Are you taking your medicine? Nearly half the time, the answer is “no.”

This blog is by Ayobola Chike-Michael, Patient Safety Project Manager at the Health Innovation Network

The real life cost of non-adherence

Medicines are made to be taken. Right? Well, medicines are being manufactured, prescribed and dispensed, but up to 30–50 per cent of prescribed medicines may not be taken as directed. This is a big issue for John Weinman, distinguished Professor of Psychology as Applied to Medicines at King’s College London, who recently gave a presentation to representatives from all 15 Academic Health Science Networks (AHSN) on this topic. It’s also a prevalent issue for doctors, pharmacists, patients, carers and relatives. If this is not an issue in your world, it should be.

“Non-adherence” to prescribed medication is when a person does not take the medications as directed. This is surprisingly very common. As a result of this, many kitchen drawers overflow with medicines that eventually get thrown away, or worse, cause harm to an unintended consumer.

A look at some of the contributing factors
It’s not only patients who feel the negative impact of non-adherence; evidence shows that there are poorer clinical outcomes and increased healthcare costs associated with it too. This 2018 OECD report states that poor adherence contributes to 200,000 premature deaths in Europe per year and costs 125 billion euros through avoidable hospitalisations, emergency care and outpatient visits. Good-quality health as defined by the OECD is three times lower in those who do not adhere to their medication. It is a huge drain on public reserves and a massive health challenge to overcome. Most significantly, it does not have to be this way.

So why would someone who is unwell and needs medication not take it? The reasons why transcend the smell or size of the tablets they are given. Some people do not believe that medication is important for them. Some worry about side effects or lose motivation and so refuse to take them or do not take them as prescribed. Research literature identifies almost 200 reasons for non-adherence. Some are obvious, others are less so. But when there are so many factors involved, how do we know where to begin supporting patients?

With adherence, patients experience an improved quality of life because their symptoms can be reduced…

Understanding the why

King’s Health Partners established a centre that addresses these questions and many others relating to matters of adherence. The Centre for Adherence Research & Education (CARE) provides a hub for understanding and addressing the reasons for non-adherence. The team of experts at CARE aim to improve patients’, caregivers’ and health and social care staff’s awareness of non-adherence and provide approaches to support patients.

CARE has carefully grouped the many reasons for non-adherence into three manageable areas: Capability, Opportunity and Motivation.

Capability. Some people do not know how to properly take their medication, or may have problems with their understanding, memory or physical ability to do so.

Opportunity. Some people are limited by situations outside of their control. These are external challenges such as financial constraints, access and lifestyle opportunities.

Motivation. Some have developed a negative perception about their medication through social pressures and stigma, or as a result of their perspectives and experiences (those of side effects or low moods, for example) can become convinced that the medications are not necessary or beneficial to them.

Improving adherence

It is important that healthcare professionals and carers understand, and support their patients’ understanding of, the impact of non-adherence. But equally important is that we promote and celebrate the benefits of adherence. With adherence, patients experience an improved quality of life because their symptoms can be reduced and they can benefit from increased physical function and improved health outcomes. This is a win-win for patients and healthcare professionals.

Some healthcare professionals feel limited in supporting their patients to improve adherence because of the tremendous time pressure they’re under, or because they don’t know how to go about it. The CARE approach enables collaborative working with the patient to find solutions. They train clinicians to understand the issues and provide them with user-friendly tools and support strategies designed for routine care. These are available on the King’s Health Partners Learning Hub.

To join our conversation around how to support patients in getting the most out of their medicines, contact a member of our patient safety team at hin.southlondon@nhs.net. Let us all in our individual capacities do what we can to make the world of medicines a better place.

Reducing Inappropriate Polypharmacy in Care Homes

Aiysha Saleemi

Polypharmacy – literally meaning ‘many medicines’ – is defined by the World Health Organisation (WHO) as use of four or more medicines and is extremely common among the older population. In fact, on average, care home residents in the UK take seven medicines a day¹. This mix of numerous medications, at times prescribed by multiple clinicians, comes with a massive 82% risk of adverse drug reactions².

Dementia week

I have been a qualified pharmacist for over 10 years and I am currently completing the Darzi Fellowship; a one year leadership course accredited by London South Bank University (LSBU). Within this year, I have been tasked with a project to ‘reduce inappropriate polypharmacy in south London care homes’. An exciting but daunting task for a 12-month period, which if I am successful in, has the potential to reduce hospital admissions, 5-20% of which are related to adverse drug events, and subsequently contribute to saving the NHS millions of pounds per year³ As part of this project, I also aim to specifically reduce the use of anticholinergics in people with dementia. Anticholinergic medicines, often prescribed for various conditions (such as hay-fever and depression), can cause a number of uncomfortable side-effects such as constipation, dry mouth, dry eyes and confusion, but beyond that, they also block the beneficial effects of medicines used for dementia.

Dementia generally affects the older population, for whom polypharmacy is commonplace. Taking numerous medications poses the risk of medication errors, non-adherence and adverse drug reactions and is particularly dangerous for the older population as some of these individuals may also be extremely frail leading to increased susceptibility to illness and slower recovery times. Between this, and the fact that at the current estimated rate of prevalence, the number of people with dementia in the UK is forecast to increase to over 1 million by 2025 and over 2 million by 2051, I was determined that my project would contribute to improving the quality of life of care home residents living with dementia.

My project has been focussed on four care homes in south London. At each of these care homes, we are trialling several interventions. One involves the nurses and carers being informed on the dangers of anticholinergic drugs for people living with dementia and which medications have high anticholinergic activity so they can highlight their use to the pharmacist or doctor. The aim is that the medicines will be reviewed and hopefully reduced or stopped if no longer providing the most benefit to the resident. Another intervention involves educating residents and relatives on the potential risks of polypharmacy so they will understand why some medicines might be stopped. Data is being collected around the knowledge and confidence of nurses and carers to highlight these medicines for review to the pharmacist or doctor and if the reviews result in reduced use of anticholinergics.

Working on this Darzi project is very new to me, but it has been a great way to not only use my pharmacy background to have a direct impact on improving outcomes for a vulnerable patient group, but it has taught me a lot about project management and the importance of building good relationships with all your stakeholders. I have thoroughly enjoyed meeting new people from different organisations and getting to share my knowledge with others, knowing it might help them to improve outcomes for care homes residents. Although there are no results to report yet, I have learnt a great deal.

My top tips so far, for how to reduce inappropriate polypharmacy in care homes are:

1. Involve everyone in the decision-making. Polypharmacy affects the care home residents, relatives and staff members and so ensuring that everyone’s voice is heard is imperative. Consider holding focus groups for residents/relatives and attending GP and care home meetings to capture healthcare professionals’ opinions.
2. Keep your stakeholders updated and informed. Engaging all stakeholders once and then not communicating with them again will lose their enthusiasm for the project. Attend regular meetings or send information to be added to their local newsletters so that everyone is kept informed. Also, ensure that the GPs have agreed for any interventions to be trialled.
3. Target the type of medicines you want to concentrate on reducing. There are hundreds of medicines available in the UK and so it is important to pick the specific medicines you want to work on first. Think about the medicines that may be causing the most harm in your chosen population.

I hope the data collected from this project will demonstrate that these simple but effective interventions can contribute to reducing the use of inappropriate polypharmacy in care homes, and – most importantly – improve outcomes for residents with dementia. And if so, I hope that other care homes in south London will be able to easily adopt some of the methods used in my project and perhaps even spread it across the rest of London.
There are no results to report on this yet but final results will be published on the Health Innovation Network website in August 2019.

Be the first to read Aiysha’s final report, by signing up here

References
1. The Royal Pharmaceutical Society (2016) The Right Medicine – Improving Care in Care homes Available from https://www.rpharms.com/
2. Prybys, K., Melville, K., Hanna, J., Gee, A., Chyka, P. Polypharmacy in the elderly: Clinical challenges in emergency practice: Part 1: Overview, etiology, and drug interactions. Emergency Med Rep. 2002;23:145–53.
3. Barnett N., Athwal D. and Rosenbloom K. (2011) Medicines related admissions: you can identify patients to stop that happening. Available from: https://www.pharmaceutical-journal.com/learning/learning-article/medicines-related-admissions-you-can-identify-patients-to-stop-that-happening/11073473.article?firstPass=false