Prescribed Medication and Non Compliance in the Elderly

In this article I will reflect on the issues surrounding the non compliance of prescribed medication taking in the elderly and the implications of caring for such patients within the community setting. The model of reflection that I have based my writing upon is Gibbs’ model of reflection (Gibbs 1998) which I feel allows me best, in a methodical and logical way, to explore my thoughts and feelings, to evaluate the care delivery and to reflect upon my actions and those of others.

Lily (pseudonym NMC, 2008) was referred to the Rapid Response Team by her General Practitioner with pneumonia; Lily has longstanding respiratory and mental health problems. Rapid Response Teams are part of Intermediate Care, formed as a result of the implementation of the National Service Framework for Older People (DOH, 2002) to prevent unnecessary hospital admission during episodes of acute illness.

Lily’s GP had requested that we visit to prompt medication and generally provide assistance during this time. I visited Lily with a colleague, prompted her medication as prescribed and asked if she had taken her other medications that morning. Lily’s other medications were in a dosette box, an aid memoir to medication administration used when multiple drugs are prescribed; each box contains an entire weeks medication and is prefilled by a registered pharmacist (McGraw, Dennan 2001). Lily had two such boxes, one which she had started that morning and had taken the wrong day and one from the previous week that still contained various amounts of medication. On questioning it transpired that Lily took only what she wanted to take, any medication that was left before the box went back to the pharmacy she placed in a bottle all together, then took these if she felt that she needed them. Lily was also prescribed diazepam, taken for panic attacks – however her old GP used to prescribe them in as a separately and she could take them when she needed them as much as 15-20mg at a time. Her new GP only prescribed the diazepam in the dosette box therefore Lily did not take them regularly but removed and stored them and used as required. Lily openly lamented the loss of her old GP and how her new one did not seem to ‘like prescribing drugs’. Lily also has an addiction to dihydrocodeine and takes up to 1500mg a day saying that they kept her awake and allowed her to function.

It is widely identified that the older person is at risk of the problems associated with non-concordance with medication and medication management (Banning 2004). They are considered to be at risk because often they are physically and socially vulnerable, suffer memory impairment and their altered physical status increases the risk of adverse drug reactions (Walker & Wynne 1994). It is estimated that the elderly make up 18% of the population but are prescribed 45% of the medication, 78% of these being repeat prescriptions (Dingwall, 2007), a Department of Health report in 2001 indicated that up to 59% of older patients, like Lily, do not adhere to their medication routines (DOH 2001a).

My initial feelings when talking to Lily were of incredulity. The amount of dihydrocodeine that she took each day is massive and she clearly had no concern regarding her dependency. Analgesics are the second most frequently prescribed preparation to people of pensionable age used to control mild to moderate pain (Edwards & Salib, 2000). Like many elderly Lily suffered pain in her joints, a chronic condition necessitating prolonged use of analgesics thus enhancing a likelihood of dependence. My other concern was that if Lily did not take the drugs that she was prescribed then she was at risk of serious illness, it could further interfere with the quality of her life and could ultimately result in her death. On the other hand, looking at it from the NHS viewpoint, non compliant medication taking results in substantial financial loss not only in wasted medication but in bed days for patients admitted to hospital as a direct result of medication mismanagement (McGraw & Drenan 2001).

There are a variety of reasons why the elderly do not take their medication. The major factors are physical difficulties leading to poor dexterity resulting in an inability to open the packet/bottle. Memory problems, cognitive difficulties, poor or ambiguous labelling leads to a lack of understanding on how to take the medication. Lastly, poor or inadequate explanations of the side effects, or what the drug is for also adds to non-compliance (Wade 2004).

My encounter with Lily, although somewhat shocking, did allow us to highlight inadequacies in her care. We gained Lily’s trust in that she shared with us what she was doing and allowed us to return some of her unused medication. However it cannot be forgotten that we then went on to betray her trust and inform her GP of her actions. In Lily’s case we had a duty of care (NMC 2008). Continuing not to take her medication will result in further deterioration of her condition resulting in harm. Standard 9 of the Standards for medicines management, (NMC 2008) requires that as a registrant even if patients are self administering, you have a continuing responsibility to report any changes in the patient’s condition. Discussing Lily’s medication problems with her GP was an ethical judgement and as nurses we explore ethical issues on a daily basis, good practice demands a reasoned assessment of what we do, and ethics allow us to critically analyse it (Chaloner (2007).

Non-adherence to medication management exists in two forms – overdosing and under dosing, both of which are evident with Lily. However what cannot be proven is whether she exhibits intentional or non intentional traits (McGraw 2001). On reflection Lily intentionally hoards her diazepam but the question is does she intentionally not comply with her other medication or does she have an underlying cognitive impairment that prevents her from complying with the regime. Lily also shows signs of Obsessive Compulsive Behaviour, with fastidious washing of her hands, her clothes and housework. In my opinion, Lily’s addictive nature, with her dependence on painkillers and alcohol all contribute to her non compliance with her medication.

Watson (2000) says that medication has an important role to play in enhancing patients lives. It allows them to live with conditions such as Parkinson’s, diabetes, and pulmonary disease which in times gone by would have resulted in premature death or decreased quality of life. For the elderly multipathology is an overwhelming problem resulting in increased amounts of medication, which in turn leads to an increase in side effects. This is known as polypharmacy – each drug has its own effect, its own set of side effects and a different way interacts with others. This multipathology often results in complex regimes which contribute to non-compliance (Watson 2000 & Banning 2004).

In relation to a medication regime compliance/adherence results in the patient taking the prescribed medication in the right way, at the right time as recommended (Cushing & Metcalfe 2007). Compliance, adherence, concordance are all terms which are frequently used to describe a patients role in a medication regime.

Compliance is, as it seems, when the patient is told what to do and does so. In my opinion this is how the majority of patients see themselves. The doctor is the expert, therefore knows best and I must do as I am told in order to achieve well being. Horne et al (2005) reveals that this creates a passive role and a paternalistic approach. If the patient does not comply then they only have themselves to blame. Adherence attaches a no blame philosophy to medication taking and tries to emphasise freedom of choice. For me, compliance and adherence do not differ enough, an adherent patient is still complying, they are still being told what to do and when to do it, there is no actual patient input. Concordance however, goes that step further. It differs because it focuses on a consultative process rather than behaviour. It is a shared approach to care and a sharing of knowledge; the prescriber has as much to learn as the recipient. In medication terms, I see this as the patient first fully has to understand the condition for which they are being treated, what they can expect and the prescriber needs to understand how the recipient is feeling. Secondly, a discussion needs to take place on the various medications available and how these will achieve well being. Thirdly all side effects should be discussed and importantly understood by the patient. Lastly, and most importantly, the discussion should end with the implications of not taking the medication and the prescriber ensuring that the patient fully understands this. Following on, we have to ask if medication concordance is the same as medication compliance /adherence. I would answer no, but, they are integrally linked, and compliance/adherence is greater if concordance is achieved first. Therefore as nurses we have an important role to play in helping older people to adhere to their medication routines. Watson (2000) states that wherever an older person is, whether hospital or community setting the nurse has a responsibility to explain and reinforce any instructions the prescriber has made. If after all this a patient then refuses to comply with their medication routine we as nurses must continue to support them, the Mental Capacity Act (2005) tells us that an unwise decision does not imply lack of capacity.

Lily is a complex individual; she has her own ideas on how to take her medication. It is evident from talking with her that this concordant discussion has not taken place with her GP. Lily feels that he does not fully understand her, and after talking with him I too felt somewhat despondent, and it is evident that he is at a loss on how best to proceed.

I do not feel that Lily fully understands the implications of her medication mismanagement, furthermore the longer she does not take her medication properly, the more she will deteriorate and potentially the more confused she will become. Lily has been referred to the Community Mental Health Nurse, who works for Intermediate Care (ImCS), this will allow for further discussion to be held with Lily to explore her addictions and compulsive behaviour. The IMCS pharmacist will also visit Lily to discuss her medications and to try and reiterate that importance of not just taking them, but taking them as prescribed. This will also allow the opportunity to look at Lily’s medications, ensure that the regime is not too complicated and that they are not interacting with each other, potentially increasing Lily’s cognitive impairment. Recommendations have also been made for Lily to increase her package of care from once to twice daily. This will allow her to have further assistance with household chores, which in turn, in my opinion, will decrease the strain on her physical well being. It is also anticipated that the carer’s will prompt Lily’s medication. A further referral to the Community Nurse for Older People has been made; who will take over Lily’s care once ImCS withdraws and will provide a regular check on her.

For Lily, I feel that her experience with the Intermediate Care Service has been a positive one. It has provided an all encompassing, holistic approach to her care, not just treating the original condition, but seeing Lily as a whole person, socially and emotionally, and pulling in the resources of a multi-disciplinary team. Communication between the individuals has further enhanced Lily’s care by documenting on a central computer programme that ensures relevant information is accessible to all team members immediately.

Following my care for Lily and reviewing relevant literature, I am able to draw the following conclusions regarding medication management and the elderly in the community. In order for there to be compliance there has to be concordance, in order to achieve the following should be considered. Most importantly, in this era, where emphasis is on care in the community and decreasing hospital admissions I would like to see every elderly person on multiple medications assigned a relevant healthcare professional. These individuals will form part of a multi-collaborative approach and include GP, pharmacist and carers to define specific interventions for individual patient needs. Above all the Healthcare Practitioners need to ensure that they have up to date knowledge and use evidence based practice to care. Secondly, patient understanding of the need for medication and prescriber understanding of the patients needs. Use of medication management aids where multiple medications are prescribed and/or use of medication prompts. This will decrease error especially in patients with decreased memory or cognitive impairment, and lastly simplify medication regimes.

Some or all of the above interventions will go some way to decreasing the amount of non compliance in medication management.

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