70 specific conditions common in older people,
including: dementia and management of behavioural symptoms, cardiovascular diseases, fall
prevention, osteoporosis, palliative care issues, COPD, insomnia, depression as well as some broader
concepts.
Drug choices are ranked as first line/other options or arranged by disease severity or symptoms,
with dosing information specifically for the older person.
Ordering and subscription information is available here.
The Medical care of older persons in residential aged care facilities – The Silver Book: This Royal
Australian College of General Practitioners (RACGP) publication is now in its Fourth Edition. It aims to
provide general practitioners, with a resource for delivering quality health care in residential aged
care facilities. The overall content was developed and reviewed by a national taskforce of health
professionals working across the aged care sector. In addition, general practitioners, consumer
representatives and aged care experts provided valuable input and feedback.
This publication encourages collaboration between health professionals and provides suggestions
for implementing systematic care involving residents and all who care for them.
The Silver Book can be downloaded from the RACGP website here.
Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian
Hospitals 2009: The Guidelines are designed to assist hospitals and health professionals reduce the
risk of falling for older people receiving care. They contain the latest evidence and best practice, and
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are a supplement to the clinical judgement of health professionals providing care to older patients
and those at risk of falling.
The guidelines, an abbreviated guidebook and an implementation guide for use in Residential Aged
Care facilities may be downloaded here.
Pain in Residential Aged Care Facilities – Management Strategies: This 2005 publication of The
Australian Pain Society is a comprehensive and considered exploration of the ways in which pain
reduction and improved quality of life can be achieved for long-term aged care residents. The
recommended strategies are based on the best available research evidence.
The publication and other related resources, including The Pain Management Guidelines (PMG) Kit
for Aged Care can be downloaded here.
#8. Reference resources for Pain Management
This list of resources may be useful to pharmacists as they are completing the AACP case studies.
Therapeutic Guidelines: Analgesic version 6, 2012: The publishers of Therapeutic Guidelines pride
themselves on publishing expert, unbiased and objective information. The publications are intended
specifically to meet the needs of busy health professionals who want reliable, practical and userfriendly therapeutic information. Hard copy and electronic versions are available.
Opioid Prescription in Chronic Pain Conditions-Guidelines for South Australian General 2008: The
purpose of this document is to provide information to GPs about the medical treatment of chronic
pain using opioid drugs. The goal is to achieve a better balance in addressing the treatment of pain
while minimising abuse, addiction, and diversion of these pain medicines.
www.dassa.sa.gov.au/webdata/resources/files/Opioid_prescription_chronic_pain_guidelines_for_S
A_GPs.pdf
Safe prescribing of opioids for persistent non-cancer pain 2012
http://www.australianprescriber.com/magazine/35/1/article/1250.pdf
NPS News 69: A planned approach to prescribing opioids 2010
http://www.nps.org.au/__data/assets/pdf_file/0003/88302/News69_prescribing_opioids_0610.pdf
NPS Prescribing Practice Review 51: Opioids in chronic non-cancer pain: use a planned approach
2010
http://www.nps.org.au/health_professionals/publications/prescribing_practice_review/current/pre
scribing_practice_review_51
The American Geriatric Society Clinical Practice Guideline: Pharmacological Management of
Persistent Pain in Older Persons 2009: The American Geriatrics Society (AGS) published its first
Clinical Practice Guidelines on management of persistent pain in older adults in 1998. The document
was first revised in 2002, and subsequently in 2009. The recommendations in this guideline
represent the consensus of a panel of pain experts and were derived from a synthesis of the
literature combined with clinical experience in caring for older adults with persistent pain.
The recommendations are grouped under the following headings: non-opioids, including
acetaminophen and non-steroidal anti-inflammatory drugs; opioid analgesics; adjuvant drugs; and
other medications. General principles are discussed first, followed by the panel’s specific
recommendations for use of the medications.
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_r
ecommendations/2009/
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The American Geriatrics Society Statement on the Use of Opioids in the Treatment of Persistent Pain
in Older Adults 2012
http://www.americangeriatrics.org/files/documents/Opioid_Statement_April_2012.pdf
Pain in Residential Aged Care Facilities – Management Strategies 2005: Pain in Residential Aged
Care Facilities – Management Strategies is a comprehensive and considered exploration of the ways
in which health professionals can reduce pain and improve the quality of life of long-term aged care
residents.
http://www.apsoc.org.au/owner/files/9e2c2n.pdf
Medical care of older persons in residential aged care facilities (4th edition) 2006: This publication,
also known as the ‘silver book’ aims to provide general practitioners, and other health professionals
with a resource for delivering quality health care in residential aged care facilities. The overall
content was developed and reviewed by a national taskforce of health professionals working across
the aged care sector. The discussion on pain management in the chapter on Common Clinical
Conditions has useful information.
http://www.racgp.org.au/download/documents/Guidelines/silverbook.pdf
The British Pain Society’s Opioids for persistent pain: Good practice 2010: A onsensus statement
prepared on behalf of the British Pain Society, the Faculty of Pain Medicine of the Royal College of
Anaesthetists, the Royal College of General Practitioners and the Faculty of Addictions of the Royal
College of Psychiatrists.
http://www.britishpainsociety.org/book_opioid_main.pdf
#9. Clinical Practice Guidelines
Clinical Practice Guidelines: There are a number of high quality drug information resources that are
of value for pharmacists undertaking the accreditation assessment process. In addition to the
standard resources, there are guidelines, statements and updates issued by certain Australian
organisations, developed for use in this country.
Clinical practice guidelines contain statements that include recommendations, strategies, or
information that assists health care practitioners and patients make decisions about appropriate
health care for specific clinical circumstances. They are generally produced under the auspices of
medical specialty associations; relevant professional societies, public or private health organisations,
non-government agencies or government agencies at the federal or state level for current use within
Australia.
The National Health and Medical Research Council (NHMRC) website has a link to a clinical practice
guidelines portal
The Australian Clinical Practice Guidelines Portal has been developed to help Australian clinicians
and policy-makers access clinical practice guidelines via a single entry point.
You will find links to clinical practice guidelines developed for use in Australian health care settings.
Each guideline on the portal has been assessed according to rigorous selection criteria to help health
professionals find the type of guideline they are looking for.
This site provides direct links to guidelines, with the majority available free of charge.
This site links only to Australian clinical practice guidelines. For consumer health information, the
Australian Government’s HealthInsite portal may be of interest.
Some guidelines which may be of use to candidates include the following:
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The Heart Foundation
http://www.heartfoundation.org.au/information-for-professionals/clinicalinformation/pages/default.aspx
Kidney Health Australia
http://www.kidney.org.au/HealthProfessionals/CKDManagementinGeneralPractice/tabid/789/Defa
ult.aspx
COPD guidelines
http://www.copdx.org.au/the-copd-guidelines
Osteoporosis Australia guidelines, research and position statements
http://www.osteoporosis.org.au/health-professionals/research-position-papers/
RACGP clinical guidelines (including guide to management of type 2 diabetes in general practice)
http://www.racgp.org.au/your-practice/guidelines/
Gastroenterological Society of Australia (GESA) Clinical Updates
http://www.gesa.org.au/professional.asp?cid=9&id=51
National Evidence Based Guideline for Blood Glucose Control in Type 2 Diabetes
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/di19-diabetes-blood-glucosecontrol.pdf
#10. Use of SOAP format in the GP report
In order to present drug-related problems in a logical manner to GPs, pharmacists undergoing
accreditation should consider adopting the use of a format commonly used for the documentation
of clinical notes called SOAP.
The Subjective Objective Assessment Plan (SOAP) format is widely used in medical practice to
document patient encounters. The advantages are many and include encouraging comprehensive
records, reducing unnecessary documentation, assisting in the organisation of the note, saving time,
and facilitating rapid and easy retrieval of information from the record.
When composing their answers to question three of the accreditation assessment, the report to the
GP, candidates should avoid making assumptions or diagnoses.
Subjective and objective information can be obtained from the information provided in the case
study which relates to the patient’s medication history. Recommendation statements need to be
clearly identified so that the GP can quickly identify the action steps.
The following should be considered when using this method for providing recommendations to GPs
in medication management reports:
Subjective Data
 Patient information, such as the presenting complaint, including the severity and duration of
symptoms


Whether this is a new concern or an ongoing/recurring problem
Relevant past medical history

Objective Data


Any relevant physical signs and symptoms and observations from the interview
Laboratory Test results

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Assessment


Any patient risk factors or ongoing/recurring health concerns
Review of medications and laboratory results

 Statements relating to the current medication-related issues in order of priority and
reflective of the presenting complaint (s).
Plan


Discussion of recommendations and treatment options for action by the GP
New medications recommended including dosage, frequency, duration and an explanation
of potentially serious adverse effects
Any other patient advice or patient education provided

An example of this format is described below:
Mr Smith is currently taking a high dose of esomeprazole but is not currently experiencing any GORD
symptoms and has not done so for several months. (Subjective and objective data)
Patients whose GORD symptoms have been well-controlled with high dose PPI therapy should be
trialled on step down therapy. Symptoms may be well controlled with use of either a PPI on a ‘when
required’ basis, an H2 receptor antagonist such as ranitidine, antacids and/or lifestyle interventions.
(Assessment)
A trial of PPI step-down therapy may be considered. (Plan/Recommendation)
A summary of the use of this format can be found in Appendix 8 (p26) of the PSA’s Standard and
guidelines for pharmacists performing clinical interventions
http://www.psa.org.au/download/practice-guidelines/pharmacists-performing-clinicalinterventions-guideline.pdf
#11. Prioritisation in the GP report
In order to present their findings in a clear and concise manner, candidates should think carefully
about prioritisation as they compose their answer to question three of the case study assessmentthe report to the GP.
As a general rule of thumb, patient concerns and/or the reason for the referral should be considered
priorities. The discussion in the answer to question two should inform the prioritisation in the
answer to question three.
Careful consideration of the layout of the answer should ensure that priorities for action are clearly
identifiable. The most important patient-focused aspects should be mentioned first, with the less
important issues discussed later.
The GP may only read the first few suggested recommendations and consider whether or not to
implement these prior to any others. It is important to focus on the key issues as they relate to the
patient when you are conveying information to the GP. Consider which issues in the case study are
impacting on the patient’s/resident’s lifestyle. Remember that the GP may not be aware of some of
these issues!
#12 – Taking a Medication History
Medication histories are important in preventing prescription errors and consequent risks to
patients.
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A medication history is often the first step for the pharmacist conducting a medication management
review. Question one of the case study component of the AACP accreditation process asks
candidates to consider the information that has been provided to them and to identify gaps and
suggest methods for obtaining missing information which would be useful as part of the review.
Obtaining an accurate medication history ensures that medication –related problems are identified,
whilst compiling a complete and comprehensive list of medications taken.
Accurate medication histories are also useful in detecting drug-related pathology or any changes in
clinical signs that may be the result of drug therapy.
A good medication history should encompass all currently and recently prescribed drugs, previous
adverse drug reactions including hypersensitivity reactions, any over-the counter medications,
including herbal or alternative medicines, and adherence to therapy.
The Australian Commission on Quality and Safety in Healthcare has recently produced a video to
guide health professionals on how to take a Best Possible Medication History (BPMH).
Designed for medical, nursing and pharmacy staff, the video includes a short, role play scenario
which highlights the steps in taking a BPMH and provides important tips when reviewing sources of
medicines information. All pharmacists undergoing accreditation are encouraged to view the video.
The video can be accessed via the Commission’s YouTube channel.
Limited DVD copies are also available for those unable to access the tool online. To request a DVD
please email [email protected]
#13 Update on references for the Management of Type 2 Diabetes
This list of resources may be useful to pharmacists as they are completing the AACP case studies.
General practice management of type 2 diabetes 2014–15
General practice has the central role in type 2 diabetes management across the spectrum, from
identifying those at risk right through to caring for patients at the end of life. These guidelines
support general practitioners (GPs) and their teams to provide high-quality management by
providing up-to-date, evidence-based information tailored for general practice.
In the development of the 2014–15 edition of General practice management of type 2 diabetes, the
RACGP has focused on factors relevant to current Australian clinical practice. The RACGP has used
the skills and knowledge of your general practice peers who have an interest in diabetes
management and are members of the RACGP’s National Faculty of Specific Interests Diabetes
Network.
http://www.racgp.org.au/your-practice/guidelines/diabetes/
Australian Diabetes Society (ADS) Position Statement on A New Blood Glucose Management
Algorithm for Type 2 Diabetes
This position statement developed by the Australian Diabetes Society (ADS) outlines the risks,
benefits and costs of the available therapies and suggests a treatment algorithm incorporating the
older and newer agents. Summary of this ADS Position Statement is as follows:
 Lowering blood glucose levels in people with type 2 diabetes has clear benefits for
preventing microvascular complications and potential benefits for reducing macrovascular
complications and death.

Treatment needs to be individualised for each person with diabetes. This should start with
selecting appropriate glucose and glycated haemoglobin targets, taking into account life

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expectancy and the patient’s wishes. For most people, early use of glucose-lowering
therapies is warranted.

A range of recently available therapies has added to the options for lowering glucose levels,
but this has made the clinical pathway for treating diabetes more complicated.

https://diabetessociety.com.au/downloads/20141218%20A%20New%20Blood%20Glucose%20Mana
gement%20Algorithm%20for%20Type%202%20Diabetes.pdf
The McKellar Guidelines for Managing Older People with Diabetes in Residential and Other Care
Settings
The McKellar Guidelines consist of 18 Guidelines and five Risk assessment Tools. The McKellar
Guidelines define current best practice and were developed to support general practitioners (GP),
facility/nurse unit managers, nurses and other care staff to plan, provide and monitor diabetesspecific care for older people in all care settings: community, acute and residential care.
The McKellar Guidelines encourage those caring for older people with diabetes to proactively
identify diabetes-related risks that could compromise the older person’s safety and to plan care to
manage the risks they identify.
The individual guidelines and risk assessment tools are compiled into a single document and were
designed to link to each other to help GPs, nurses, pharmacists and all those providing care to access
comprehensive diabetes care, proactively plan diabetes care and reduce adverse events such as
hypoglycaemia, hyperglycaemia, falls, confusion, pain and glucose lowering medicines (GLM)-related
adverse events.
The McKellar Guidelines promote a personalised, proactive, preventative approach to assessing,
managing and supporting older people with diabetes and focus on identifying changes in health
status and safety risks early and individualising care plans to minimise risks and enhance safety and
quality of life.
http://www.adma.org.au/clearinghouse/doc_details/133-the-mckellar-guidelines-for-managingolder-people-with-diabetes-in-residential-and-other-care-settings_9dec2013.html
#14 Medication problems and the prescribing cascade
Question two of the AACP case study assessment asks the following:
Based on the information provided, identify potential and actual medication-related and diseaserelated problems, and patient concerns. Suggest how these could be addressed and/or monitored.
An important aspect of the medication review process is an understanding of the overall picture of
patient care and how medications, both prescribed and not prescribed, fit into this picture.
Monitoring is a critical component of patient care. Once a medication has been commenced, it is
important to determine whether or not it is effective, or maybe whether the patient is experiencing
adverse effects which might necessitate a reduction in dose or change in therapy.
It is also important to consider whether or not the desired outcomes have been achieved or if the
specific targets have been met, e.g. is blood pressure lower?
If the desired outcomes are not being achieved, it may be necessary to increase the dose of
medication, add another medication or cease the original medication and change to an alternative
one.
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When answering the AACP case study assessment question, and when conducting medication
management reviews (MMRs) it is useful to remember that monitoring is an important part of the
patient care process for the older patient. It may be that adverse effects from medication use are
not initially recognised as such, instead being attributed to other co-morbidities or simply ‘old age’.
These symptoms of adverse effects from medications can then be treated with a new medication.
This can result in what is known as the prescribing cascade. The addition of a second drug can then
cause more unwanted adverse effects leading to the addition of a third drug and so on.
Examples of the prescribing cascade include the following:

Misdiagnosis of extrapyramidal side effects from metoclopramide, resulting in the initiation
of therapy with l-dopa or other medication/s for Parkinson’s disease
Concomitant prescription of a cholinesterase inhibitor (donepezil, rivastigmine or

galantamine) with an anticholinergic drug to manage urinary incontinence, leading to a
reduction in benefits of each medication.
For further examples of medicines implicated in prescribing cascades and a discussion on how they
can be avoided, this Australian Prescriber article is recommended reading.

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