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Innovation

Can nurse prescribing improve medication concordance in people with dementia?

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People with dementia often have problems taking medication. A memory clinic nurse prescriber was effective in offering timely advice and support for patients 

Author

Louise Stapleton, NMP, RMN, is memory clinic nurse, Bracknell Memory Clinic, Berkshire Health Care Foundation Trust,  Berkshire.

Abstract

Stapleton S (2010) Can nurse prescribing improve medication concordance in people with dementia? Nursing Times; 106: 46, early online publication.

Research has suggested that nurse prescribing can improve medication compliance in older people with mental health problems. An independent nurse prescriber at a memory clinic in Berkshire used a questionnaire to determine dementia patients’ attitudes to and awareness of nurse prescribing. This article describes how the survey responses were used to improve medication adherence and change practice at the clinic.

Keywords: Dementia, Medication, Memory clinic, Nurse prescriber

Practice points

  • Ensure patients know what drugs they are taking, why they are taking them, and when.  Also check that they are aware of any possible side effects, and what to do if they experience them.
  • Check that all patients with dementia are able to take their medication safely by organising dosette systems, and ensure carers can help patients where necessary.
  • Give all patients and their families’ information about how to contact the clinic nurse by providing verbal information and written leaflets.
  • Ensure patients have a written treatment plan.

Introduction

Just under half of all medications prescribed in the UK are for people aged 65 and over, with 36% of those aged 75 and over taking four or more prescribed drugs. However, up to 50% of those on prescribed medication may not be concordant with the prescribed regimens (SCIE, 2005).

People with dementia often have problems taking prescribed medication. They may forget to take it without prompting or supervision, and can lack awareness of their health problems. Some believe they do not need medication as they think there is nothing wrong with them.  

Research has suggested that nurse prescribing can improve medication concordance in older people with mental health problems. Murray (2007) said nurse prescribing has demonstrated it can greatly improve the service the NHS provides for its patients, including older people with dementia.  In a growing number of mental health practices, nurse prescribing is gaining momentum, demonstrating effectiveness and additional benefits to the patient group including effective medicines management  

Memory clinics

Memory clinics diagnose and treat Alzheimer’s disease. Originally developed in the US, they were first set up in the UK in the early 1980s (Royal College of Psychiatrists, 2004), and are recommended by the National Institute for Health and Clinical Excellence (2006) as a single point of referral for all suspected cases of dementia.

Early diagnosis and intervention of dementia is one of the main aims of the Department of Health’s dementia strategy (Department of Health, 2009).  

The memory clinic in Bracknell, Berkshire, is staffed by a psychiatrist and a clinic nurse. The memory clinic will see a person of any age who is suspected of having dementia.

As the memory clinic nurse (MCN) I completed training as non-medical prescriber (NMP) in 2006, and have practiced as an independent prescriber for the last three years, the first year as a supplementary prescriber. 

Sometimes patients are seen by the consultant psychiatrist and medication is initially prescribed by him, they are referred to me for ongoing prescribing and monitoring. I usually see patients for follow up appointments, either in an outpatient clinic or in their home, depending on their preference.

Nurse prescribing

Nurses were first able to prescribe independently in April 2006, making them responsible and accountable for the assessment of patients with undiagnosed and diagnosed conditions, and for decisions about the clinical management required (DH, 2006). In the same year the Nursing and Midwifery Council set standards of proficiency for nurse prescribers (Box 1).

Box 1. Standards of proficiency for nurse and midwife prescribers

Non-medical prescribers must have sufficient knowledge and competence to be able to:

  • Assess a patient’s clinical condition;
  • Undertake a thorough history, including medical and medication history and diagnose where necessary;
  • Decide on the management of the presenting condition and whether or not to prescribe medication;
  • Identify appropriate drugs if medication is required;
  • Advise the patient on the effects and risks of medication;
  • Prescribe medication if the patient agrees;
  • Monitor responses to medication and lifestyle advice. 

Source: Nursing and Midwifery Council, 2006

According to The National Prescribing Centre et al (2005), non-medical prescribing undertaken by mental health nurses can benefit patients by:

  • Allowing them quicker access to medication
  • Providing services more efficiently and effectively
  • Increasing service user choice
  • Making better use of nurse’s skills and knowledge.Essential competencies for nurse prescribers outlined by Courtenay and Griffiths (2005) include the ability to:
  • Establish a relationship based on trust and mutual agreement;
  • See patients as partners in the consultation process;
  • Apply the principles of concordance as the preferred method of communication in prescribing consultations.

Wix (2007) suggests that patients who have contact with a nurse prescriber receive a different type and quality of prescribing intervention than they receive from a medical practitioner. He argues that nurses are skilled in combining medication and psychological therapies and says that quality of care and patient satisfaction can increase, but concludes that nurse prescribing should not be considered to be ‘instead of’ traditional medical prescribing, but in addition to it.

Studies by nurse practitioners in the US suggested quality of care and patient satisfaction can increase when nurses prescribe, and that nurses are skilled in combining medication with psychological therapies (Talley and Richens, 2001,).

The benefits of nurse prescribing reported by nurses include more effective use of time, increased job satisfaction, status and autonomy, and being able to deliver complete episodes of care (Latter et al, 2005; Brookes et al, 2001; Rodden, 2001; Luker et al, 1997).

Nurse prescribing in memory clinics

There is little evidence about nurse prescribing in memory clinics. However, a study by Page et al (2008) found patients had confidence in the competence of the nurse prescriber, who they felt had a good understanding of their circumstances and illness.

The study considered the experience of patients and their families and carers in the early stages of implementing nurse prescribing in a memory clinic.  The study highlights the indispensible roles played by the family and carers in helping

ensuring medication concordance as well as clinic attendances.  It went on to say that NPs work particularly well when front line staff are perceived as empathetic, but backed by a well organised multidisciplinary team

Page et al say that they found that the nurse prescriber was empathetic and approachable, and the study identified that the patients and families were happy with the level of support they had from the nurse prescriber.

Concordance in healthcare

According to Cheesman (2006), concordance is an innovative approach to achieving the best use of medication involving the sharing of information between healthcare professionals and patients. The prescriber can promote an effective therapeutic relationship by building a patient’s confidence in their ability to self-manage their condition.

According to Jones (2009), nurse prescribing gives nurses the opportunity to educate patients about their medication. The amount of time nurses spend in contact with patients gives them the opportunity to negotiate treatment plans and increase concordance with treatment. Nurse prescribers’ enhanced consultation skills also allow them to engage patients in discussions about medication (Cheesman, 2006).

Medication non-compliance

Non-compliance with medication can be intentional and unintentional.

Intentional reasons include:

  • Concerns about the value or effectiveness of medicines and side-effects;
  • The inconvenience, and frequency of taking the drugs at the prescribed times.

Unintentional reasons for non-compliance include:

  • A lack of easily understandable information about how and when to take medication;
  • Difficulties reading labels and opening containers;
  • Taking several different drugs, or doses.

The following patients are most likely to have lower medication adherence rates:

  • Patients with depression, anxiety or cognitive impairment;
  • Elderly patients;
  • Patients on multiple medications and with complex regimens;
  • Patients on preventive medication;
  • Patients with chronic illnesses (DiMatteo et al 2000).

Before I became a nurse prescriber, medication was often returned to the clinic by patients and their families. The reasons for this included:

  • The patient stopped taking the medication without informing the team.
  • The patient did not take the medication because there was no one to administer it (for example if they were living alone)
  • The medication may not have been supplied in a monitored dosage system pack and the patient would forget to take it without help. All medications have to be dispensed into a monitored dosage system by a pharmacy in order for home carers to be allowed to administer them.
  • When the medication was prescribed by the psychiatrist, new patients were not reviewed until I saw them three months. Any problems patients had with their medication had already started and I would have to wait to see the psychiatrist to get the drug chart rewritten.

Patient survey

In 2009 the MCN sent a survey to 100 patients and their families to explore their views on nurse prescribing. Of these, 49 were returned. The survey results can be seen in Tables 1 and 2. Some of the questions were not answered by all respondents.

Some questions were not answered by all respondents.

Survey results 

Eleven of the patients surveyed said they felt they were not told about the  possible side effects of their medication or how the doses are usually increased over a period of time to the maximum therapeutic dose .  

Every one seen in the outpatient clinic are given booklets about their medication. However, they were not always available  during home visits.  Some patients may forget some of the verbal information given to them and may not read the booklets for numerous reasons.

To rectify this, I now take a supply of written information to give to patients on home visits. They also receive a review letter after every appointment detailing how their medication may change, side effects they may experience, and a reminder that the medication has been prescribed by a nurse.

The report also includes their treatment plan, details of any discussion about their medication, and details of how to contact me if they have any worries or concerns.

I also inform patients verbally about the medication, including side effects and how the dosing is titrated. Other changes to practice undertaken after the survey are outlined in Box 2.

Box 2. Changes to practice following patient survey

Always write to the patient after their appointment, including a summary of how medication may change.

  • Discuss the possible side effects of medication with the patient and/or their carer.
  • Ensure they know who to contact and when if they have a problem with the medication.
  • Maintain regular communication with the pharmacy.
  • Ensure enough time is allocated for writing prescriptions.
  • Keep up-to-date with any changes to medications.

Only six surveys were returned with comments. Although one person was “doubtful” that a nurse could diagnose and prescribe medication, the majority of the comments were positive about nurse prescribing.

Discussion

The more information patients and carers are given about medication, the more likely patients are to take it properly. Medication and treatment issues are always discussed at length with the patients, and carers are given written, easy to read leaflets before the patient starts the medication.  

I identified that the half hour slots originally offered for outpatient clinic appointments were not long enough, so they were extended to 45 minutes. Although this meant fewer people were seen in outpatient clinics, I felt that patients needed more time to discuss their medications, address their concerns and assess their progress.

Most patients are seen in their own home which can take up to an hour. This gives me a better understanding of their home situation and any difficulties they may have about taking their medication.

Becoming an independent NMP has enabled me to work more autonomously and efficiently. Being able to prescribe for patients after making the diagnosis has improved their access to prescribed medication, meaning they can start taking it sooner as they do not have to wait to see the psychiatrist.

However, there have been times when this has been difficult, mainly due to the extra work load involved in prescribing in addition to an already demanding and busy role. It has been essential to develop prioritising skills, set regular time to write prescriptions, and have medical supervision, a requirement of the NMP role.

Other benefits include an improvement in my assessment skills, which are now more structured, knowing when to and when not to prescribe, and when to stop medication. My understanding of prescribed medications for older people with dementia, in particular the difficulties caused by polypharmacy, has also increased.

Evidence from the survey showed that patients feel confident and satisfied that the MCN can give them timely advice and support about their illness and medication.

Conclusion

Non-medical prescribing for patients with dementia has improved my skills, in particular knowledge about medication and communication and assessment skills. It has been evidenced that concordance in dementia patients has improved.

I have been promoted from a band 6 to a band 7, reflecting the extra responsibility taken on when prescribing.

Undertaking the non-medical prescribing course has been very worthwhile and satisfying, although at times quite difficult due to the time commitment while working full time.

The memory clinic patients state they are happy with a nurse prescribing their medication, and it has reduced wastage of medication by ensuring patients are given timely information and are able to contact me with any concerns. The survey was done early in 2009, and I believe that the changes in practice made as a result have contributed to the improvement in concordance. 

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