Elderly patients and multiple medicines

Encouraging questions about medication is a first step towards concordance, says Professor David Haslam.

About 80 per cent of people aged over 75 years old are taking at least one prescribed medicine and over a third of that age group take four or more prescribed drugs.

The trend to reduce numbers of medicines at all costs now seems to be slowing down, with increasing evidence that many older people benefit from multiple medications.

Polypharmacy brings many challenges in making sure expensive and potent drugs are used safely and effectively, and not simply left in the bathroom cabinet.

Aside from the impact of the ageing process on the body’s ability to process medication, cognitive impairment and loss of physical dexterity can create problems.


Older patients are much more likely to be at increased risk from drug interactions. But non-compliance is also a recognised problem. There is plenty of evidence that over half of medicines for long-term conditions are not taken as prescribed and that non-com- pliance results from intentional and non-intentional factors.


Identifying practical barriers that may prevent older people for making optimal use of their medicines is important. However, the beliefs and views of any patient are a key influence on whether, when and how they take their medicines — and older people are no exception.

Patients may be concerned about the cumulative impact of side-effects and how the medicines will react with each other.

It is not uncommon for an older patient taking four different tablets, twice a day to space out each tablet at half an hour intervals to avoid any possible medicine interactions.

PROBLEMS WITH POLYPHARMACY
  • Taking four or more medicines.
  • Specific medicines (warfarin, NSAIDs, diuretics, digoxin).
  • Recent discharge from hospital.
  • Low level of home support available.
  • Physical condition (poor vision, hearing, dexterity).
  • Mental state (confusion/ disorientation, depression).

Source: Medicines for Older People: Implementing Medicines-related Aspects of the National Service Framework for Older People

Barriers

Other barriers to the optimal use of medicines in the elderly fall into a number of categories. There are professional barriers such as misdiagnosis and underdiagnosis, errors in prescribing or dispensing.

Practical barriers include problems accessing the pharmacy, difficulty opening containers, forgetfulness and complexity of the regimen.

Then there are information barriers where instructions are not understood or poor knowledge of condition and lifestyle choices over unpleasant side-effects, inconvenience, no perceived benefit. Beliefs about medicines such as that they are unnatural, addictive or poisonous, and diminishing efficacy can also affect compliance.

The key to effective medicine use is partnership — an informed agreement between the GP and the patient. A MORI survey conducted for Ask About Medicines in 2004 revealed that almost half of people aged over 64 want the doctor to decide the best treatment for them, compared to only a third of those aged 55–64 years and a quarter of those aged 35–54. However, 46 per cent of older people say they prefer to have some say in prescribing decisions.

All older patients should be encouraged to ask questions about their medicines. Understanding the purpose of a medicine, how and when to take it and its possible side-effects enables patients to make better-informed decisions about medicine-taking and leads to safer and more effective medicine use.

Carers

Carers will often be the gatekeeper to older patients’ medicines, helping them to manage when and how to take the medicines they are prescribed. Carers’ beliefs can influence how, and even if older patients receive their medicines at all.

A carer may also not be on hand at all times. Therefore, medicines may be administered at times that suit the carer’s daily commitments. Wherever possible – and with the agreement of the patient – it is helpful for carers to be invited to ask questions about medicines and be involved in the treatment partnership.

PATIENTS' AND CARERS' QUESTIONS
  • Older patients and carers should be encouraged to ask:
  • What does this medicine do?
  • Why is it important that I take this medicine? Are there any other treatment options?
  • When and how should I take it?
  • How long should I take it for?
  • What should I be aware of when taking this medicine?
  • Where can I go for more information?

Hospital stay

Some of the most common problems older people face with medicines follow a stay in hospital. After discharge patients may have had changes to their medication that they do not completely understand. Perhaps the chances were not communicated accurately to the primary care team.

Once the patient is at home, it may be too late to ask questions, especially if the older person is housebound or has limited access to their GP or pharmacy. The Healthcare Commission’s recent report highlighted lack of access to information and advice about medicines as a major issue for hospital patients.

Medicine reviews

GPs are often left to deal with confusion over new medicines prescribed to older people discharged from hospital. Post-discharge is therefore a good time to invite patients for a medicines review.

The NSF for Older People stated that by 2002 all people over 75 years should normally have annual medication reviews, and those taking four or more medicines should have a review every six months.

Medicine-use reviews can take different forms, but a face-to-face review that allows an older patient to ask questions is a useful way to work towards a concordant approach to taking medicine. Medication reviews often result in a reduction of the number of medicines the patient is taking, making treatment regimens easier to follow. For patients over 75 this can be done as part of their annual health check.

Encouraging older patients and carers to ask more questions about medicines will help GPs identify their concerns about medicines and create a two-way dialogue that can ultimately help work towards better concordance in the elderly.

- Professor Haslam is a member of the Ask About Medicines Advisory Group, President elect of RCGP, and national clinical adviser for the HealthCare Commission

References

  • DoH. Medicines and Older People – Supplement to the National Service Framework for Older People. 2001
  • DoH. National Service Framework for Older People. 2001
  • MORI Research commissioned by Medicines Partnership. Medicines and the British 2003; the Public and Prescribed Medicines 2004.
  • National Prescribing Centre: http://www.npc.co.uk/med_partnership/index.htm

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