2.5 NONCOMPLIANCE IN THE ELDERLy
2.5.2 Strategies to improve compliance
The pharmacist plays a vital role in addressing the issues of noncompliance in the elderly. By improving compliance through careful management of these factors, the pharmacist should be able to substantially improve the health and quality of life of elderly patients. Compliance can be improved in a number of ways:
• Written information
Increased delivery of written communication such as patient information leaflets, package inserts and patient specific instructions has certainly increased patient's knowledge of their conditions and medicines, however it does not appear to have much impact on compliance. In addition to this, there are a large number of patients who are illiterate or are unable to understand the labels or instructions. Despite these limitations, written information still plays a role improving compliance, especially in re-inforcing verbal communication with written reminders.
• Verbal communication
Verbal communication in the form of face-to-face interaction is critical in improving compliance. This includes listening to the patient and understanding their needs and capabilities as well as talking to them. It is important that the patient feels that they are taking an active part in their health care. Elderly patients should be motivated and encouraged to make decisions regarding their medicine regimes according to their needs rather than just being told to take their medicines by the pharmacist. The following suggestions are important in verbal communication:
Ensure that the patient understands and accepts the diagnosis and need for medication and taking the medicine as directed.
Spend time explaining the need for the medication and what side effects may be expected.
- Explain to the patient what action to take if side effects are experienced.
Tactfully explore whether the patient has the ability to remember to take the medication and ways to improve the patient's memory to take the medication.
Drug related problems among geriatric out-patients at a public sector hospital: An intervention study
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Strategies can be used for remembering to take drugs. The pharmacist can enquire about daily routines and tie in doses accordingly.
• Understanding changes in health in the elderly
It is important for the pharmacist to understand the physiological changes (Section 2.1.2) that take place in the elderly and apply the appropriate management procedures.
For example, digestive difficulties and intestinal upsets are a problem in the elderly and they are often exacerbated by the medication they are taking, thereby reducing compliance. The most commonly purchased OTC medications in the elderly are laxatives and analgesics/anti-inflammatories, both of which affect the gastrointestinal system. Elderly patients should be advised to take their medication with plenty of water and if necessary with food. Drinking lots of fluids also prevents constipation, which is a common problem in the elderly. Because of delayed transit time, the patient should remain upright at 5-10 minutes in order to allow the passage of the drug. For those patients on chronic medication, the dangers of discontinuing medication must be made apparent.
• Visual aids
For patients who are hard of hearing, the use of visual aids can also be used to re- inforce discussions on medication. An example of a visual aid might be calendar charts (daily; breakfast, lunch dinner, etc.) with each drug represented as a different colour. A common mistake is to assume that a hearing-impaired patient is also mentally impaired. If a patient, especially an elderly patient feels that they are being patronised, theyare less likely to take into account what the pharmacists is saying and compliance will deteriorate.
• Optimise DrugIDosage Regimens
Adverse drug reactions are often the cause of non-compliance. As patients get older, pharmacokinetic parameters such as renal clearance and hepatic function are altered resulting in increased drug concentrations. This may lead to increased side effects or require a decrease in dosage. Polypharmacy can also lead to increased incidence of adverse drug reactions and iatrogenic disease. The pharmacist is in a position of knowing which medicines the patient has been prescribed as well as which OTC
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Drug relllted problems among geriatric out-patients at a public sector hospital: An intervention study
medicines they are taking. Steps can be taken to ensure that side effects are kept to a minimum by correcting dosing, preventing drug interactions and simplifying drug regimens as much as possible.
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As a rule: Use the fewest number of drugs or drug products with the fewest number of doses per day whenever possible, to reduce the incidence of noncompliance.• Assessing patient capabilities
Patients who suffer from arthritis, tremor or other motor disorder may have problems with opening containers, pouring liquids, breaking tablets, using inhalers, etc.
Pharmacist should ask the patient to demonstrate that they can perform the appropriate action required, as elderly patients may be unwilling to tell that they cannot manage these tasks anymore. Dosage regimens should be structured to minimise these tasks.
The following should help the elderly with the administration of their medicines:
Ensure that the container in which the medication is dispensed is adequately labelled with bold instructions and the reason for taking the medication, to improve patient understanding.
Ensure that the container is not too difficult for the patient or caregiver to open as is many of the children resistant containers.
Unit dose packaging can be used to improve the ease of taking the medication and reduce forgetfulness. Such packaging lists the day and time at which the medication in the unit dose must be taken.
• Regular Support
Many elderly people live alone and do not have anyone to check if they are taking their medication correctly and regularly. They may also forget which medicines to take at particular times; therefore, regular re-enforcement of medication instructions is essential in improving compliance. Patient memory aids may assist patients to remember to take their medicine (Table 2.6). In community pharmacies a monthly follow-up programme involving a phone call, reminder postcard etc) has been shown to be a useful tool in ensuring repeat prescriptions are filled for elderly patients on
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Drug reloted problems among geriatric out-patients at a public sector hospital: All intervention study
chronic medication. A patient's circumstances may have changed during the month;
therefore, the pharmacist should always ask questions to determine that the patient is still following the same regimen.
Table 2.6 Patient memory aid
MEDICINES MON TUES WED THUR FRI SAT SUN
Eltroxin 7am oF
Lasix 7am oF
2pm .t
Premarin 8pm oF
While the elderly patient may form only a small percentage (10-15%) of the total population, they consume a far greater proportion of the overall medicine expenditure.
So by improving compliance in the elderly it is possible to reduce unnecessary healthcare costs as well as improve their quality oflife (Miot, 1998).
Pharmacists have an opportunity to educate patients about their condition, their medication and how to cope with both. Pharmacists and other health professionals must move from the concept of patient compliance to patient concordance, where increasing attention is placed on gaining patient participation in drug therapy and taking time to negotiate with ways of improving treatment outcomes. Patients' appreciation of the benefits as well as the risks of medication is necessary for them to take part in the decision to add or discontinue treatments (Hudson, 1997). With a combination of empathy, professional expertise and time, pharmacists may improve the compliance, bioavailability and ultimately, assist the geriatric patient to attain the best quality of life that their medication regimen can give them.
Drug related problems among geriatric out-patients at a public sector hospital: An intervention study