Hi everyone, this week we will have another guest blog post. Today we have Dr. Sofie Rosenlund Lau (MScPharm, PhD in medical anthropology) discussing how anthropology and ethnography can be used in deprescribing research and to facilitate deprescribing in clinical practice.
What is anthropology and how can it add a layer to the understanding of deprescribing?
Anthropology is the study of humanity – of what makes us human. Medical anthropology is the study of how health and illness is shaped, experienced and understood in the context of local and global cultures.
The main methodology linked to the science of anthropology is ethnography, including participant observation. Anthropologists most often go into the world to experience on their own, the phenomenon they investigate. The studies often hold an explorative element of “what is going on here?” and subsequently “why?” and “with what causes?”
Deprescribing in the context of everyday life
Use of medications is entangled with many other aspects of daily life. This is clear in the following example with Betty. Betty is participating in my postdoc project on frail seniors and medications. Over almost a year, I have participated in the home care of seniors in a Danish municipality and conducted in-depth interviews with seniors, their relatives and general practitioners, in order to explore what polypharmacy means from the perspectives of older persons and healthcare providers. The following is a summary of field notes from my visits at Betty’s:
Betty lies in her bed in the living room when the homecare worker and I enter. As always, she complains about the early wake-up with a combined laugh and rattling cough. […] Six years ago, Betty lost both her legs due to blood clots in her legs. She is able to transfer herself into her wheelchair for short trips to the fridge but moving is troublesome and she prefers staying in bed most of the day. The homecare worker changes Betty’s diaper and brings a dish with clean water for Betty to wash her upper body, but as usual, Betty denies. Sometimes the care worker convinces her to change the bedding or her shirt, but most often, Betty does not want the trouble. Today she wants coffee and cigarettes before anything else. The worker accepts and enters the kitchen to prepare the breakfast. […] She finds Betty’s morning pills, which are prepacked from the pharmacy in small dose-dispensed plastic bags. The home care worker rips the bag open and pours the pills into a small cup, while counting: “1-2-3-4-5-6, here you go”. She asks Betty to swallow the pills, while she watches. “Urgh, I hate taking pills”, Betty routinely complains. Afterwards, they chat a bit about Betty’s 80-year-old birthday coming up soon. Then the worker leaves and Betty turns on the TV.
Routinization and complexity intertwined
For Betty, as for the nine other seniors in my project, taking multiple medicines is a routinized daily practice. No one enjoys taking the many pills several times per day, especially when combined with low appetite, dry mouth and problems swallowing. At the same time, however, taking pills may only be a minor thing in lives with many larger issues at stake. Physical and mental impairments, social isolation, loneliness and boredom takes up much of daily life. Before Betty lost her legs, she was a social person hosting many gatherings in the same living room, in which she is now stocked. The immobility had slowly put a stop on being social, combined with the fact that in the age of 79, many of her friends have passed away. She lost her husband in 2007, which deeply influenced the stability of her life. Today, Betty’s medication list reflects 20 difficult years. In 1998, Betty was transmitted several times to psychiatric departments with mania and anxiety. Paroxetine and zopiclone stem from that. She also takes apixaban, to prevent more blood clots, gabapentin due to phantom limb pain, and magnesium for constipation. Levothyroxine and vitamins were added later. Betty also has severe COPD but does not take her inhalers. She does not have a dementia diagnosis but the GP suspects some degree of dementia, probably in combination with increased alcohol consumption. Hence, medication has been added continually over the years as new symptoms and diagnoses have arisen.
But Betty’s medication list also reveals cultural changes in how we perceive and manage life crisis and aging and the complex relationship between the definition of diseases and the development of new medication therapy practices in care of older persons. Betty entered into psychiatry just as a new era of treating depression and anxiety with new classes of SSRIs was about to settle. Betty was offered cognitive therapy but, for reasons not coming to the fore in my study, the anxiety has lingered on and is managed only by sedative drugs. The pain medication is tightly linked to the amputations but also to the lack of rehabilitation opportunities for people like Betty, who has a mental disorder, increased age and little social network to support her.
The “pill paradox”
When talking to Betty about her medication, she expressed both a dislike and a need for pills. Having done ethnographic research among medication users for some time, this ambiguity of aversion and necessity is not new. I call it the “pill paradox” – the perception of medicines as something that you ought to avoid but, at some points in life, cannot do without. Betty trusts her GP, and the medical system in general, for providing her the best possible care. She has no considerations as to whether it could be any different.
Her GP on the other hand acknowledges that changes could be beneficial. Zopiclone could be worth withdrawing, the same goes for gabapentin. At the same time, the physical, mental and social vulnerability so prominent in Betty’s life makes decisions around how and where to start deprescribing, hard to oversee. Furthermore, Betty does not visit the clinic herself. The GP has stopped by a few times and has also tried to follow up on her on a regular basis. However, she does not open the door herself and her hearing is too poor for informed phone conversations. Making arrangements with the family and/or home care is a time-consuming task, and this is all compounded by Betty’s own lack of engagement in her health. The routinization of medication management in-home care leaves little room for reflections on effects or inappropriateness of treatments. The automated dose-dispensing offered by the pharmacy, only reinforces this routinization of daily pill-taking, as no trained healthcare personal are needed to manage the daily intake of Betty’s pills.
How to solve a wicked problem?
Everyone agrees that polypharmacy is a complex problem and deprescribing a similarly complex act. It includes a variety of people, places and procedures that do not always collaborate nor perceive the problem in the same way. Armstrong and Swinglehurst have referred to polypharmacy as a ‘wicked problem’, “arising at the interface of patients, clinicians and diseases and encompassing cultural, technological, economic and sociopolitical dimensions”. Yet, interventions promoting deprescribing tend to focus mainly on medical or clinical barriers: medication lists, sector transitions, clinical practice guidelines and scientific knowledge, just to name a few. These factors are important, indeed. However, if polypharmacy in old age is to be solved with the tools offered by the concept of deprescribing, then we (as healthcare professionals, relatives and, at some point, patients ourselves), need to be aware that the complexity associated with long medication lists are deeply rooted in perceptions and ideologies of health, illness, and the good senior life.
Ethnography alone cannot solve the problem of inappropriate medication use, but the methodology and especially the link to the historical and cultural dimensions of medications can help unravel the complexity by deepening the insights into what polypharmacy means from the perspective of users and healthcare professionals alike.
Sofie works at Center for Research and Education in General Practice, University of Copenhagen. Her postdoc project is funded by VELUX FONDEN. You can find Sofie on Twitter (@lau_sofie) or reach out to her at firstname.lastname@example.org
Photo Credit: Adam Nieścioruk on Unsplash.