Adherence with medication in nursing homes for older people: resident enforcement or resident empowe

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Adherence with medication in nursing homes for
older people resident enforcement or resident
empowerment?

• Roz Goldie and Carmel M. Hughes
• School of Pharmacy

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Mi-Ricordo-Quando-Ero-Fanciulla- I remember when
I was a child Angelo Morbelli (1852-1919)
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Background

• Medicines in nursing homes a major research focus
• Prompted by observation of unusual prescribing
  trends for nursing home residents
• Very high numbers of prescriptions for nursing
  home residents
• Very high numbers of prescriptions for
  psychoactive drugs
• Anti-psychotics, hypnotics, anxiolytics
• Large quantities long duration of use

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Nursing home residents

• Vulnerable population
• Average age is 80
• Over 70 are women
• Tend to be more physically and mentally disabled
  than those living in their own homes
• Need help with a range of activities
• Tend to receive more medication than age-matched
  patients who live in the community

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Recent N. Ireland findings
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Prescribing of medicines in nursing

• Prescribing is one of the most common medical
  interventions experienced by residents
• Residents have multiple medical conditions
• Residents experience polypharmacy
• Over-use of inappropriate medication
• Under-use of beneficial medications

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Concerns about medication in nursing homes

• Legacy of inappropriate use of medicines
• Chemical restraints
• Inadequate review and monitoring of medication
• Commission for Social Care Inspection reports
  highly critical of a range of issues related to
  medication in care homes
• Examples-incorrect storage, wrong medication
  being administered to residents, poor
  record-keeping and inappropriate handling of
  medicines by untrained staff

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Terminology around medicine-taking

• Compliance
• extent to which a persons behaviour (in this
  case, taking medications) coincides with medical
  or health advice
• Paternalistic
• Adherence
• Recognises a patients autonomy and the need for
  their agreement with a health professionals
  recommendations
• Concordance
• Patients can assume responsibility and contribute
  to decisions in health care, particularly in
  relation to medication

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To take or not to take?

• Intelligent or intentional non-compliance/adher
  ence may be exercised by patients
• Avoidance of side-effects
• What happens in nursing homes?
• Enforced compliance?
• Erratic compliance?
• Residents involvement in decision-making around
  taking of medicines?

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Aim of study

• To explore, using qualitative methodology, issues
  related to adherence with medication in the
  nursing home environment in Northern Ireland,
  resident input into medication decisions, and
  their involvement in these processes.

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Overview of methodology

• Focus groups and key informant interviews
• GPs, nursing home managers and those nurses
  involved in medication administration and nursing
  home residents
• Similar topic guides used for all participants
• Polypharmacy (use of multiple drugs)
• Compliance
• Administration of medicines
• Consent and refusal in medication-taking
• Patient involvement in prescribing decisions and
  medicine-taking
• Ethical approval received in November 2006
• All focus groups/interviews took place between
  Feb-May 2007

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GP recruitment

• GPs who provided care to nursing home residents
• Identified n19 via contacts in the four Health
  and Social Services Boards
• Received a telephone call, followed by letter,
  information sheet and consent form
• Attempted to recruited at least 2 GPs per Board
  area
• Interviews took place at each consenting GPs
  practice and were guided by topic guide
• All interviews were tape-recorded

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Nursing home manager/nurse recruitment

• All nursing home managers (n112) in N. Ireland
  were contacted by telephone using information
  provided by RQIA
• Further information was sent by mail (information
  sheet and consent form)
• Attempted to recruited at least two
  nurses/managers per Board area
• Two focus groups were planned which took place in
  either University or Health Board accommodation
• Focus groups guided by topic guide and all
  discussions tape-recorded

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Resident recruitment

• Participating nurses/managers were asked to help
  recruit residents who would be capable of
  participating in interviews
• Residents provided with information sheet and
  consent form
• Interviews took place in residents own room in
  the nursing home and were guided by topic guide
• All interviews were tape-recorded

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Analysis of the data

• All audio-tapes were transcribed verbatim and
  transcripts checked against the original
  recordings
• Analysis undertaken by two researchers using
  constant comparison principles
• Data saturation achieved
• Hierarchy of superordinate and subordinate themes
  were established

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Results

• Participants
• 8 GPs
• More males than females extensive experience
  with nursing home residents (gt10 years)
• 14 nurses/managers dispersed across two focus
  groups (n4, n5)
• All females all registered as nurses for at
  least 15 years working in present home 3-15
  years
• 17 residents
• 9 female, 8 male most over 75 years receiving
  at least 7 prescribed medications

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Major themes
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Prescribing and administration processes

• Both groups of health care professionals needed
  control of the prescribing or administration
  processes in order to ensure safety and
  continuity of care
• Prescribing was difficult to control
• Administration was more easily controlled

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Prescribing

• There is a bit of a tendency, in my opinion, for
  us to keep adding on incremental prescribing
  (GP2)
• I wish they could be more specific (about
  directions) (N9)
• I think the nursing homes would be very keen
  that they have control of the medication. (GP1)

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Administration

• Unlike patients in their own homes, they
  probably get most of their medication most of the
  time (GP2)
• Oh yes, you just stay with them with every
  medication that is given. You stay with them to
  make sure its all taken. (N2)
• They give me them to you with a glass of water
  and they stand there until you take them and give
  the glass back (R2)
• With nursing home care you adapt the rounds to
  suit the patients, you know. They dont have to
  be rigid. because its basically the residents
  home (N1)

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Problems with compliance?

• Most of the residents are very compliant. There
  havent been a lot of problems with compliance
  (N4).
• I havent come across many patients without
  dementia in nursing homes with compliance
  problems (GP7)
• I just get them and take them (R16)

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Factors affecting control

• Medication records
• Polypharmacy
• Control of disease versus control of side-effects
• Review of medication

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Medication records

• So, theres all these different sets of records
  and trying to make sure theyre all the same is a
  bit of an issue. (GP2)
• They come in (to the nursing home) and they do
  not have the right medications with them. (N5)
• Very poor discharge summaries with medication
  advice So that three of her vital medications
  were missing (N4)

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Polypharmacy

• Polypharmacy per se is a major problem in
  nursing homes. (GP6)
• Its just theres a serious mix of drugs there,
  you know. And Im still very concerned that shes
  on far too much. (N4)
• I get 6 tablets in the morning and 1 to make me
  go to the toilet and then 4 tablets at night and
  1 for sleeping. (R1)

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Control of disease versus control of side-effects

• ..In one way it is getting easier because we
  know the groups of medicines that we are supposed
  to use and in another way it is getting more
  complicated because we are definitely using more
  of them (GP4)
• We probably expect the nurses to know to expect
  these sort of side-effects. (GP2)

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Medication review

• We very rarely go and see what we can remove
  from their list or try to rationalise it. Just
  tend to add on and they end up on massive
  amounts. (GP6)
• They (residents) actually can improve with some
  of the medication being stopped. (N1)
• Id like to see the provision of a gerontologist
  to visit homes, say, every month. (GP8)

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Resident autonomy versus maintaining control

• Need for control was tempered by recognition that
  residents had the right to be involved in
  decisions about their own care
• Role of resident in decision-making
• Self-administration of medication
• Refusal of medication
• Loss of autonomy and disempowerment

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Role of resident in decision-making

• If it were appropriate (consulted about new
  drugs) we would attempt to do it but on lots of
  occasions we dont (GP4)
• They dont really want to take that
  responsibility (making decisions) (N5)
• No, I wouldnt need to say anything really about
  it. I just take what I am given. (R5)

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Self-administration of medication

• It maintains their independence and dignity
  and if theyre capable, why not? (N2)
• I feel its very much up to the individual and
  whether they want to self-administer. (GP7)
• At what point do you decide that theyre not fit
  to self-administer medications? (GP1)
• No, no. I cant take them myself. They come
  round. I could take them myself but they wouldnt
  allow me to. (R17)

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Refusal of medication

• They should be allowed to refuse if they want
  to. (GP6)
• If they do refuse we cant force we cant
  force the issue. (N1)
• Oh no, I have to take it. (R8)
• You think it would be in their interest to take
  it but if they wont take it you have to
  sometimes coax them and chivvy them to take it.
  (GP1)
• If it is in the best interest of the patient,
  then you have to find a way of getting it into
  them whether it is covert or not. (N5)

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Loss of autonomy and disempowerment

• Well they dont have much choice really. They
  have surrendered all their rights and personality
  and they just take their tablets and say
  nothing. (GP3)
• I think theyre of a generation that would be
  very compliant. (N4)
• I just take what I am given. I believe in
  doing what I am told. (R5)

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What does it all mean?

• Compliance is not a problem in these nursing home
  residents
• Other processes are more difficult to control
• Records, prescribing, polypharmacy, review
• Support for greater resident involvement in
  decision-making and self-administration
• Tension with the need to control because of
  safety concerns
• Loss of autonomy and independence

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Limitations

• Self-selected group
• Health professionals are potentially a gold
  standard
• Can we extrapolate to all nursing homes in N.
  Ireland/UK?
• Qualitative work does not seek to be
  generalisable, but seeks to be transferable
• Data saturation was achieved
• Main theme confirmed by triangulation of three
  data sources

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Independence vs. control

• Residents seemed to lose independence and the
  right/ability to makes choices when they entered
  a nursing home
• Reinforcement of control
• If residents were more independent and active in
  their own care, could affect the control of
  running of the home in an efficient way.
• Safety considerations
• Regulatory demands

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Total institutions

• Daily life is organised and regulated according
  to a predetermined schedule and all aspects of an
  occupants existence are provided for by that
  institution
• Nursing homes in this sample did not reflect all
  of these characteristics
• Tried to demonstrate flexibility
• Control may not always be negative
• Safe practices
• Psychological security for residents

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Balance between control and autonomy?

• Current policy thinking is in favour of patient
  engagement in decisions about their own health
• Empowerment may lead to better outcomes and
  better quality of life
• Takes time
• Does (should) this include nursing home
  residents?
• Understaffed homes, external control of
  regulatory bodies and internal control needed to
  run the home

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The dual environment

• Health care environment and home environment
• Medicalisation of the home environment
• Alternative approaches to the nursing home model
• Eden Alternative, Wellspring Model, Green House
  concept
• All seek to change the culture of nursing home
  care

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Irish Times, November 11th 2006
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Future directions?

• Potentially greater demands for some kind of
  residential care as the population ages
• Will future residents be less passive and more
  demanding?
• How can autonomy and empowerment be promoted in
  this setting without compromising safety?
• Alternative models of long-term care?

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Acknowledgements

• All participants
• Dr. Lisa Maguire, Mrs. Susan Patterson, Mrs.
  Naomi Baldwin
• Mrs. Roz Goldie
• Changing Ageing Partnership (CAP), funded by the
  Atlantic Philanthropies