There are different reasons why patients of all ages either fail to comply with a particular medication or present with low concordance. This behaviour can be risky and can result in reduction of a patient’s health improvement or they can even cause a decline in their health status. In order to reduce the level of non compliance and non concordance and keep it to the minimum possible, the causes of these actions must be identified. The Primary Health Care Team is only then able to find ways and increase both concordance and the percentage of patients who comply.
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To begin with, compliance describes a traditional relationship between the doctor and the patient. It refers to the extend at which a patient follows the recommendations of the prescriber( and it includes taking medication as directed in terms of timing and dose, following any preventative health behaviours, keeping medical appointments and taking self-care actions when required. According to Ley in 1997, 40-45% of patients consistently do not comply with doctors’ advice, while 20-40% does not obtain the recommended immunizations and 20-50% misses their scheduled appointment. Compliance is often failed to be achieved because the beliefs and preferences of the patients are not met during a consultation. The concept of concordance can be introduced here. This new concept acknowledges the fact that non-compliance can be a result of a reasonable behaviour of a patient whose personal perceptions were not taken into account by the doctor. The term therefore, refers to the decision about medication prescriptions and the support in medicine taking, as a consequence of a style of consultation that involves exchange of views between the patient and the doctor.
The Primary Health Care team should therefore try to increase the involvement of the patients in making decisions about their medicines. Thus, a good communication between the practitioner and the patient is crucial in order for this to be accomplished. Considering that each individual is unique the practitioner should try to adapt the style of the consultation so as to meet the patients’ needs and also make sure to use all possible communication aids. In this way they can reassure that the patients receive all the information delivered and can understand the benefits of the treatment and the risks of not taking it. By clearly explaining all the details about a medication indicating both advantages and disadvantages and by talking to the patients and listening to their views, the relationship between the two sides can be improved, leading to a reduction in the incidence of non-compliance and non-concordance.
One of the major causes of the reduction in compliance and concordance is polypharmacy. Polypharmacy is derived from the Greek words “poly” meaning many and “pharmacy” meaning medicine, and in fact it denotes the simultaneous use and administration of a large number of drugs by the same individual. These drugs could be considered avoidable as they usually exceed the clinical needs of the patient. However some evidence argues that most of these drugs are prescribed appropriately due to the multiple health problems. Any person suffering from numerous illnesses, either an adult or a child can be provided by many different drugs at the same time; nonetheless the incidence of polypharmacy is particularly common amongst the elderly.
The increasing life expectancy observed during the last decades, implies that there is a continuous increase in the number of people who belong to the elderly group. In fact in the United Kingdom, adults over the age of 60 comprise about one fifth of the population but still they are the ones to obtain 59% of total prescriptions. Similarly in the United States, patients older than 65 years of age make up less than 13% of the population and yet they are the greatest consumers of drugs, consuming about one third of the total prescribed medications. According to the Centres for Disease Control and Prevention elderly Americans receive twice as many prescription and non-prescription medications as they did in 1990 and correspondingly a similar duplication is obtain in the UK during the last decade, with the number of prescribed drugs to people older than 60 increasing from 21.2 to 40.8 prescription per person per in one year.
As people get older, there is a decline in their health status and therefore an increased number of multiple chronic diseases, such as type II diabetes, high blood pressure that must be managed. These are often interacting diseases of which the progression is slowed and the symptoms are reduced by combining a plethora of medication therapies . During the last decade new drugs have been introduced and have become available to the public. In instance, instead of treating type II diabetes mellitus with just sulfonylureas, which was the only class of oral medication available until 1995, we now use second-generation sulfonylureas, biguanides, glucosidase inhibitors, and thiazolidinediones and some of those also require a combination with other hypoglycaemic agents. The expansion in the number of drugs consumed by the patients is also a result of following the evidence-based clinical practice guidelines. Therefore, for example, instead of using digoxin and a diuretic to treat a patient with heart failure, doctors now give the patients a variety of different drugs according to the severity of their condition. These include an angiotensin converting enzyme inhibitor, a loop diuretic, an Î²-blocker as well as spironolactone and digoxin. In that way, the use of numerous drugs benefits the patients, decreasing both morbidity and mortality. However, polypharmacy can mainly lead to many adverse outcomes, and thus it is necessary that prescriptions follow a good clinical judgement and require cautious follow-up and sporadic adjustments of dosage where it is needed.
One of the main concerns for polypharmacy is potential risk to which the patient is exposed. This arises from the fact that as the number of medications increases, so does the possibility of drug – drug interactions. Nevertheless the relationship between the two is exponential, rather than linear implying that the probability of potential drug interaction increases faster than the drugs taken by an individual. In a study to evaluate their actual connection, the theoretical probability for an old person who takes five drugs per day was calculated between 50-60% and that was increased to almost 100% for someone who receives seven medications, while the observed results in real patients were very similar, indicating how significant it is to keep the number of prescribed drugs lower. In addition to this, polypharmacy leads to a number of clinical consequences, including adverse drug reactions, a higher risk of hospitalisation. As a matter of fact, the incidences of hospital admissions due to adverse drug reactions (ADRs) increased drastically over the last 20 years, especially in people older than 80 years of age. In a study carried out in Sweden, it was found that about 3% of all deaths are iatrogenic and occur due to fatal ADRs in men and women of older than 80 years. Furthermore according to Rollason and Vogt, patients who need to take many different medications in one day can be confused more often and either take more of one drug or not enough of another and finally there is an observed increase in the incidence of non-compliance in patients with multiple medications. In another study, people suffering from hypertension were given oral potassium in a range of one to six tab tablets per day. An inversely proportional correlation was observed between the number of tablets given and the percentage of compliance obtained. Consequently patients on just one tablet showed a compliance of 92% and this was reduced by 9% in patients on two tablets and fall as low as 58% when the patients were given six drugs.
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Taking into consideration all of the above, it is shown that a reduction in the inappropriate prescribing can also help improving compliance. One of the ways indicated to reduce polypharmacy in the elderly, is by keeping the number of prescribers as low as possible. Good communication between the general practitioner who usually prescribes the medication and the people in secondary care, who are the ones to adjust or begin it, is essential. In this way not only a significant decline in the number of unintentional discrepancies can be obtained in older patients who leave the hospital, but also a decrease in the incidences of adverse drug reactions.
The problem of inappropriate prescribing appears to be greater in older people who take multiple medication hence medicine reviews are necessary to decide which drugs need to be maintained and which should be stopped. In essence patients should be reviewed annually if they take less than four drugs and twice per year if they take four drugs or more. The general practitioner allows repeat prescriptions for only a period of time so the patient must then come into surgery for a follow-up appointment where the doctor can review their medication. It is recommended that old patients with multiple and complex medical needs should be referred to a geriatrician for a specialist review(7) but reviews made by the pharmacists are also considered effective (11). Even with regular counselling through the telephone, a hospital pharmacist is able to improve concordance and reduce the number of deaths (14). In fact, when I interviewed the pharmacist during my GBM experience, he informed me that patients, especially those with chronic diseases that visit the pharmacy quite often feel free to ask him questions and express any particular worries. In the example he gave me, one patient was experiencing some night cramps due to Simvastatin tablets and was asking for reduction of the dose. The pharmacist suggested tablets that could lessen the cramps but also asked for consideration of the statin dose by the GP. During the reviews the pharmacist assesses whether the patients take the medicine as prescribed, but also discusses with them about the formulation, side effects and any other issues, provides more information when required and ensures that they are aware of the reasons of using the particular medicine.
What needs to be taken into consideration is the fact that old patients respond to drugs differently than the average adult does (7) thus the dosage must be adjusted regularly according to the age. These adjustments could be done without mush difficulty by a younger person but as people become older they can more easily forget to do so. This consequence of age also indicates the need of different means that will help the patients remember what medicine they need to take and when.
Furthermore, supporting adherence, which refers to the extent to which agreed recommendations from the prescriber are followed by the patient is another way to improve compliance and concordance and this can be achieved after adherence is assessed. Thus, whenever a practitioner needs to prescribe or review a medication, they can ask the patient in a non-judgmental way if they have missed any doses and if there is proof of non-adherence then they can discuss together what the causes are. For instance, if they don’t comply due to the side effects, the practitioner could explain to them how to deal with them or consider adjusting the dosage. In a study of hypertensive elderly it was shown that advice about diet was given and was modified at repeated visits by a dietician has better outcomes than when it was given briefly by the doctor. As a result the 24-hour urine tests, showed that a reduction by 82 mmol/day more in the urine sodium excretion when the dietician was involved.
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