This domain is split into 2 areas; it is about pain and the management of medications. I’m going to discuss the pain bit at the end of this blog. Medications effectiveness and side effects vary from person to person.
Almost every older person has some medications and within a care home, they would be managed by the carers. I’ve only had one client who took no medications. So virtually everyone would score at least low needs, as they medication would have to be administered.
Moderate for medications would be the score if someone was non compliant with their medications, either refusing to take them or spitting them out. Non-concordance, within the definitions is a lack of understanding of medications (and their potential benefits and side effects). The assessors rarely score moderate for someone cognitively impaired and not understanding their medications, so moderate is really based on non compliance. On occasions, some medications are given in liquid form and as it’s easier to have a slight slip of the hand and dispense more, this takes more skill, so is scored as moderate. This should not be confused with dispersible medication, which is a pill medication that has been dissolved. There is no risk of a slight slip, as the pill is already a prepared dose.
High score is about medication that needs careful monitoring. Some medications can have some nasty side effects, so need monitoring for that reason. Some medications need to be monitored for their effectiveness especially closely, (as all medicines need monitoring). This monitoring of medications can vary and some people on some medications can have a different response and the medication is not affective, so it is not simply about noxious medications that have nasty side effects.
There is also what is known as PRN medications, which are given “as and when required”. If someone has to make a judgement about when a medication is given, this requires skill and monitoring. This however is subject to what I choose to call the “Boots Test”. If you can go to a chemist and obtain a medication without a prescription and without limit, then it is not that noxious, so things that pass the Boots Test, even if given PRN, would not score as high.
Severe score is about the same needs as high, except that it is not working. This often means that the medications are changed a lot. It could be that the dose is changed or the time of day it is given is changed, but it is not uncommon if there is a real healthcare problem that mediations are changed almost weekly to try to work out the most effective way forward. If they are changed, it may only score severe for the period of the change and if it can be sorted out, will drop the scoring. Sometimes it happens that it is never sorted out, so would remain at severe.
I’ve never had a client who was at risk of relapse, as my client’s tend to be elderly and with dementia, rather than learning disabled or those that suffer from mental or physical health issues which can relapse. Sadly my clients just decline.
I’ve never had a client score priority, but I would expect them to be in a specialist unit or hospital and funding would not be an issue.
The other aspect of this is pain, so the scoring is about the level of pain and is relatively self explanatory on the DST. It is about the impact on other domains or the provision of care, so it is about looking for what the impact of the pain is. Is the person eating, drinking and sleeping? Are they anxious, withdrawn or reluctant to mobilise etc? It is also about what pain medication is being used and whether that medication is working or not. There are increments of pain medication, with paracetamol at one end of the spectrum and intravenous morphine at the other end, with plenty of things in between.
The other thing that gets considered in this domain is the number of visits by healthcare professionals to review the person, this can include Consultants, District Nurses etc. So if the person gets a visit on average once a month from someone to consider their healthcare needs, then that is far more than someone who only sees their GP once a year for a medication review and sees no-one else.