Medication management during risk of dehydration: A qualitative study among elderly patients with impaired renal function and informal caregivers.

European Journal of General Practice 2024, VOL. 30, NO. 1, 2413097 https://doi.org/10.1080/13814788.2024.2413097 Research Article Medication management during risk of dehydration: A qualitative study among elderly patients with impaired renal function and informal caregivers Tristan Coppesa, Daphne Philberta, Mijke Van Rieta, Teun van Gelderb, Marcel Bouvya and Ellen Kostera Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, The Netherlands; bDepartment of Clinical Pharmacy & Toxicology, Leiden University Medical Centre, Leiden, The Netherlands a KEY MESSAGES • Elderly patients and informal caregivers seem to have little knowledge about medication adjustments during sick days or heatwaves • Informal caregivers appear to be more interested than patients in information about medication management on sick days • GPs should involve informal caregivers in providing information on medication management during risk of dehydration. ABSTRACT Background: Patients with impaired renal function are at an increased risk of dehydration due to vomiting, diarrhoea or fever (so-called sick days). Temporary medication adjustment during sick days is necessary and current initiatives and information materials for patients are available. However, the knowledge, experiences and information needs of patients and informal caregivers about sick day guidance are unknown. Aim: To gain insight into the understanding of safe medication use during periods of dehydration risk in elderly patients with impaired renal function and their informal caregivers. Design and setting: Qualitative interview study with patients with impaired renal function and unrelated informal caregivers from three community pharmacies in the Netherlands. Method: The interviews were conducted by telephone or live by two researchers in November 2020–September 2021 and audiotaped and transcribed verbatim. The coding of transcripts was performed deductively and inductively in Nvivo 12, a thematic analysis was applied. Results: In total 12 patients and 11 unrelated informal caregivers were included. Three main themes were derived from the interview guide and subthemes emerged from the transcripts. The included patients and informal caregivers had limited knowledge about medication management during sick days. In contrast to patients, informal caregivers seemed interested in a medication management protocol for sick days. Conclusion: Patients with impaired renal function and informal caregivers have little knowledge about and experience with dehydration and safe use of medication during sick days. General practitioners and pharmacists should involve the care network, including informal caregivers, when implementing sick day guidance. ARTICLE HISTORY Received 21 July 2023 Revised 23 September 2024 Accepted 1 October 2024 KEYWORDS Impaired renal function; informal caregivers; dehydration; elderly; sick day guidance CONTACT Marcel Bouvy Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, The Netherlands Supplemental data for this article can be accessed online at https://doi.org/10.1080/13814788.2024.2413097. © 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. 2 T. COPPES ET AL. Introduction One out of ten avoidable medication-related hospital admissions in the Netherlands results from not adjusting medication in patients with impaired renal function [1]. Elderly patients with impaired renal function are at increased risk of acute kidney injury (AKI) due to hypovolemia, especially during periods with a risk of dehydration [2], such as vomiting, diarrhoea, fever (so-called ‘sick days’) or high environmental temperatures. Many of these, mostly elderly, patients use diuretics and angiotensin-converting-enzyme (ACE) inhibitors [3,4]. Ongoing use of these medications during sick days and heatwaves, combined with a decreased thirst sensation in the elderly, could lead to the development of AKI [5,6] which often results in hospital admission [7]. To prevent adverse events during sick days and heatwaves, patients with impaired renal function and their (informal) caregivers must be aware of the risk of continued medication use during periods with a risk of dehydration. Currently, evidence shows that the knowledge of patients is low and patients are often not informed about sick day management [8]. Therefore, providing patients with information and instructions regarding temporary medication adjustment is necessary. This can for example be done by GPs during prescription or by pharmacies during dispensing of medication. The pharmacists’ role is to promote the safe use of medication, however, they are likely not aware when patients are sick because patients would contact their GP. Therefore, the current role of pharmacists is limited to information provision to patients. Several guidelines and recommendations have been developed in, for example, the United Kingdom [9,10] and Scotland where they released a ‘Medicines Sick Day Rules Card’ with instructions on when and how to adjust medication [11]. In the Netherlands, the Dutch general practitioner (GP) guidelines on chronic kidney disease suggests GPs to consider temporarily adjusting certain medications during periods with increased risk of dehydration [12]. In addition, the Dutch Kidney Foundation published a brochure with instructions during sick days for patients [13]. However, these initiatives have not been evaluated and their effectiveness has not been studied yet. Thus far, it is unknown whether patients or informal caregivers are receiving any information from their GPs or pharmacists about the risk of dehydration during sick days and the included temporary medication adjustments. Alignment between healthcare professionals about implementing sick day guidance seems to be difficult [14]. Research is needed to study this possible knowledge and information provision gap and to align patient education and counselling materials with the needs and wishes of patients and informal caregivers. Therefore, this study aimed to gain insight into the current knowledge, information needs and experiences of elderly patients with impaired renal function and their informal caregivers about safe medication use during periods with increased risk of dehydration. Methods Study design and setting Semi-structured int (...truncated)