When it comes to the cost of mal-adherence, there is no denying that age is a factor. In the last 25 years, advances in medical science have achieved what no one could have thought possible; the number of over-85s has doubled. It’s hard to believe that by 2035, there will be more over 65s than under 16s, and that around half of over 75s will be living alone. Yet this demographic shift presents a call to action for pharmacists, prescribers and carers – how to keep our elderly population in good health for longer, using the limited (and rapidly dwindling) resources available.

When it comes to complying with prescribers’ and pharmacists’ instructions, the elderly typically have more to contend with than most:

  • Swallowing problems – associated with a range of age-related conditions, dysphagia is a common obstacle to taking medicines as prescribed;
  • Memory loss or confusion – despite best intentions, patients forget to take medicines in the intervals or quantities required;
  • Convenience – patients who live alone have difficulty ordering or collecting prescriptions, therefore relying on pharmacists to manage this for them.

Dysphagia and delivery systems
According to the Stroke Association’s Aileen Donald, acquired physical difficulties in swallowing are a common reason why many older patients fail to take medicines as prescribed. “Dysphagia is very closely linked with a stroke and other neurological conditions. In fact, up to 40 per cent of people who have a stroke have immediate significant dysphagia on the day of their stroke. With over two thirds of care home residents suffering from swallowing difficulties6, a one-size-fits-all approach to prescribing can seriously hamper their chances of recovery or a positive health outcome and have a significant impact on quality of life.”

Providing prescribed medication in an alternative format is an obvious choice to counteract the adherence issue in dysphagia sufferers. Most commonly prescribed medicines are available in a liquid form, whether licensed or unlicensed, whether as a solution or suspension. However, switching to a more easily consumable medicine must take account of two key issues.

Firstly pharmacists cannot put themselves at risk by mixing liquid medicines on-site. In this litigious society, crushing tablets or emptying capsules in the back room may seem like a quick and cost effective way to re-formulate medicine for patients, but it leaves pharmacists exposed in the event of a mistake. In the busy pharmacy environment, errors are completely comprehensible and can lead to two outcomes; either the pharmacist inadvertently renders the drug ineffective, or an incorrect ratio of active ingredients could lead to unintentional overdose. Either way, this compromises the patient’s welfare and critically, puts pharmacists in the spotlight of blame.

Secondly, replacing tablets or capsules with solutions or suspensions is, in itself, not a panacea for dysphagia sufferers struggling with compliance. As Ms Donald points out: “carers and nurses must still follow safe swallowing guidelines and consider how awake and alert someone is, use careful positioning and pacing and watch for any signs of difficulty. Switching tablets for liquids is not the whole solution.”

 Improving compliance for dysphagia sufferers is a team effort between prescriber, pharmacist and carer, where the pharmacist plays a vital role. Through MURs, pharmacists hold vital information on compliance which should be shared with prescribers to make sure patients are given medication in an easily consumable format. Plus, when producing solid medicines in a liquid format, rendering them unlicensed, it’s essential to outsource the process to a reputable partner to ensure medication is effective, safe and of the highest quality.

Dealing with dementia
For over 600,000 dementia-sufferers in the UK, understanding and coping with complex medicine regimes is a daily struggle. Yet according to the Alzheimer’s Society, it’s a problem many pharmacists aren’t equipped to manage. Recent research8 shows that only a third of pharmacists are sufficiently informed to confidently support those suffering with dementia. As a result, patients and their carers are missing out on a valuable source of counsel in the community on how to cope with this common condition.

However, in pockets of the UK, pharmacists are taking the initiative on dementia by supplying prescriptions in a patient-friendly monitored dosage format, with excellent results. Pharmacists providing dementia sufferers’ medication in pre-measured, colour-coded and personalised Biodose monitored dosage systems (MDS), have reported up to an 80 per cent increase in adherence9 across patients at home or in residential care. These simple systems have proven their worth in helping dementia patients overcome the confusion of managing multiple medicines at once, taking them at the right time and in the right quantities.

Until now however, these tools have only contained licensed medicines, ruling out the many patients who suffer from swallowing difficulties and dementia and rely on unlicensed medicines in a liquid format.

In reality, community pharmacies are ideally placed to offer a lifeline to dementia sufferers. While the pricing structure of generics is out of their control, introducing systems to contain all patients’ medicines, regardless of colour and shape, whether liquid or solid, is a step in the right direction in helping them take medicines as prescribed.

Community care campaign
As the NHS crackdown on overspending comes into force and services deemed non essential are cut from our menu of health services, the role of community pharmacists in supporting the elderly is absolutely critical. Although squeezed by competition from multiples, many community pharmacies have made going ‘above and beyond’ their USP as they help older people maintain their independence.

Stories of pharmacists braving all weathers to deliver medicines on time, and continuing to make house calls to vulnerable patients who cannot leave the house, are hard to believe in the current trading environment. However, pharmacies’ role in the community is essential to their longevity and to the continued health of patients. Having suppliers with that same philosophy is critical, particularly when it comes to unlicensed medicines, which are notoriously difficult to source and take time to produce.

As government calls for us to pull together to deliver the savings to public funding, pharmacists are an even more vital part of the healthcare family than ever before. With a call for more elderly patients to be cared for in their own homes, the adherence challenge will move further into the spotlight and pharmacists’ knowledge and relationships with patients will be called upon more and more. If there were ever an opportunity to take a bespoke approach to patient care and work with prescribers to emphasise quality over quantity, this is the time.

Quantum Pharmaceutical

1. Daily Mail, 28 July 2011.
2. Daily Mail, GPs want to spend more time with patients, 29 July 2011.
3. Medicines adherence, Involving patients in decisions about prescribed medicines and supporting adherence. NICE 2009.
4. Costing statement: Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, NICE 2009.
5. Office of National Statistics. ‘Fastest increase in the oldest old’ – 1985 vs 2010’
6. Steele CM, Greenwood C, Ens I, Robertson C, Seidman- Carlson R. Mealtime difficulties in a home for the aged: not just dysphagia. Dysphagia 1997; 12: 43–50.
7. Report published by National End of Life Care Intelligence Network, June 2010.
8. www.alzheimers.org.uk, Pharmacists need more support to advise people with dementia, Feb 2011.
9. Protomed, 2009/ 2010.

Further information
For more information on stroke and dysphagia, visit www.stroke.org.uk. And to find out more about unlicensed solutions for patients with swallowing difficulties, see www.quantumpharma.co.uk.