Medication Management in Older Adults - a Critique of Concordance

Topics: Middle age, Old age, Psychiatry Pages: 17 (5909 words) Published: August 8, 2010
Medication management in older adults: a critique of concordance Austyn Snowden
across the hfe span; older people are just as unlikely to take a medicine that interferes with their lifestyle or behefs as younger people (Carter et al, 2003). The concept of concordance has emerged as a principle underpinning many suggested solutions to these problems (Medicines Partnership, 2003). This article examines the concept of concordance and concludes that, while useful as a principle, it is difficult to translate into practice. This is implicit in practical attempts to do so where concordance is either not found (Latter et al, 2007) or is quickly substituted for something more meaningful, such as 'shared decision making' (Clyne et ai, 2007 p4), 'adherence' (Cribb and Barber, 2005) or even 'compliance' (van Eijken et al, 2003).

Abstract
This article shows that the terms compliance, adherence and concordance are used interchangeably in the medication management literature. As such, it is argued that nurses should focus on those interventions that are demonstrably effective in enhancing medication management for the older adult rather than attempt to make sense of a meaningless ideal. In this article the concepts of concordance, compliance and adherence are first critiqued and it is then argued that all the terms remain valid for practical purposes. That is, a literature search of all the terms is required to comprehensively discuss medication management. Focus then switches to factors that have been shown to be beneficial as weU as detrimental to medication management in older adults. While many factors appear to correlate with good and bad management of medication the conclusion is that individual, tailored approaches are most effective. For the purpose of this article, the term 'older adult' refers to those over 65 years where not otherwise specified. Key words: Adherence • Compiiance • Concordance • Medication management • Oider adults

Concordance, compliance or adherence?
Concordance is seen as the best way of managing medication (Medicines Partnership, 2003; Weiss and Britten, 2003; Latter et al, 2007). The term means 'together-heart' and infers complete agreement on a contract. If a patient does not adhere to a regimen that arose from a concordant discussion then it is the discussion that was at fauit, not the 'non-adherer'. This is a worthy ideal, but operationally problematic. For example, what if the medication prescribed is the best available option for someone? This knowledge can be based on high-quality evidence, yet the person can remain equally unconvinced Qessop and Rutter, 2003). (See Table 1 for definitions of concepts in medication management.) This suggests that the automatic practice of concordance is problematic when negotiations do not result in what the

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ompliance with prescribed medication is about 50% according to the National Prescribing Centre (Clyne et al, 2007). Given that 15% of the NHS budget is spent on medication (Clyne et al, 2007 p5) and the total NHS budget for 2007-2008 is ;£90.8 biUion (Department of Health [DH],2007 pl31) then non-compliance could cost about ;{^6.8 billion this year. As older people take more medication than younger people the majority of this amount is attributable to people over 65 years of age (Lenaghan et al, 2007). Reasons for non-comphance range from the unintentional and practical, such as an inability to open the bottle, to the intentional and attitudinal, such as the belief that the medicine does not work or does more harm than good. There is no evidence to suggest that these latter reasons differ

Table 1. Definitions of key concepts in medication management Concept Compliance Summary definition The paternalistic view that the person is a passive party who has his or her prescribed treatment enforced Adherence The (still paternalistic) view that the informed (but still passive) person will stick (adhere) to taking the recommended treatment Concordance...
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