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How to support patients to take ownership of their medication

Patients can only benefit from their medicines if they take them correctly. Pharmacists are able to identify non-adherence and provide patients with the support they need to manage their medicines

Lisafx/Dreamstime.comAs much as 30–50% of patients with long-term conditions do not take their medicines as intended.1 Moreover, researchers suggest that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.2
Medicines adherence is defined as the extent to which a patient’s behaviour matches agreed recommendations from his or her prescriber.1 Pharmacy staff should try to tackle non-adherence as part of their day-to-day practice. So, if you have a suspicion that your patient may not be adherent with his or her medication regimen, one of the first things to do is establish whether or not this is intentional.

Intentional non-adherence

For patients who have made conscious decisions not to take their medicines (intentional non-adherence), it is important to explore their beliefs and concerns about their medicines and diseases. These patients can be hard to identify unless they disclose information about their non-adherence themselves. Look out for clues such as:

  • Unused medicines
  • Items not ordered on a repeat prescription
  • Old dates on a repeat prescription or on medicine labels
  • A lack of response to therapy (or in hospital, when given their medicines by nurses, a larger than expected response, eg, antihypertensives lowering the blood pressure substantially)
  • How much patients know about what a medicine is for and how it should be taken

When you suspect non-adherence you must remember that, if the patient is making an informed decision not to take the medicines, this is his or her right (so long as they have the capacity to make that decision). Do not be judgemental but try to explore reasons for non-adherence. Is it due to a side effect? Has a friend had a bad experience with the medicine? Do they understand why they need the medicine and its risks and benefits?

Establish an effective way to communicate with the patient: use verbal or written information, pictograms or any other means that helps the patient to understand, and ask about the goals of treatment. Use open-ended questions and be supportive and non-judgemental.

Once you have identified reasons for non-adherence, it is important to try to address patients’ relevant beliefs or concerns, involve them (or their carers) in decisions about their treatments and consider alternatives if necessary.

Unintentional non-adherence

Patients who are unintentionally non-adherent tend to be easier to identify, because there is often a practical problem that may be limiting their medicines taking (eg, poor vision or manual dexterity).

Look out for obvious clues when you see patients — are they struggling to open packaging of a product? Can they read small print? Do they seem forgetful? The first step in addressing unintentional non-adherence is getting patients to talk about their medicines. By understanding a patient’s existing routine for managing their medicines, it may be possible to identify potential problems and suggest slight adjustments to improve their adherence. Some of the following questions may encourage a patient to talk about their medicines:

  • How do you take your medicines? Are they in the original packs, in blisters or in multi-compartment compliance aids (MCAs)?
  • Who helps you take your medicines?
  • How do you remember to take your medicines?
  • What concerns do you have about your medicines?

Many hospitals will have resources to help pharmacy staff assess patients’ adherence needs (see Box 1 for an example adapted from a compliance aid assessment form used at Imperial College Healthcare NHS Trust). It provides questions to ask patients, with some examples of solutions for practical issues. However, you will need to tailor your approach and solutions to the individual.

 Box 1: Compliance aid assessment

 Theme

Questions used in assessment

 

 

Examples of solutions

 

 

 Knowledge

What is each of your medicines for?

 

When do you take each of your medicines?

What are the main side effects of your medicines?

What should you do if you miss a dose of your medicines?

Would you like any further information about your medicines?

 

Medication counselling, including written information if appropriate; medication record chart, including details of indications, directions for use and side effects for each medicine 

 

 

Visual Issues

 

 

Are you able to read the labels on the packaging? (If so, ask them to read a label)

 

Do you have problems with colour differentiation, or are you colour blind?

Large font labels; colour-coded bottles (eg, one colour for morning medicines, a different for night medicines); large-print record chart with medicine directions; use a different system to identify tablets that are usually differentiated by colour, ie, warfarin

 Manual Dexterity

 

 

 Can you:

 

 

  • Open the bottles?

  • Push out of the foils/blisters?

  • Measure out liquids?

  • Instil eye, ear or nose drops?

  • Use your inhalers?

  • Swallow all your tablets or capsules?

  • Halve or crush tablets?

Note: you should ask the patient to demonstrate these where possible

Non-child-resistant lids; remove medicines from foils and place in bottles; use of measuring cups; use of auto-dropper for eye-drops; inhaler technique counselling and use of spacers; formulation change — to liquids or dispersible tablets; use of tablet cutter or crusher

 Cognition

Often people get confused or miss a dose of their medicines. Does this ever happen to you? How often?

 

When did you last miss a dose of your medicines? Why do you think this happened?

 

Note: you should also consider what family or carers say — does the patient have help with other activities of daily living? What do other healthcare providers think?

Where possible, link medicine taking with the patient’s daily routine (try to encourage the patient to come up with suggestions of how they will remember to take their medicines); simplify medicine regimens to once or twice daily; use reminders and tick charts; record medication taking in a diary; use multi-compartment compliance aids filled by either patient, carer or community pharmacist*

 Supply

How do you obtain your medicines — from the GP or community pharmacist? Do you collect your medicines or are they delivered?

 

How often do you do this?

Do problems with ordering or collecting ever cause you to miss a dose of your medicines?

 

Review of ordering and collection with the GP and community pharmacist; consider repeat prescriptions/delivery services where appropriate

*Multi-compartment compliance aids are not appropriate for all patients — a patient must be aware of the day and time of day, have good manual dexterity and want to take his or her medicines; pharmacists must also consider issues around drug stability

Encourage patients to suggest solutions to any problems identified, and let them choose what will work best for them. When introducing a solution, where necessary, ensure that community providers have the capacity to deliver similar solutions (eg, not all community pharmacies can provide large-font labels).

If you decide that an MCA filled by a community pharmacist is an appropriate option, remember the pharmacy does not have to supply this if the patient is not covered by the Equality Act 2010. Contact the community pharmacy to ensure it is happy to continue supply; do not assume it will do so automatically.

The Royal Pharmaceutical Society has recently launched guidance on the use of MCAs (see Box 2).

Box 2: RPS guidance

The Royal Pharmaceutical Society has issued professional guidance on multi-compartment compliance aids (MCAs), which points out the lack of evidence for the use of MCAs in improving adherence.

The guidance recommends that patients are assessed to identify what intervention could best improve their adherence and that only patients with a specific need for an MCA should be supplied their medicines in this way. For more information and to read the guidance visit www.rpharms.com/mca. Further coverage is available on PJ Online.

Dependent patients

When patients are unable to manage their medicines independently, you will need to consider different factors contributing to non-adherence, and find alternative ways to improve their medicines taking. You will need to work with the patient, his or her family, nursing staff and primary care providers to determine the most appropriate solutions to improve adherence. The most important factors to consider are:

  • Who is supporting the patient in taking his or her medicines?
  • How often do they visit?
  • What level of support do they provide — do they administer the medicines or prompt the patient to do it?

Family support If a patient’s family helps the patient take medicines, contact them to establish the facts and how much they can be involved. Ensure they understand why the patient has been prescribed each medicine and how each one is administered, and work with them to ensure the regimen is appropriate for the patient and the family.

Carers If carers visit the patient, confirm within your local area what level of care is  provided. If the carer is prompting only, then the patient still needs to be able to self-administer the medicines. You may need to ensure that medicines are given at the times that the carers are visiting the patient (eg, if the carer only visits twice daily, there is no point giving a regimen that requires administration four times a day). Care agencies within the same area often provide different levels of care. It is worth contacting carers before supplying medicines to patients to ensure that they are given their medicines appropriately.

District nurses The patient may have a district nurse (DN). Because DNs are trained nurses, they can administer medicines from original packs; however, DNs can be under a lot of pressure, particularly when they have to administer medicines alongside all their other responsibilities. Work with a DN to determine the best course of action for the patient.

Residential and nursing homes
If a patient is living in a residential home or rehabilitation unit and administering their own medicines then you need to assess how they take their medicines as described above.

If a patient is having his or her medicines given to them by nursing staff, find out how this is being done and, if possible, review how appropriate this is — taking into account the needs of the patient but also the capabilities of the staff and the systems in place at the home.

For all patients

Supporting medicines adherence can be challenging and there are many factors to consider. It is crucial to establish the type of non-adherence, involve patients in decisions and be flexible with your approach.

ACKNOWLEDGEMENT Thanks to Bryony Dean Franklin for reviewing the content of this article.

Sarah Reynolds is lead pharmacist for emergency medicine at Imperial College Healthcare NHS Foundation Trust.
E: sarah.reynolds@imperial.nhs.uk 

IN SHORT

Non-adherence to prescribed medicines is a well known problem. If you suspect a patient is not taking his or her medicines as prescribed, the first step is to ascertain whether or not this non-adherence is intentional.

For patients who have made conscious decisions not to take their medicines, you should try to identify and then address the reasons behind these decisions. If patients’ non-adherence is unintentional, you should work with them, and their carers or family, to tackle barriers to medicines taking.

 

Citation: Clinical Pharmacist DOI: 10.1211/CP.2013.11124988

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