‘Troubling’ medication reviews in the context of polypharmacy and ageing: a linguistic ethnography

Problem

Healthy ageing is a global priority. Polypharmacy (the use of 5+ medicines) amongst older people is increasing, with over one-third of adults in England, aged 80-89, prescribed at least eight medications. Polypharmacy can sometimes be harmful; the risk of harm increases with age and with the number of medicines prescribed. Medication reviews are recommended as one way of reducing the potential harms of polypharmacy. However, previous studies indicate that medication reviews do little to change prescription counts. What happens in medication reviews in practice is poorly understood.

Approach

We used a linguistic ethnography approach to explore how medication reviews proceed and what is (and is not) accomplished during these consultations. We conducted in-depth microanalysis of 18 video-recorded medication review consultations from three general practices in England. The consultations involved patients aged 65 or older, prescribed 10+ medications (‘higher risk’ polypharmacy). Video-recordings were gathered as part of a wider ethnographic study, involving 422 hours of observation of polypharmacy practices in primary care settings (2017-2020). Our microanalysis of the interactional data was informed by ethnographic appreciation of the organisational, institutional and domestic contexts of polypharmacy.

Findings

Medication review consultations were time-consuming and involved lengthy stretches of interactional trouble: non-understandings, misunderstandings and misalignments. Interactants spent considerable time and effort seeking agreement on which medicine is under review and what it is for, without which meaningful progress was difficult. Uncertainties seeped further into ‘troubles talk’ concerning ageing and mortality. The routinised structure of ‘going through’ the patient’s list of medicines provided a safe space for patients to raise existential concerns about enduring illness, ageing and mortality and for clinicians to witness these. Existential concerns were partially articulated. Although both parties engaged in interactional work to acknowledge these concerns, such ‘troubles talk’ was left unelaborated, unresolved and unfinished. The patient’s lived predicament - ambiguous, uncertain, irresolvable – played out linguistically, marked by misunderstandings, lack of clarity, markers of ‘trouble’ and interactional loose ends. Clinicians and patients succeeded at maintaining relationships and respect for each other but fell short of addressing polypharmacy more directly. Clinicians may not feel confident to address the existential concerns that medication reviews raise.

Consequences

The rich, multi-layered nature of medicines-talk could be more explicitly recognised in policy guidelines and in consultation skills training. Medication reviews offer an open field of possibilities for articulating key topics and areas of concern for individual patient care, including exploring patients’ existential concerns regarding chronicity, ageing and mortality. If medication reviews are to reach their full potential, patients and clinicians need time, support and education to enable this. It is also likely to require deliberate policy and professional engagement with critical debates regarding preventive interventions in older age.