This site is intended for health professionals only

Concordance and the elderly: a challenge for nurses

Soline Jerram
BSc(Hons) NP MCGI RGN EN(M)
Nurse Practitioner - Older Adults
Head of Community Nursing
Western Sussex PCT
Community and Intermediate Care Directorate
E:s.jerram@btinternet.com

The use of medicines is fundamental to the control and prevention of many chronic health problems. Four out of five of the over-75s take at least one prescribed medication, while 36% are taking four or more.(1) Adverse reactions to medications are implicated in 5-17% of hospital admissions,(2,3) and it is estimated that 50% of medications prescribed for chronic conditions are not taken as prescribed.(4)
The National Service Framework for older people sets out specific targets aimed at improving the health and wellbeing of older people. Good management of medications is an integral element of achieving many of those standards.(5)
The challenge for clinicians working with older patients is to ensure that medicines management is appropriate to meet the needs of the individual's condition, that it is a collaborative decision, that it has identified and addressed any practical problems involved with the obtaining and taking of medication, and that there is a plan of review.
The introduction of the term concordance was proposed by a working party set up in 1997 by the Royal Pharmaceutical Society of Great Britain in recognition of the need for professionals to work with clients to achieve effective medicines use and to reduce waste.(4)
In further work the Medicines Partnership defined concordance as follows:

"Concordance is the new way to define the process  of successful prescribing and medicine taking based on partnership." (6)

It is based on three elements:

  • That patients have enough knowledge to ­participate as partners.
  • That prescribing consultations involve the patients as partners.
  • That patients are supported in taking medication.

What should a medication review comprise?
There are no defined rules for what a medication review should comprise of. However, the Medicines Partnership has identified three levels of medication review.(7) Level 0 is when the patient is not present and level 3 involves a full clinical review.
Table 1 identifies some of the areas that need consideration when reviewing older adults' medication regimens.

[[NIP12_table1_31]]

Case study
Mavis is an 82-year-old woman who due to several falls and increasing frailty moved in to sheltered accommodation. The warden at the complex was concerned that Mavis had a large number of boxes of medication and eyedrops, some of which she was sure were not being taken correctly, and she asked for a visit by the nurse practitioner to review the situation.
Mavis's medication review included consideration of her physical, mental, social and practical status and a review of her medical notes (see Table 1).
Following the consultation the main areas of concern were found to be:

  • Mavis had very poor eyesight and identified her pills by their shape.
  • Mavis was low in mood since having had to move home and was not very motivated.
  • The repeat prescription had a number of ­medications printed on it which had not been ­dispensed for a period of 6 months or more.
  • There were medications on the prescription under a generic name, which had been dispensed under a trade name, and this was confusing the carers.
  • All the medications that Mavis was taking were ­running out at different times.
  • A recent ophthalmologist outpatient consultation had resulted in a need for a change in her eyedrops but this had not resulted in a change in Mavis's use or appeared on her prescription.

There are some key lessons to be learned from Mavis's case:

  • It is important that one-off medication does not become a repeat and that when a medication is changed it is taken off the repeat prescription.
  • That as part of the medication review the ­individual's understanding of what their ­medication is for and when they should take it must be explored.
  • Manual dexterity, vision, and in some instances swallowing should be assessed in order to identify any possible difficulties in the process of taking the medication.
  • If the patient is on a range of medications that are becoming due for repeat at different times of the month there is greater scope for confusion, and either stockpiling of medication or of running out. As much as is possible all medication should become due for repeat at the same time.
  • It is important that carers are informed about medications so that they can support the older ­person with confidence.

To address Mavis's difficulties, a prescription was dispensed for all her oral medication and eyedrops for a 28-day period so that there would be uniformity in repeat requests. It was arranged with the local pharmacist to dispense the tablets in a box which identified the day and time by touch. Using this service also meant that the pharmacist was delivering the medication to her home, ­monitoring Mavis's concordance and identifying any difficulties. Mavis and her carers were given information about the different medications and their purpose, verbally and in writing. The practice computer system was set to identify at the bottom of the repeat prescription slip the need to review medication in 6 months.

Conclusion
Regular face-to-face medication reviews can identify difficulties that may not be identified in any other way.
Supported medication concordance in the older person has the potential to maximise the benefits of therapeutics to the individual's quality of life, reduce wastage, therefore reducing costs, and reduce incidents of medication-related admissions to hospital.

References

  1. Joint Survey Unit of the National Centre of Social Research and the Department of Epidemiology and Public Health at University College London. Health survey for England ­findings. Vol 1. 1998. Available from URL: http://www.doh.uk/ public/hthsurep.htm
  2. Manness CK, Derkx FH, de Ridder MA, Man in't Veld, van der Cammen TJM. Contribution of adverse drug reactions to hospital admission of older patients. Age Ageing 2000;29:35-9.
  3. Cunningham G, Dodd TR, Grant DJ, McMurdo ME, Richards RM. Drug-related problems in elderly patients admitted to Tayside hospitals: methods for prevention and subsequent reassessment. Age Ageing 1997;26:375-82.
  4. Royal Pharmaceutical Society of Great Britain. From ­compliance to concordance - achieving partnership in medicine taking. London: RPSGB; 1997.
  5. Department of Health. National Service Framework for older people. London: DoH; 2001.
  6. Medicines Partnership. From compliance to concordance. Achieving shared goals in medicine taking. London: RPSGB and MSD; 2003. Available from URL: http://www.medicines-partnership.org/concordance
  7. Medicines Partnership. Medication review. 2002. Available from URL:http://www.medicines-­partnership.org/medication-review.

Resources
Task Force on Medicines Partnership
W:www.concordance.org

Medicines Partnership
Royal Pharmaceutical Society of Great Britain (RPSGB)
T:020 7572 2474
F:020 7572 2508
E:info@medicines-partnership.org
W:www.medicines-partnership.org