Practice question

Practice question

Concordance concerns the ability of a person to take medication as prescribed. Whether the person with cognitive impairment chooses, or is able, to take medication as prescribed is multifactorial:

Nature of the medication, form, frequency and specific administration requirements.

Personal preference.

Nature of the cognitive impairment and its effect on understanding, memory and decision making.

Functional ability.

Social situation.

Medication management

How can medication concordance be effectively achieved in patients with cognitive impairment, including those with dementia?

A dosette system can help older people to take multiple medications on the right day

Picture credit: Getty

In recommending medication, practitioners tend to expect concordance. The ability to take medication as prescribed is often not explored. For the person with cognitive impairment, and their carer, resulting problems include:

Anxiety and frustration.

Over or under-dosing.

Under-treatment.

Unresolved pain, discomfort and distress.

Compromise in health.

Hospital admission.

Reviewing prescription

When concordance with medication is a problem, the opportunity should be taken to review the prescription. With the person and their carer/advocate, consider the risks and benefits of each medicine alongside the practical reality of taking medication. Involve the prescriber and a pharmacist in discussion if possible. Some medication is difficult to take correctly, for example, bisphosphonates. The risk of inability, or fluctuating ability, to follow administration requirements may outweigh the potential benefits of prescription. A person may not be able to take regular medication four times a day, but could manage one or two. The quantity of tablets may be problematic.

As well as considering the nature and number of medications explore the act of taking medication. Is it possible that medication would be more palatable in another form? Are there problems with opening boxes/blister packs? Can the instructions be seen, read and understood? Can the person remember to take medication at the right time and on the right day? What strategies could be used, for example, easy-open bottles, large print labels, visible notices, an alarm, a phone call, a carer visit or a timed digital voice message from a loved one.

Many people benefit from having medication dispensed into a dosette system. Suggestions to prompt are available, particularly for people who live alone (Social Care Institute for Excellence 2005, Alzheimer’s Society 2014a).

Solutions and capacity

If you work in a hospital or care home, explore possible solutions with colleagues as well as with the person and their family. There may be a member of staff who is trusted or a noted ritual that helps, for example, a particular drink or a particular use of words. A quiet environment may help. You may need to assist the person either at the end or beginning of a ‘round’ to ensure that you have more time.

The first principle in considering capacity (Alzheimer’s Society 2014b) is to assume the ability to make decisions. You must seek to enable people to make informed choices about when, whether and how to take medication. The means and degree of detail in which information is offered depends on the recipient. Some people seek repeated comprehensive information, others like an accessible list of each medication, what it is for, what it looks like and when and how to take it. Some will be satisfied with ‘this one is for your blood pressure’.

If the person lacks capacity to make decisions related to taking medication as prescribed, the process of review and exploration of aids must consider, in consultation with carers/attorney, the person’s best interests. A risk/benefit analysis of each medication must occur, coupled with consideration of how it could be taken, culminating in an agreed plan.

Exceptionally, if you have worked together to minimise the number of medications that are essential and are unable to find a way to enable the person to take them, consider administering medication covertly, that is, disguised in another substance. Such a prescribed intervention must adhere to professional, organisational and national guidance (National Institute for Health and Care Excellence 2015).

The nature of cognitive impairment, whatever the cause, is that it is rarely stable. It is therefore essential to regularly review and adapt strategies that maximise the potential for safe and therapeutic medication management.

Do you have a question?

This page is written by members of the older people’s specialist nurse and senior practitioner group, British Geriatrics Society. Questions can be emailed to lisa.berry@rcni.com

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