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Adherence in Older Adults

For our latest blog, CARE had the honour of speaking to Dr Jennifer Stevenson, Honorary Senior Lecturer at the Institute of Pharmaceutical Sciences, King’s College London, and a Highly Specialist Clinical Pharmacist working at Guy’s and St Thomas’ NHS Trust, about adherence in older adults. Dr Stevenson specialises in the optimisation of medicines in older adults. Her research aims to generate a better understanding of medication-related harm in older adults living with frailty and explores how to identify those at greatest risk of harm, especially at the transition of care.

What led your research focus to older adults and medicines use specifically?

Aside from a personal drive to give back, my professional drive was the complex and dynamic nature of the role. It’s a bit like a jigsaw puzzle: standard approaches often don’t apply to geriatric patients, making treatment very individually based. Also, the collaborative aspects – working with carers, next of kin, or even a patient’s neighbour, but also other professionals - geriatricians, physiotherapists, occupational therapists, social workers, GP’s and dieticians. To devise a collaborative plan of care to optimise health outcomes for the individual can be very rewarding.

What do we know about older adults and adherence to medicines? Can we distinguish any patterns and pitfalls?

We know that around 50% of older adults are non-adherent to their medication. In the context of frailty this is significant. Frailty is an individual’s vulnerability to external stressors. Older adults are much more prone to frailty. A minor stressor, like a UTI, can be harmless to a young person with the physical and psychological reserve to bounce back. But, in someone with frailty, it can lead to cognitive decline, hospitalisation - and they may never fully recover. The clinical implications of not adhering to medicines can be a source of stressors. A pattern we found is that almost a quarter of patients who experienced harm from their medicines in the eight weeks after leaving hospital were harmed due to non-adherence. That harm resulted in NHS care and costs.

A pitfall is that we still view capability as the main driver of non-adherence – both physical and cognitive. But, dosette boxes (multicompartment compliance aids) don’t work if the motivation to take pills in the first place is lacking. We don’t understand how social isolation and loneliness lead to negative health outcomes and mortality and how this relates to non-adherence and frailty. We need to get this right as there is a growing ageing population who need appropriate care.

Regular medication reviews would improve safety, clinically and personally.

What are some of the healthcare professional barriers in providing healthcare and addressing nonadherence? What do we need to change to make it better?

There is less evidence around older adults than in other populations or single conditions. Older adults often have multiple illnesses and take lots of different medicines, but there has never been a clinical trial to test all these treatments in an 85-year-old with multiple conditions and frailty. The risk versus benefit of treatment is, therefore, more uncertain and this feeds into adherence issues and harm from medication.

Regular medication reviews would improve safety, clinically - but also personally. Working with patients to find what works for them – their beliefs, concerns, and goals - and making shared decisions. Healthcare professionals need more skills, tools and techniques to do this. We also need better systematic continuity and communication between services and professionals as patients move between care settings.

How could we support adherence in older adults?

When prescribing, it is essential we look beyond medicines and consider patients’ social context, such as their package of care. For instance, prescribing a medicine taken three times a day when a carer only comes in once a day, is a problem. This increases the risks of harm from medicines. To improve medicines' safety, care providers need the time and skills to deliver medicines support.

Any last words of wisdom?

We have an ageing population who are living with multimorbidity, but we also have a segment of older adults who are incredibly fit and sharp – so we must bear that in mind during our consultations. Ageism is rife within our society; we so often think of what an older adult can’t do rather than what they can do. If we shift our mind set this would change a lot.

In this story

Jennifer Stevenson

Jennifer Stevenson

Honorary Senior Lecturer and Highly Specialist Clinical Pharmacist

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