Non-compliance/ concordance with medicines - the never ending challenge! Joan MacLeod, Lead Pharmacist, Aberdeen City CHP

A few scenarios……. Patient on warfarin (in blister pack) – has carer support - dose is increasing but INR remaining at 1.0 COPD patient started on Symbicort 200/6 – tells you that it helps sometimes – has ordered 4 in the last yr – says he takes it every day Care home patient - #NOF – Rx Natecal D3 – usually spits it out or refuses to take Patient – h/o stroke & glaucoma – using 4op of eye drops each month Formal carer has not been giving a patient their painkillers – paracetamol & dihydrocodeine.

Scenario Explanations Patient is lonely – stalled the carers by being non- compliant; didn’t think about the implications re: INR Had never been shown how to use the inhaler – if the inhaler rattled he continued to use (he was hearing the desiccant) Patient hates aniseed flavour Limited manual dexterity = poor control = more than one drop at a time Directions on label were ‘2 as directed’ and ‘2 when required’; carers not able to make clinical decisions

What can we do to help?

1.Involvement of Patient (& Carer) in Process Do they want another medicine? Think about the OUTCOME that will be achieved – is this agreeable with the patient/carer Offer choice but be prepared to make the choice! Keep options open: “How about we trial this ? – if it doesn’t agree with you then we go back to what you had.” Encourage honesty : “If you don’t want this, just say….” Review, Review, Review

2. Clear Instructions Avoid ‘PRN’ & ‘MDU’ wherever possible State dose, max daily dose and indication e.g. 1 tab up to twice a day for agitation Formal carers will not make professional decisions re: PRNs Update repeat prescriptions Option of care plans for complex patients

3. Timings of Doses Keep regimens as simple as possible – easier for all to remember! –Consider MR/SR/XL preparations to reduce dose frequency –Consider alternative drugs which may make regimens easier Compromise – better the statin is given in the morning than forgotten at night Care packages – find out the times of day they are in – if a carer isn’t in at teatime, don’t prescribe meds at teatime

4. Tolerabilty Taste (e.g. CaVitD, Movicol, Gaviscon) Texture (e.g. Fybogel, lactulose) Route Side effects –always highlight common side-effects and how to manage/ when to seek help Monitoring requirements –will the patient want to/be able to comply with blood monitoring etc

5. Do they really need the drug? What is the outcome you are trying to achieve? –Statins, antihypertensives in frail elderly Remember the negative consequences of drugs on quality of life –Polypharmacy: falls risk, confusion, constipation –Antimuscarinic s/e More medicines = reduced ability to manage for many frail elderly –De-prescribing is as important as prescribing

6. Aides EYE DROPS: Autodrop® Autosqueeze® Opticare® Opticare Arthro® INHALERS: Haleraid®, Spacers® Pill splitters/ cutters Pill punches Pill boxes (dossette boxes) Timers (Telecare- Pivotell® )

7. Pharmacy Filled Compliance Aids

Compliance aids (MCAs) Although ideal for some patients, not the solution we all think Some drugs cannot be safely packaged in an MCA They do not help the patient remember They remove choice RPS recommendations:

‘Marginal Gains’