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Medication Management in Older Adults - a Critique of Concordance

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Medication management in older adults: a critique of concordance Austyn Snowden
across the hfe span; older people are just as unlikely to take a medicine that interferes with their lifestyle or behefs as younger people (Carter et al, 2003). The concept of concordance has emerged as a principle underpinning many suggested solutions to these problems (Medicines Partnership, 2003). This article examines the concept of concordance and concludes that, while useful as a principle, it is difficult to translate into practice. This is implicit in practical attempts to do so where concordance is either not found (Latter et al, 2007) or is quickly substituted for something more meaningful, such as 'shared decision making' (Clyne et ai, 2007 p4), 'adherence' (Cribb and Barber, 2005) or even 'compliance' (van Eijken et al, 2003).

Abstract
This article shows that the terms compliance, adherence and concordance are used interchangeably in the medication management literature. As such, it is argued that nurses should focus on those interventions that are demonstrably effective in enhancing medication management for the older adult rather than attempt to make sense of a meaningless ideal. In this article the concepts of concordance, compliance and adherence are first critiqued and it is then argued that all the terms remain valid for practical purposes. That is, a literature search of all the terms is required to comprehensively discuss medication management. Focus then switches to factors that have been shown to be beneficial as weU as detrimental to medication management in older adults. While many factors appear to correlate with good and bad management of medication the conclusion is that individual, tailored approaches are most effective. For the purpose of this article, the term 'older adult' refers to those over 65 years where not otherwise specified. Key words: Adherence • Compiiance • Concordance • Medication management • Oider adults

Concordance, compliance or adherence?
Concordance is seen as the best way of managing medication (Medicines Partnership, 2003; Weiss and Britten, 2003; Latter et al, 2007). The term means 'together-heart' and infers complete agreement on a contract. If a patient does not adhere to a regimen that arose from a concordant discussion then it is the discussion that was at fauit, not the 'non-adherer'. This is a worthy ideal, but operationally problematic. For example, what if the medication prescribed is the best available option for someone? This knowledge can be based on high-quality evidence, yet the person can remain equally unconvinced Qessop and Rutter, 2003). (See Table 1 for definitions of concepts in medication management.) This suggests that the automatic practice of concordance is problematic when negotiations do not result in what the

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ompliance with prescribed medication is about 50% according to the National Prescribing Centre (Clyne et al, 2007). Given that 15% of the NHS budget is spent on medication (Clyne et al, 2007 p5) and the total NHS budget for 2007-2008 is ;£90.8 biUion (Department of Health [DH],2007 pl31) then non-compliance could cost about ;{^6.8 billion this year. As older people take more medication than younger people the majority of this amount is attributable to people over 65 years of age (Lenaghan et al, 2007). Reasons for non-comphance range from the unintentional and practical, such as an inability to open the bottle, to the intentional and attitudinal, such as the belief that the medicine does not work or does more harm than good. There is no evidence to suggest that these latter reasons differ

Table 1. Definitions of key concepts in medication management Concept Compliance Summary definition The paternalistic view that the person is a passive party who has his or her prescribed treatment enforced Adherence The (still paternalistic) view that the informed (but still passive) person will stick (adhere) to taking the recommended treatment Concordance The process of enlightened communication between the person and the healthcare professional leading to an agreed treatment and ongoing assessment of this as the optimal course Adapted from: Treharne et al (2006)

Austyn Snowden is Lecturer in Mental Health Nursing, School of Health Nursing and Midwifery, University ofWest of Scotland, Paisley Accepted for publication: December 2007

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prescriber thinks is best. To give an example, Latter et al (2000) found that when people had beliefs that facilitated medicine-taking, nurses worked with these beliefs and did not try to change them, even when the beliefs were related to the persons' hallucinations. However, when people had behefs that stopped them from adhering to their medicine regimen, nurses tried to modify these beliefs. In other words, the principle of concordance is fine as long as it does not compromise what the nurse sees as the duty of care. A further problem is that to assume concordance is optimal is to assume that everybody wants enlightened communication with the prescriber. There is evidence to suggest this is not so, particularly in an older adult population. For example, Neame et al (2005) showed that 78% of older adults felt they should be free to make 'everyday' decisions about medical problems, meaning more than one in five did not. When it came to 'important' medical decisions three out of four wanted to defer these decisions to the doctor and 50% would comply even if they didn't agree. However, it has been argued that this acknowledgement of the person's wishes is within the spirit of concordance. That is, the person's view still takes precedence because their wish is to delegate decision-making authority to the prescriber (Pollocket al, 2002). This justification highlights the major difficulty with the concept: if concordance can be made to encompass any type of agreeable person-centred discussion then it becomes meaningless - it cannot be tested empirically if it simply encompasses all good practice in medication management. If it is beyond testing it is beyond criticism. A further complication is that concordance, in the context of medication management, contains a prescription and the recipient of a prescription. A prescription is an instruction that surely alludes to an unequal (non-concordant) relationship. A patient has to be told about the script and given directions. It could certainly be argued in the spirit of Pollock et al (2002) that implicitly, if not explicitly, the patient and the prescriber therefore come to an agreement, a concord. It is clear, however, that this justification suffers from the same tautological problems as above. If concordance can be made into an all encompassing good it loses coherence as a concept and therefore cannot be tested empirically. What concordance seems to imply in the literature is respect for individual care through better communication. If this is the case then there is no justification for this principle to automatically exclude compliance or adherence. For example, van Eijken et al (2003) make a strong case for compliance being compatible with a personcentred approach. The words concordance, compliance and adherence are, therefore, interchangeable in the literature - not because they are misunderstood but because they often seek the same end. The need for a change in language to describe medication management can be seen inTreharne et al's (2006) definitions in Table l.The problem seems to be that the concepts of compliance and adherence ahgn, to some degree, with a paternahstic approach. The rejection of this approach on moral grounds has played a large part in the demise of overtly paternalistic thinking. So if paternalism is highly correlated with an intervention then that intervention must be bad. Compliance and adherence, therefore, have to go.Yet this assumes two ideas: they can be replaced with something else, and paternalism is never justifiable. This is highly questionable. For an excellent discussion on the philosophical and ethical implications of this debate please see Cribb and Barber's (2005 pi 15) analysis in Concordance, Adherence and Compliance in Medicine Taking. In brief they

argue that concordance is too wide a concept for the purpose of research and evaluation. Instead they identify aspects of medication management that have demonstrable effects and can therefore be assessed, including wider public health and economic considerations. These aspects can be placed into four categories that they suggest can be represented as a process. The categories are shown in Table 2. It can be seen that the principle of concordance runs through the model but elements of compliance and adherence also persist. For example, the first aspect refers to following through with professional recommendations as a measure of medication management. This is compliance and has nothing to do with idealized notions of concordance. However, Cribb and Barber's (2005) inclusive set of positive measurable aspects of medication management is arguably more meaningful than simply abandoning terms because they are no longer politically acceptable. There is also a more pragmatic reason to keep all the terms in mind. Since the term concordance is relatively new much of the research on medication management is

Table 2. Measurable aspects of medication management
A. Following through decisions over time Including: - Following through with professional recommendations about treatments/ action, and/or - Following through with patient informed choices about treatments/action. (Following through here means carrying out and/or appropriately reviewing). B. Good quaiity decision making Including; - Supporting informed patient choice (patient education, understanding, decision-making involvement, responsibility), and/or - supporting informed professional choice (knowledge of patient specificities, perspectives and preferences) C. Good quality healthcare relationships Including: - Broader and deeper communication, and/or - Mutual respect, and/or - Elements of partnership working D. Good outcomes Including: - Patient satisfaction with medicine taking, and/or - Optimal health gain for individuals, and/or - Promoting cost-effective use of treatments, and/or - Stewardship - avoiding the waste of (often collective) resources (e.g. medicines, consultation time), and/or - Public health From: Cribb and Barber (2005)

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filed under the key terms 'compliance' and 'adherence'.The terms need to stay alive if only for a comprehensive search of the literature.

Box 1. Effective interventions in medication management for oider peopie Appropriate prescribing for older people, and monitoring of their conditions, are key objectives. However, it is not only prescribing but how medicines are used by patients that is important. Patients and their carers need more support for medicine taking. There are five main types of intervention: • Prescribing advice/support • Active monitoring of treatment • Review of repeat prescribing systems • Medication review (with individual clients and their carers) • Education and training From: Department of Health (2001b p4) stopped than started, but the drugs started were newer and more expensive. Lenaghan et al (2007) found much the same in their study of home-based medication review in people over 80 years. They demonstrated no positive outcomes in relation to clinical outcome or quahty of life. Like Zermanski et al (2006), Lenaghan et al (2007) noted a change in overall prescribing but here there was also decreased cost associated with the change. They noted this was probably offset by the cost of the reviewing, but there may well be secondary benefits as yet unseen. What is notable in both studies is that outcomes are measured in terms of measurable 'goods', mainly relating to cost. However, Leneghan et al (2007) make the point that reducing falls and taking more appropriate or less overall medication may well correlate with longer term benefits associated with reduction in polypharmacy. There is no evidence which shows that older people are more or less likely to be non-adherent than members of other age groups (Carter et al, 2003). Ho et al (2004) found good compliance with prescribed inhalers in their study of 500 people over age 70 years with chronic obstructive pulmonary disease. The researchers found that people were not as compliant as they thought themselves to be. This is a common finding and suggests studies that simply measure self-reported medication-taking might be over-estimating compliance rates. However, there is also more objective evidence that older people are competent at managing complex medication regimens (Bytheway et al, 2000). Given that these studies show that older adults can manage their medication then one conclusion must be that a proportion of older people fail to take their medications as prescribed because they do not want to take it, just like the rest of the population (Carter, 2003). One opinion (Crome and Pollock, 2005) suggests this may be to do with issues of control. That is, autonomous people want to exert control over their illnesses, even to the extent of suffering pain rather than taking medication they don't believe in. However, at least 10% of hospital admissions are thought to be a direct result of non-adherence to medication (Chia et al, 2006).Therefore, it is important to explore all potential factors relating to the causes of non-adherence; that is, hospital admission must surely be seen as undesirable by the vast majority, and especially by people who view themselves

Literature search
So for the purpose of discussing the literature on effective medication management strategies in older adults all terms were searched in CINAHL and MEDLINE. Search terms used were: ('old*' OR 'geron*') and ('concordance' OR 'comphcance' OR 'adherence' OR 'medic* management') in the title in CINAHL from 2000 to present. It is interesting to note that PubMed returned no results for the search term 'concordance'. The assumption implied hy Cribb and Barber (2005) and accepted here is that effective interventions specifically addressing aspects of concordance, compliance or adherence — however defined — are likely to improve medication management. For example, Ryan-Wolley and Rees (2005) found that a medicine organizer (e.g. a dosette box) reduced drug waste from 18.1% to 1% in a study of frail elderly people. A medicines organizer would then be of practical use to improve any prescriber relationship. The secondary finding that there was also a significant decrease in the number of prescribed drugs and dosages in the intervention group shows the benefit of increased professional attention to medication management in general.

Medication management in oider aduits
Prevalence of chronic disease increases with age (Alder et al 2005; Scottish Executive, 2005) and older adults receive the majority of prescriptions (Lenaghan et al, 2007). Most prescriptions are for chronic disease, which infers that older adults use and waste the most medication. Within 10 days of filling a prescription, 30% patients with chronic disease have missed at least one dose, half unintentionally and half not (DiMatteo, 2004). Four in five people over age 75 years are prescribed at least one medicine and 36% are prescribed four or more medicines (DH, 2001a). This does not necessarily suggest that too much medication is being prescribed. More than 10% of older adult admissions to hospital are thought to be a direct result of not taking prescribed medication (Chia et al, 2006). As a further complication some suggest that older adults are not being prescribed medication when they should be. Rudd et al (2004) presented evidence that whereas 71% patients under 65 years receive lipid-lowering drugs following admission for stroke, only 54% patients over 75 years received the drug. Competing concerns such as these were the impetus for the National Service Frameworkfor Older People (DH, 2001a), which

proposes a regular review of care home residents' medicine as specified in the accompanying publication. Medicines and Older People (DH, 2001b) {Box i). Zermanski et al (2006) tested these recommendations {Box 2) by reviewing the medication of older adults living in care homes in Leeds. They reviewed 315 people in 65 care homes over 6 months. They found no change in hospital admission, mortality, cognitive function or activities of daily living. However, they found a reduction in falls and a change in medication regimens; more drugs were

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as autonomous agents. George et al's (2006) study of residents in sheltered housing complexes in Aberdeen found non-adherence in 28% of people. Factors correlated with non-adherence inciuded younger age, confusion about drugs, lack of drug supply and administration, perceived view of risics outweighing benefits, and the fact that treatment recommendations interfered with lifestyle. Lowe et al (2000) found that factors of non-adherence included experience ofthe medicines in terms of side-effects and the perceived inefficacy of treatments prescribed. It is clear that side-effects and inefficacy encompass a broad range of issues from the practical to the rational and emotional. As such it is no surprise to find they are difficult to address with a single strategy. But each person is different and has his or her own unique set of circumstances and beliefs about medication management. Interventions should ideally reflect this; however, there is common sense in looking for broader commonalities and targeting demonstrably effective interventions at those most in need. In other words, avoid those factors that make matters \vorse and focus on interventions that improve medication management. These will be discussed in turn. the problem of the prescribing cascade — where drugs are added to counter the side-effects ofthe last drug, and so on. Constipation, nausea, headache and confusion are frequent consequences of prescribed medication and not necessarily a new disease. Treatment should include medication review rather than addition of (for example) aperients, analgesics or antiemetics. Hirst (2003) relates a case study of how stopping haloperidol as part of medication review drastically improved one woman's wellbeing: the symptoms the woman was showing could easily have been mistaken for the sideeffects of haloperidol and another drug (procyclidine) been added instead. Not taking medication as prescribed Chia et al (2006) conducted a systematic review to explore the effects of beliefs on medication adherence in older adults. They found a number of factors were implicated in adherence. The researchers found the most potent predictor of adherence was self-efFicacy, the belief that one can perform a specific behaviour under differing conditions, i.e. confidence in one's ability to maintain control over a medication regimen. Medication efficacy was also a factor. That is, if a medication was perceived to be of great benefit or necessity then it was more likely to be taken. This belief was found to be tempered by the perceived likelihood and severity of adverse events (Home and Weinman, 2000) or the presence of alternatives (Brown and Segal, 1996). For example, major barriers to effective pain relief in older adults with cancer have been shown to be related to fears about tolerance and addiction (Thomason et al, 1998). Illness perception is also a factor. For example, better adherence to asthma medication was found in older women who believed they had asthma and that it could be controlled. Also factorial were the beliefs that it was not caused by external factors, such as pollution or chance. Long-term adherence was also predicted by these beliefs (Jessop and Rutter, 2003). In other words, if older adults feel any of the following, they are less likely to take medication as prescribed:

What makes medication management worse?
Many different risk factors have been identified, such as dislike of taking medicines, concerns regarding efficacy and side effects, decreasing manual dexterity, cognitive dysfunction and incompatible personal beliefs (Marriot and Nation, 2002; Lewis et al, 2003; George et al, 2006). These risk factors can be grouped around two main findings for the purpose of discussion, namely, older people are more likely to: • Take multiple medicines with high dose frequencies (DH, 2001a) or • Not take medication as prescribed (Chia et al, 2006). Taking multiple medications Polypharmacy is a known risk factor for non-adherence and more importantly, adverse events. When two drugs are given together it becomes very difficult to know how exactly they and the body will interact and react. Some of the more common interactions are in Table 3. Reasons for these interactions differ, but, for example, if both drugs are metabolized by the same enzyme then that enzyme may not be able to effectively metabolize both. This is increasingly the case with advancing age where kidney and liver function are known to decrease in most people (Durrance, 2003).The net efFect may be an accumulation in the body of one or both drugs/metabolites. The cascade effect of that becomes difficult to predict. It is easier to predict that there will be an increase in falls, mental health problems, car accidents and hospital admission as a result (Loftipour and Vaca, 2007). Adverse reactions to medicines in older adults are implicated in between 5% and 17% of hospital admissions (Clyne et al, 2007). Polypharmacy is common because older people have more chronic disease (Scottish Executive, 2005) and subsequently need more treatment. However, even this simphstic view belies that finding that many older adults are prescribed unnecessary drugs. This can be illustrated with

Table 3. Common drug-drug interactions
Second drug
ACE inhibitors Aminoglycosides Carbamazepine Digoxin Griseofulvin Lithium Nitrates Simvcistatin Sulphonylureas Warfarin Potassium-sparing diuretics Diuretics Many antidepressants St John's wort Warfarin Many analgesics Sildenafii Itraconazole Ketoconcizole Antifungais Many antibiotics Increased risk of hyperkaiaemia Increased risk of ototoxicity Anticonvulsant effects reduced Plasma concentration of digoxin reduced Anticoagulant effect reduced Lithium excretion reduced Hypotensive effect incresased Increased risk of myopathy Increased risk of hypoglycaemia Anticoaguiation may be increased From: Reid and Chrome (2005)

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Do not believe they can take the medication as prescribed Do not see the necessity of it Do not believe in the effectiveness of it Feel concerned that adverse events outweigh perceived benefit. Not all of these beliefs are necessarily unreasonable or groundless. In an extremely candid letter to the BMJ Masters (2003) admitted to consulting the British National Formulary on 'quite a few occasions' to discover the clinical indication of some of the medicines he was responsible for prescribing. Given that this act may be more commonplace than generally acknowledged, older adults may be right to question some prescriptions. Admissions such as this should be borne in mind when examiningfiguresabout prescriptions not being dispensed or not taken as prescribed.

• • • •

How is medication management improved?
One of the most widely used practical medication aids is the dosette box or medicines organizer (Ryan-Woolley and Rees, 2005). This is a compartmentalized device filled under supervision of a pharmacist and designed to simplify complex oral medication regimens. Dosette boxes/pill organizers are widely believed to be effective and practical for people with difficulties remembering or with other sensory deficits. However, Moisan et al (2002) found pill organizers to have no effect on compHance in their study of older adults who had difficulty reading. McGraw (2004) found them to be beneficial for people trying to control diabetes but ineffective for people with hypertension. The reasons for this were not absolutely clear but thought to be attributable to participants' views of the severity of their illness and the need for medication. The populations studied were not exclusively older though, and the review had very strict exclusion criteria. Attempts to improve other factors of medication management have proved similarly complex. In a very small study Higgins et al (2004) found 'concordance therapy' to enhance antidepressant medication compliance in older adults, but not by much. Higgins et al (2004) described concordance therapy as an amended version of Kemp et al's (1996) 'compliance therapy' with increased focus on the negotiation element of medication management. Compliance therapy has proved successful outside the ' clinical trial context according to Surguladze et al (2002) and could offer real benefit. It can be broken down into the following three areas: 1. Eliciting the patient's stance towards treatment 2.Exploration of ambivalence 3. Working towards treatment maintenance. It was difficult to see how concordance therapy as described by Higgins et al (2004) differed from cornpliance therapy, as they followed the same three-stage process. The intervention was based on a model of cognitive behaviour therapy and outcome measures were related to adherence. Nevertheless it had a marginal effect and it was interesting to note that the control group in this study also improved their medication adherence. This would suggest some other factor might be involved. For example, the Hawthorne effect is an enduring, if flawed, theory of the beneficial

consequences of increased observation and attention (Mayo, 1933). Undoubtedly the act of intervention can itself be beneficial (Atkinson, 2000). In reviewing the evidence on the efficacy of written instructions, Raynor et al (2007) reviewed over 50000 citations and concluded that written information alone was not valued by patients. This would add weight to the theme that simplistic generic or non-individualized approaches appear broadly ineffective in enhancing medication management. For example, Roter et al (1998) conducted a systematic review of interventions designed to improve compliance in people taking antipsychotic medication. They found individualized tailored approaches most effective. In a review of interventions targeted at enhancing compliance in the general population, Haynes et al (2000) also concluded that the best interventions were complex and individually tailored. However, even they did not lead to large improvements in treatment outcomes. One ofthe more unusual studies was that of Dow et al (1991). Their study differed in that it focused on educating patients about how to ask questions regarding their medication instead of attempting to educate patients about their medication. This method had the added benefit of improving patient confidence when talking to prescribers, which in turn enabled prescribers to elicit more pertinent and relevant information, which subsequently enhanced compliance. In many ways this should be no surprise as this patient-centred intervention aligns with the best-practice concepts of learning. This was the only study found which sought to systematically empower patients rather than teach them. This theme was picked up by Nolan et a! (2004) who suggested that the best predictor of good medication management is the extent to which people feel able to discuss their treatment options with the prescriber. This makes sense as it allows for a more thorough investigation of beliefs and related actions that may or may not align. That is, if a person is acting in a certain way because she believes she should, yet her actions contradict this or her information is incomplete, then discussing this may improve the chances of the her actions being congruent with her fully informed beliefs. Conciusion i There are no simple strategies for improving medication management in older adults. Concordance is a useful concept only to the degree that it engenders individual approaches and encourages deeper communication to elicit medicationtaking beliefs. Success is still measured and discussed in terms of compliance and adherence in the literature. There are useful frameworks to guide the nurse in supporting these discussions (e.g. National Prescribing Centre, 2007). Good outcome predictors include patient confidence to discuss medicines. Multiple medicines are a good predictor of non-compliance and should be reviewed. An older adult's view of the efficacy of medication and perception of illness are useful indicators of treatment adherence. Individually tailored approaches to medication management are undoubtedly best and should be explored as far as is practical. uM

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Tlie Pharmaceutical Journat 271(7270): 493 Zermansky AG, AUdred DP, Petty D R et al (2006) Clinical medication review by a pharmacist of elderly people living in care homes-randomised controlled trial. Age Ageing 35(6): 586-91

KEY POINTS
I Positive medication management is currently discussed under the term concordance, I However, concordance is a normative concept and thierefore impossible to meaningfuiiy evaluate. I It is more dinicaiiy useful to focus on interventions that are demonstrably effective in addressing all aspects of medication management, I Oider people have similar reasons for non adherence as younger people, I Individually tailored approaches focused on empowering people to discuss their views of iiiness and medicines appear most effective, I This does not exciude discussions on compliance and adherence.

British Journal ofNursing, 2008, Vol 17, No 2

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