Adherence and medication instructions. Review and recommendations

The older orthopaedic patient: general considerations

People older than 65 years are more likely to need elective and emergent orthopaedic surgery compared with younger persons. They also experience significant benefits. Although age-related changes increase the risk of perioperative complications, understanding those changes allows prevention or at least early recognition and treatment when problems arise. Because of comorbidities, older persons take more medications that need to be managed in the perioperative period. Care could be simplified if patients were to bring their medications to the preoperative evaluation. Central nervous system sensitivity to certain pain medications (meperidine and propoxyphene) means that these drugs are best avoided as good alternatives exist (morphine and oxycodone). Adverse reactions to drugs are an important cause of acute confusion (delirium) that often complicates orthopaedic care. Early mobilization after surgery, avoiding certain drugs, avoiding restraints (including Foley catheters), attending to hydration, promoting normal sleep, compensating for sensory disorders, and stimulating daytime activities can prevent delirium. Patients with dementia are more likely to have delirium develop and, like many older people, will present special challenges in communication and decision making. Including family members in discussions may be helpful in ensuring truly informed consent.

Development and validation of the medication regimen complexity index

BACKGROUND

Medication regimen attributes, such as the number of drugs, dosage frequency, administration instructions, and the prescribed dosage forms, have been shown to influence patient outcomes. No single tool for quantifying the complexity of general medication regimens has been published in the medical literature.

OBJECTIVE

To develop and validate a tool to quantify the complexity of prescribed medication regimens.

METHODS

Literature findings and the expertise of the authors were used for developing the tool. Eight pharmacy researchers helped in establishing the tool's face and content validity. The new tool was tested on 134 medication regimens from patients with moderate to severe chronic obstructive pulmonary disease. Six regimens with a spread of scores on the tool were presented to a 5-member expert panel that subjectively ranked these regimens to confirm the tool's criterion-related validity. The relationships between scores on the tool and various independent variables were tested to judge the tool's construct validity. Two raters scored 25 regimens using the tool to test its inter-rater and test-retest reliabilities.

RESULTS

A 65-item Medication Regimen Complexity Index (MRCI) was developed. The expert panel had strong agreement (Kendall's W = 0.8; p = 0.001) on their individual rankings of the 6 regimens. The panel's consensus ranking had perfect correlation with the MRCI ranking. The total MRCI score had significant correlation with the number of drugs in the regimen (Spearman's Rho = 0.9; p < 0.0001), but not with the age and gender of the patients. Inter-rater and test-retest reliabilities for the total score and scores for individual sections on the MRCI were > or = 0.9.

CONCLUSIONS

The MRCI is a reliable and valid tool for quantifying drug regimen complexity with potential applications in both practice and research.

Age and Medication Acceptance

Patients' willingness to take a newly prescribed medication is an important, but little studied, part of the medication process. The authors studied the impact of patient age on the perceived importance and interaction of three factors known to influence young people: severity of their medical condition, extent of possible medication side effects, and level of trust in their physician. A convenience sample of 170 French adults aged 18 to 93 rated their likelihood of taking a medication intended to alleviate physical suffering in 27 scenarios in which three levels (low, moderate, and high) of each of the above three factors were combined in an orthogonal factorial design. Among younger participants, high trust in the physician was not considered a sufficient reason for high acceptance of a new medication; it had to be accompanied by low side effects. Among very elderly participants, high trust led to high acceptance almost irrespective of the severity of possible side effects. Among the middle aged, trust and side effects had largely independent effects. To promote patients' acceptance of newly prescribed medications, physicians need to establish trust, but not abuse its power in elderly patients.

Determinants of eye drop size

Ophthalmic solutions are available for multidose or single-dose administration in a wide variety of glass and plastic dropper bottles which deliver drops with a volume between 25 and 70 microl. From a biopharmaceutical and economic point of view, however, smaller volumes of 5 to 15 microl should be instilled. In this review, the technical, pharmaceutical, and therapeutic aspects of eye drop formation and delivery are presented. The different types of containers are described and the determinants of eye drop size are discussed, such as the design and physical characteristics of the dropper tip and bottle, the physico-chemical properties of the solution, and the manner in which the patient dispenses the drops. Preferred and alternative instillation techniques and aids to facilitate the administration of eye drops by elderly patients are described.

Patient-centered instructions for medications prescribed for the treatment of heart failure

BACKGROUND

Chronic heart failure (CHF) is associated with reduced functional capacity and quality of life, particularly among older adults. Complex medication regimens for CHF challenge older patients' ability to adhere to them, in part because of age-related cognitive decline and poor communication about medications.

OBJECTIVE

This article describes patient-centered instructions for taking CHF medications that were developed as part of a multifaceted pharmacy-based intervention to improve medication adherence and health-related outcomes among older adults with CHF. The findings of 3 initial validation studies investigating patients' reactions to the instructions are reported.

METHODS

Patients' responses to the instructions were measured using focus group (study 1) and questionnaire (studies 2 and 3) techniques.

RESULTS

Overall, older adults with CHF in the 3 studies preferred the patient-centered instructions to the standard pharmacy instructions (93.8% in study 1, 65.0% in study 2). In addition, participants' preferences depended on their medication-related goals. A preference for patient-centered instructions reflected a focus on ease of understanding (as supported by the use of large type size, icons, and patient-centered organization), whereas a preference for the standard pharmacy instructions reflected a focus on the amount of information provided about drug interactions (studies 2 and 3).

CONCLUSIONS

In the 3 validation studies, older adults with CHF tended to prefer the patient-centered instructions to the standard pharmacy instructions, although the results were not statistically significant in study 2. This suggests that the use of such instructions may improve patients' medication knowledge and their adherence to treatment regimens.

Medication adherence in persons with cardiovascular disease

The purpose of this investigation was to determine medication adherence rates among 3 groups of elderly individuals 62 years of age or older, experiencing comorbid conditions including at least 1 cardiovascular disorder. Data, taken from a 3-week period, were combined across the groups to calculate the percentage of prescribed doses taken, percentage of days with correct number of doses, and percentage of expected doses with the correct timing of administration. Multiple linear regression also was performed on several sociodemographic variables to determine their ability to predict adherence. Risks for poor adherence and suggestions to increase adherence are presented.

Effects of label format on knowledge acquisition and perceived readability by younger and older adults

This research examines consumers' information acquisition and preference for labels of a simulated over-the-counter (OTC) medication. Twelve otherwise identical OTC drug bottles were compared with different back labels varying in (a) print size, (b) amount of white space between text, and (c) label design (standard vs extended/pull-out). A no back label condition served as a control. Older (mean age=77.7 years) and younger (mean age=21 years) adults were given one of the 12 bottles and asked to perform one of two information acquisition tasks: (a) they examined the bottle for 3 minutes and then completed a questionnaire with the bottle absent, or (b) they answered the same questionnaire while the bottle was present. Afterwards, participants were given all of the bottles and asked to rank them according to perceived readability. The younger adults' information acquisition performance was significantly better than the older adults' for all label conditions except the control condition where both groups' low performance did not differ. Specifically, the older adults' performance was significantly better in the medium and large print conditions than in the small print conditions--with the latter conditions not differing from the control condition. Younger adults showed no performance differences among the different print-size conditions. No substantial effects on knowledge acquisition performance from the white space manipulations were found. However, the perceived readability ranks showed that both groups preferred larger print size and white space. The white space effect was smaller than for print size, particularly for older adults. The extended/pull-out label design was facilitative for older adults in that it allowed the use of larger print. The results suggest that older consumers may be unable to acquire information in the 'fine' print frequently found in various kinds of product literature.

[A literature review on pharmacists' interventions in the use of medication by elderly patients]

The total proportional geriatric population in Brazil is projected to increase from 9.05% in 1999 to approximately 13% in 2020. Non-communicable diseases are common in this age group, and medication is used frequently. Inadequate prescription and improper use of drugs can produce undesirable outcomes, leading to avoidable hospitalization and increasing health care costs. The objective of this paper was to conduct a literature review of pharmacists' interventions and their influence on use of medication by elderly patients, based on five databases from 1970 to 1999. The sample consisted of 76 studies, of which 15 were analyzed and discussed. Research on this subject is scarce, and limited to developed countries. In general, the interventions presented favorable outcomes. Most actions were limited to counseling patients and their physicians, and there was a lack of interventions to adjust the medication to the user.

Geriatric pharmacology

With the dramatic demographic change that has resulted in the "graying of the population" has come a compelling interest in the health and health concerns of older adults. The increasing incidence and prevalence of systemic diseases, especially chronic diseases, among older adults, and the concomitant increase in medication use, have provided impetus for the subspecialty of geriatric pharmacology. This article reviews the physiologic changes, nonphysiologic aspects, and pharmacologic changes associated with aging and their implications for dental practice.

Principles of drug therapy in older patients: rational drug prescribing

Health care providers must be aware of the issues involved in using drugs therapies in older patients because older patients are very vulnerable to the adverse effects of drugs. Although more data are needed to guide clinical decision making in prescribing drugs to older patients, some simple considerations can make drug use safer and more effective (Table 10). Careful, compassionate attention to these factors can have a profound effect on improving the quality of life, medication use, and the overall cost of health care in this vulnerable population.

A prediction model for polypharmacy: are older, educated women more susceptible to an adverse drug event?

INTRODUCTION

This study attempts to account for variation in the number of prescription medications concurrently consumed in geriatric populations.

METHODS

Data were selected from The National Health and Nutrition Examination Survey, III, 1988-1994 (NHANES III), Adult Household Questionnaire, a complex, multistage, clustered sampling of civilian, non-institutionalized populations, which included a volunteer sample of 5,249 individuals aged 65 and older who participated in NHANES III survey, representing four broad geographic regions and twelve states.

RESULTS

Age, income, and educational level accounted for nine percent of the variation in the number of prescription medications concurrently taken (p < 0.0001); though non-significant, there were gender differences regarding polypharmacy; in addition, there were significant differences with respect to educational levels by region and age by region (p < 0.05).

CONCLUSIONS

Educational level accounted for the most variation in polypharmacy. Women, on average, consumed more prescription medications than men. Older, more educated women may be most likely to engage in polypharmaceutical consumption, suggesting a greater likelihood of an adverse drug event.

Physician-patient congruence regarding medication regimens

OBJECTIVES

To characterize the degree of disparity between physicians' perceptions of older patients' medication regimen and patients' perceptions of their regimen.

DESIGN

Prospective observational. Physicians and patients were blinded at index visit; after, trained medical students made home visits, collecting information about medications that was compared with physician questionnaires.

SETTING

Community family medicine residency program.

PARTICIPANTS

Patients age 65 and older presenting for routine visit, taking at least four prescription medications, and seen by index physician three or more times in the past year. Physicians were family medicine faculty and second- and third-year residents.

MEASUREMENTS

Fifty physician-patient pairs were analyzed. Average age was 75 (standard deviation (SD) +/-5.5); patients averaged 7.0 prescription medications (range 3-17, SD +/-2.89). Three hundred seventy-five prescription medications were identified; the most commonly prescribed were antihypertensives (134/375; 36%).

RESULTS

Congruence, defined as agreement between physician and patient regarding all prescription medications, dosages, and frequency, averaged 70% for faculty (range 53-89%) and 58% for residents (range 41-81%) (P = .08). Fourteen percent (7/50) demonstrated complete congruence; 74% (37/50) had at least one medication that either the physician was unaware the patient was taking or the physician thought the patient was taking but that was not part of the patient's regimen; 12% (6/50) had dose and/or frequency discrepancies.

CONCLUSIONS

This study demonstrates significant disparity in a population where it is crucial for healthcare providers and patients to be in close agreement about intended medication regimens.

Providing information to help Medicare beneficiaries choose a health plan

Many Medicare beneficiaries have limited knowledge of the Medicare program and related health insurance options. This is due in part to the complexity of the Medicare program and supplemental health insurance market. A recent congressional mandate through the Balanced Budget Act of 1997 called for broad dissemination of information to educate beneficiaries about their health plan options and to encourage informed health plan decision-making. In response, the Health Care Financing Administration (HCFA) launched the National Medicare Education Program (NMEP) to support the educational objectives of the BBA. This paper provides an overview of the components of the NMEP information campaign. We also review lessons learned from our experience in designing and testing a prototype consumer handbook that explains the different health plan options to Medicare beneficiaries. Through our discussion of the handbook, we highlight several ways to communicate information effectively about a complex publicly funded program to an older adult population.

Self-reported medication adherence and health status in late adulthood: the role of beliefs

In this study, we explore the role of subjective beliefs in determining self-reports of medication adherence and health status in 90 older adults (M age = 71.7 years, SD = 7.44). Self-reported adherence was predicted by personal health locus of control beliefs, but not by medical factors nor beliefs regarding one's own health care professionals. Self-reported health was predicted by medical factors, perceptions of one's health care professional, and health locus of control. These results suggest that self-reported adherence is primarily a belief-laden construct whereas self-reported health consists of both an objective assessment of health and a subjective belief-laden component. Exploratory analyses conducted on younger-old and older-old age groups indicated that medical factors may be less important to older-old adults' perceived health status than the younger-old adults.

Association between medication supplies and healthcare costs in older adults from an urban healthcare system

OBJECTIVES

The amount of medication dispensed to older adults for the treatment of chronic disease must be balanced carefully. Insufficient medication supplies lead to inadequate treatment of chronic disease, whereas excessive supplies represent wasted resources and the potential for toxicity. We used an electronic medical record system to determine the distribution of medications supplied to older urban adults and to examine the correlations of these distributions with healthcare costs and use.

DESIGN

A cross-sectional study using data acquired over 3 years (1994-1996).

SETTING

A tax-supported urban public healthcare system consisting of a 300-bed hospital, an emergency department, and a network of community-based ambulatory care centers.

PATIENTS

Patients were >60 years of age and had at least one prescription refill and at least two ambulatory visits or one hospitalization during the 3-year period.

MEASUREMENTS

Focusing on 12 major categories of drugs used to treat chronic diseases, we determined the amounts and direct costs of these medications dispensed to older adult patients. Amounts of medications that were needed by patients to medicate themselves adequately were compared with the medication supply actually dispensed considering all sources of care (primary, emergency, and inpatient). We calculated the excess drug costs attributable to oversupply of medication (>120% of the amount needed) and the drug cost reduction caused by undersupply of medication (<80% of the amount needed). We also compared total healthcare use and costs for patients who had an oversupply, an undersupply, or an appropriate supply of their medications.

RESULTS

The cohort comprised 4164 patients with a mean age of 71 +/- 7 (SD) who received a mean of 3 +/- 2 (SD) drugs for chronic conditions. There were 668 patients (16%) who received <80% of the supply needed, 1556 patients (37%) who received between 80 and 120% of the supply needed, and 1940 patients (47%) who received >120% of the supply needed. The total direct cost of targeted medications for 3 years was $1.96 million or, on average, $654,000 annually. During the 3-year period, patients receiving >120% of their needed medications had excess direct medication costs of $279,084 or $144 per patient, whereas patients receiving <80% of drugs needed had reduced medication costs of $423,438 or $634 per patient. Multivariable analyses revealed that both under- and over-supplies of medication were associated with a greater likelihood of emergency department visits and hospital admissions.

CONCLUSIONS

More than one-half of the older adults in our study have under- or over-supplies of medications for the treatment of their chronic diseases. Such inappropriate supplies of medications are associated with healthcare utilization and costs.

Medication schemas and memory for automated telephone messages

The present study investigated whether older and younger adults use a schema to organize and remember spoken reminder messages for taking medication. Previous research has shown that older and younger adults share preferences for organizing printed instructions for taking medication, suggesting a shared schema. Older and younger participants in Experiment 1 of the present study used a similar schema to organize medication reminder messages. This finding suggests that the medication schema generalizes across communication purpose (to remind or to instruct) as well as across patient age. Medication reminder messages were better understood and remembered when organized to match this schema, whether the reminders were presented as automated telephone messages (Experiment 2) or in printed form (Experiment 3). Schema-compatible organization especially helped people draw inferences from the messages, suggesting that organization helps older and younger adults construct a situation model of the medication-taking task from the messages. Potential applications of organized messages include increasing the impact of automated systems for delivering health services.

Elder care and the dermatologic surgeon

BACKGROUND

The elderly are an increasing percentage of the population and dermatologic surgeons will be caring for more senior citizens.

OBJECTIVE

Understanding issues in geriatric care will help both surgeons and patients have productive and rewarding encounters.

METHODS

Approaches to the care of elders are detailed in this article. Surgical tips for the senior patient are prescribed.

RESULTS

Older patients need more time and may need special assistance. Multiplicity of disease increases with age. A third-party interview can be helpful in gathering information. The elderly have sensory loss and benefit from extra attention, follow-up telephone calls, and therapeutic touch. Written handouts and instructions printed in large type are excellent. Dermatologic care should be kept as simple as possible with surgical closures designed to require minimal attention. Be cognizant of the social services available for the elderly and watch for dermatologic signs of internal disease. A skin care program for the elderly is helpful and cosmetic procedures are of interest to seniors.

CONCLUSIONS

Dermatologic surgeons can provide excellent care to elders. An understanding of gerontologic issues and surgical tips can help the dermatologic surgeon care for the older patient.

Medication education of acutely hospitalized older patients

OBJECTIVES

To determine the amount of time spent providing medication education to older patients, the impact of medication education on patients' knowledge and satisfaction, and barriers to providing medication education.

DESIGN

Telephone survey of patients within 48 hours of hospital discharge and direct survey of physicians and pharmacists.

SETTING

Internal medicine ward in a tertiary care teaching hospital.

PARTICIPANTS

Patients 65 years of age and over regularly taking at least one medication.

MEASUREMENTS

Patient demographics, medication use, time spent receiving or providing medication education, and satisfaction scores.

MAIN RESULTS

Forty-seven respondents with a mean age of 77.1 years reported that physicians spent a mean of 10.5 minutes (range, 0-60 minutes) and pharmacists spent a mean of 5.3 minutes (range, 0-40 minutes) providing medication education. Fifty-one percent reported receiving no education from either physician or pharmacist, and only 30% reported receiving written medication instructions. Respondents were generally quite satisfied with their education. Physicians identified one or more barriers to providing education 51% of the time and pharmacists 80%. Lack of time was the most common barrier (18%) identified by physicians, but pharmacists cited lack of notification of discharge plans (41%) and lack of time (39%) as the main barriers. Respondents made many medication errors and knew little about their medications.

CONCLUSIONS

Although older hospitalized patients received little medication education or written information and made many medication errors with and without medication education, approximately one half of physicians perceived no barriers to providing education.

Medication management capacity in highly functioning community-living older adults: detection of early deficits

OBJECTIVE

The Drug Regimen Unassisted Grading Scale (DRUGS) was developed and employed in testing the hypothesis that the inability to take medication independently may correlate with the presence of cognitive impairment.

DESIGN

Cross-sectional study.

SETTING

Two continuing care retirement facilities in the Greater Boston area.

PARTICIPANTS

The study population included outpatients > or = 70 years old.

MEASUREMENTS

We developed a novel performance-based measure, the DRUGS tool, involving a step-wise progression of four tasks: (1) identification; (2) access; (3) dosage; and (4) timing.

RESULTS

Fifty-nine participants aged 84.2 +/- 5.1 years (mean +/- SD) completed the study. The DRUGS tool score was inversely related to age (r = -.41, P = .001). Compared with independent-living, residence in assisted-living was associated with lower DRUGS tool scores (82.0% vs 93.8%, P = .009). The DRUGS tool score was associated with self-reported Medication Management capacity (94.8% able vs 86.2% unable to take medications independently by self-report, P = .047). Both DRUGS tool score and self-reported Medication Management capacity were associated with MMSE (P = .0008 and P = .044, respectively). The multivariate model, with DRUGS tool Summary Score as the dependent variable, adjusted for age and sex, included MMSE (P = .023) and self-reported IADL (P = .038).

CONCLUSION

There is an association between performance on the DRUGS tool and level of cognitive function. The DRUGS tool represents a unique individualized, yet standardized, assessment of the ability to function independently for ambulatory older persons. It may be useful for identifying those highly functioning older persons, at an early phase of cognitive decline, in whom targeted intervention would likely be most effective and efficient.

State Prescription Label Requirements in the United States

Objective:

To determine the current legal requirements for prescription labels and to explore the usefulness of this information in determining the utility of a standardized prescription label.

Data Sources:

State prescription label regulations were requested from Board of Pharmacy executives.

Study Selection:

Label requirements for prescriptions dispensed in community, noninstitutional pharmacies were selected for review.

Data Extraction:

Data were compiled, sorted by state, and analyzed as either federally mandated or additional state requirements. Additional state requirements were divided into 16 categories and analyzed by category.

Data Synthesis:

Responses were received from all 50 states. Five states did not list all federal label requirements. Medication name was the most frequently added requirement, followed by medication strength and name of manufacturer if the medication was generic. Only in New Jersey are pharmacists allowed to add directions not included in the prescription.

Conclusions:

States were consistent in the proper use of federal prescription label requirements. However, there was little agreement on what additional information should appear on the label. Nevertheless, there appears to be consensus for the name of the medication to be on the label. There also appears to be fairly strong consensus that medication strength and quantity should appear on the label. There is little interest in expanding the current directions-for-use requirement. Finally, the results support the utility of a standardized prescription label format.

Residential differences in the use of pharmacies by older adults and their communication experiences with pharmacists

This investigation compares adults (65 and older) living in two different types of communities on the characteristics of the pharmacies they use and their patterns of communicating with pharmacists. Telephone interviews were conducted with a random sample (N=400) of respondents, half residing in six nonmetropolitan counties (containing no towns of more than 4,000) and the other half in a single city (population approximately 130,000) located within a metropolitan county. Elders living in the sparsely populated nonmetropolitan areas were more apt to purchase their medications from an independent neighborhood pharmacy than their counterparts who lived in the large city. These pharmacies, however, were more likely to be located in another town. Differences between residential groups were also observed in the communication patterns that older patients had with their pharmacists. Elders residing in sparsely populated areas reported more frequent conversation with their pharmacists about general topics, although not about medicines or other health-related topics. The elders living in small and remote places also reported that they talked with their pharmacists longer, that communication about medications were more often initiated by the pharmacist, and that they were more likely to talk about their medications directly with their pharmacist rather than a non-pharmacist employee. The overall greater frequency of contact and communication between nonmetropolitan elders and their pharmacists would seem to be precursors to establishing a positive provider-client relationship and may increase the probability of more personal, medication-related discussions. Further research is needed, however, to determine if these potentials are transformed into realities and if they lead to more positive medical outcomes for older persons.

Enhancing Information Acquisition for Over-the-Counter Medications by Making Better Use of Container Surface Space

Most over-the-counter (OTC) pharmaceutical container labels are printed in very small type. Consequently, people with visual impairments (e.g., presbyopia in older adults) have difficult reading the material. Some OTC drugs are packaged in containers with easy-open caps. This design increases the surface area that could be used to enhance the labeling. In Experiment 1, older adults (M = 75.1 years, SD = 8.1) evaluated six container label variants for an actual OTC product. Besides having a multipanel main label, four containers had labels attached to the cap that displayed the most important information in large print but differed in color. Two control containers lacked a cap label; one had only a four-panel main label, and the other had only the front label. Participants ranked the containers on six dimensions (e.g., label noticeability, willingness to read). Results showed greater preference for containers with the cap labels. Experiment 2 again examined preferences but also measured information-acquisition performance after participants (M = 79 years, SD = 5.8) were briefly exposed to a realistic-appearing, but fictitious, OTC medication. Results showed greater knowledge and preference for containers with the cap labels. Experiment 2 showed that one of the cap colors (yellow) that was different from the main label was preferred over the white and orange (the same colors as on the main label), but color distinctiveness as an explanation was not fully supported because the green cap was not significantly different from the other cap labels. Implications for communicating information about OTC drugs using expanded labels are discussed.

The influence of list format and category headers on age differences in understanding medication instructions

We examined whether instructions are better understood and remembered when they contain organizational cues. Our previous research found that older and younger adults organize medication information in similar ways, suggesting that they have a schema for taking medication. In the present study, list formats (vs. paragraphs) emphasized the order of information and category headers emphasized the grouping of information specified by this schema. Experiment 1 examined whether list and header cues improve comprehension (answer time and accuracy) and recall for adults varying in age and working memory capacity (measured by a sentence span task). List instructions were better understood and recalled than paragraphs, and reduced age differences in answer time and span differences in accuracy. Headers reduced paragraph comprehension for participants with lower levels of working memory capacity, presumably because they were not salient cues in the paragraphs. Experiment 2 investigated if headers were more effective when more saliently placed in paragraphs and lists, and if list and header cues helped readers draw inferences from the instructions. List formats again reduced age differences in comprehension, especially reducing the time needed to draw inferences about the medication. While headers did not impair comprehension, these cues did impair recall. The present study suggests that list-organized instructions provide an environmental support that improves both older and younger adult comprehension and recall of medication information.

Metacognition and medication adherence: how do older adults remember?

Fifty-one older adults (M age = 75.9 years, SD = 6.9) reported their use of memory strategies for taking of medication using the Prospective Memory for Medication Questionnaire. Older adults used internal strategies more often when the domain was restricted to medication taking but used external strategies more often when queried across a variety of everyday situations. Surprisingly, the hypothesis that medical factors would be the primary determinants of older adults' reports of memory strategy use and perceived adherence was not supported. Metamemorial variables of non-domain-specific memory self-efficacy and memory anxiety in everyday life were significant predictors of strategy use and perceived adherence over and above variables related to the domain of health.

Improving consultations between health-care professionals and older clients: implications for pharmacists

Consultations between pharmacists and many clients are now federally mandated in the United States, but guidelines have not been developed for communication in this context. This article reviews research on communication between clients and health-care professionals in order to help develop recommendations for consultations between pharmacists and older clients. The review is organized around a collaborative approach to health communication, which identifies strategies by which speakers and listeners work together to achieve mutually defined goals. This approach is used to analyze cognitive processes underlying communication during pharmacist consultations. This review suggests that miscommunication often reflects a break-down in collaboration between health-care professional and clients. Recommendations are developed to improve collaboration, including suggestions for initiating consultations, presenting easy to understand messages, and monitoring to ensure that the messages are mutually understood. Most important, successful collaboration requires tailoring strategies to individual clients rather than basing communication on general assumptions about clients.

Medication instruction design: younger and older adult schemas for taking medication

We examined whether older and younger adults share a schema for taking medication and whether instructions are better recalled when they are organized to match this schema. Experiment 1 examined age difference in schema organization. Participants sorted medication items (e.g., purpose, dose, possible side effects) according to similarity and then ordered the items to create a preferred instruction set. Cluster analysis of the sort and order data showed that younger and older adults share a schema for taking medication. Secondary regression analyses found that verbal ability (i.e., vocabulary scores) predicted individual differences in schema organization. In Experiment 2 participants recalled instructions that were either compatible with this schema in terms of grouping and order of items or were presented in nonpreferred orders. Younger participants remembered more information than did older participants, but both age groups better remembered and preferred the more schema-compatible instructions. Secondary analyses showed that recall was also positively related to verbal ability. Along with our earlier research, this study suggests that older and younger adults possess a schema for taking medication and that instructions that are compatible with this schema provide an environmental support that improves memory for medication information.

Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure

PURPOSE

The objectives of this investigation were to prospectively assess medication compliance rates in elderly patients with congestive heart failure, to identify factors associated with reduced compliance, and to evaluate the effect of a multidisciplinary treatment approach on medication adherence.

PATIENTS AND METHODS

A total of 156 patients > or = 70 years of age (mean, 79.4 +/- 6.0; 67% female, 65% nonwhite) hospitalized with congestive heart failure were evaluated prospectively. Prior to discharge, patients were randomized to the study intervention (n = 80) or conventional care (n = 76). The intervention consisted of comprehensive patient education, dietary and social service consultations, medication review, and intensive postdischarge follow-up. Detailed data were collected on all prescribed medications at the time of discharge, and compliance was assessed by pill counts 30 +/- 2 days later.

RESULTS

The overall compliance rate during the first 30 days after discharge was 84.6 +/- 15.1% (range, 23.1-100%). Compliance was 87.9 +/- 12.0% in patients randomized to the study intervention, compared with 81.1 +/- 17.2% in the control group (P = 0.003). A compliance rate of > or = 80% was achieved by 85.0% of the treatment group versus 69.7% of the control group (P = 0.036). By multivariate analysis, assignment to the treatment group was the strongest independent predictor of compliance (P = 0.008). Other variables included in the model were Caucasian race (P = 0.044) and not living alone (P = 0.09).

CONCLUSIONS

A multidisciplinary treatment strategy is associated with improved medication compliance during the first 30 days following hospital discharge in elderly patients with congestive heart failure. Improved compliance may contribute to improved outcomes in these patients.

Using icons to convey medication schedule information

We examined older adult comprehension and memory for medication schedules conveyed by different types of visual icons as well as text. Three icons were compared: a timeline, a pair of 12 h clocks (one for AM and one for PM hours) and a 24 h clock. In Experiment 1, older and younger participants paraphrased and then recalled schedules that were conveyed by the three icons or by text. Text and timeline schedules were paraphrased more accurately than either clock icon. Paraphrase errors suggested that subjects had trouble integrating schedule information across the two 12 h clocks. Analysis of paraphrase times showed that the text schedule was paraphrased most quickly, followed by the timeline, the 24 h clock and the 12 h clock. No differences were found for the accuracy of recalling the icon and text schedules. Experiment 2 examined free and cued recall after limited study time by older adults. Because text superiority in Experiment 1 may have reflected greater familiarity with text than with icons, recall was examined across four trials in Experiment 2. Text was recalled most accurately, followed by the timeline, the 24 h clock and the 12 h clock. Study-test trials did not influence recall. Text schedules may have been generally more effective than the icons because of their greater familiarity. The timeline may have been the most effective icon because it was more compact and familiar than the clock icons used in the study. The findings suggest that including such icons in medication instructions requires training.

Self-administration of medication by patients and family members during hospitalization

The current trend of shorter hospital stays has heightened concern about the adequacy of preparation of patients and their families to understand and follow prescribed medication regimens properly following discharge. Cooperative Care, an education-intensive unit incorporating a living-in family member or friend acting as a 'care partner,' has had a self-administration of medication program (SAM) for the past 16 years. This paper describes SAM and reports on two studies of its effectiveness. The first was a 1-week survey of all patients (151) admitted to the unit. 126 (83.4%) were taking a mean of five medications, with a range of one to 17. Of those, 102 (80.9%) were able to participate in SAM independently, and 11 (8.7%) were on SAM with supervision by their care partners. The second study reviewed medication administration errors within Cooperative Care and the traditional nursing units of Tisch Hospital over a 4-year period (1991-1994). Cooperative Care accounted for 19.4% of discharges (22,164/114,206) and 10.3% of patient days (97,037/944,230), but only 4.6% of medication errors (80/1723). The medication error rate per 1000 discharges was 3.6 for Cooperative Care, and 17.8 for the traditional units. Comparative error rates per 10,000 medication orders were 3.06 at Cooperative Care and 4.01 on the traditional units. 74.8% of Cooperative Care patients were on SAM, but only 30% of the errors were attributed to patients or care partners. The other errors were attributed to nursing staff (50%), equipment defects (12.5%) or pharmacists (5%). Our data indicate that SAM during hospitalization is a safe and effective modality of care.

High-risk drugs in the elderly population

Drug therapy in elderly patients is affected by age-related changes in distribution and elimination and is further complicated by the increased sensitivity aged persons have to many of the effects of medications. Medications are often necessary in the elderly population, but care should be made to properly monitor these patients, especially those taking multiple drugs. Nurses, who are at the front lines of health care in all areas of practice, should be aware of drugs that may be high risk for use in the elderly and monitor these patients carefully for signs and symptoms of toxicity.

Assessment of capacity to comply with medication regimens in older patients

OBJECTIVE

To develop an instrument that will facilitate and focus the assessment of a patient's capacity to adhere to a medication regimen before its initiation.

DESIGN

This is a crossectional study that compares medical inpatients and outpatients to an age-matched, community-living, independent and relatively healthy group on their ability to adequately understand and implement hypothetical but realistic medication regimens.

SETTING

Department of Veterans Affairs Medical Center, Sepulveda, California.

PARTICIPANTS

Fifty-five older subjects (65 years or older) were divided into three groups: (1) generally healthy comparisons (standard group) (n = 20); (2) medical outpatients (n = 15); and (3) medical inpatients ready for discharge (n = 20).

MEASUREMENTS

Older subjects were first tested on their capacity to comply with a difficult medication regimen presented in scenario form. If scores on the first scenario did not meet a standard group-derived cutoff point, further testing was conducted with a simpler scenario to identify greater levels of impairment.

RESULTS

The outpatient group had significantly lower scenario scores than did the healthy comparison group (P < .03). The simpler scenario also showed a trend toward outpatient impairment (P = .06). In the comparison group, only 5% failed Scenario 1, and none failed Scenario 2. The outpatient group had the most difficulty, with 40% failing Scenario 1 and one-third of those failing Scenario 2. This differed significantly from the comparison groups (Fisher's Exact P < .03). In the inpatient group 20% failed Scenario 1 and 75% of those failing Scenario 2. The sensitivity and specificity of the Folstein Mini-Mental State Examination in identifying scenario-impaired subjects were 73% and 80%, respectively. Question types were analyzed to determine which questions were most frequently missed. Memory and judgment questions were found overall to be the most frequently missed. Healthy controls missed some judgment questions; however, the outpatient group was significantly worse in this category (chi 2 = 5.08; P = .01). All three groups improved their scenario performance significantly with question cueing.

CONCLUSION

A significant number of medically ill outpatients encountered difficulty in understanding or remembering correctly hypothetical but realistic medication regimens. This suggests that an older medical patient's cognitive and functional capacity to comply with medication regimens of differing complexity can be specifically assessed before the start of the regimen and probably should be assessed in patients whose compliance capacity is in question. The assessment instrument under development in this study may be helpful in detecting those who need assistance with medications, thus identifying the need for intervention before poor compliance can lead to increased morbidity, rehospitalization, and increased medical costs.

Determinants of compliance with iron supplementation: supplies, side effects, or psychology?

Iron deficiency anemia affects over 2 billion people. Particularly at risk are pregnant women and young children. Although distribution of iron supplements is practised in many antenatal care programs in developing countries, it has often been alleged that pregnant women do not take them. Poor compliance arises not only because of patient behavior but also from factors out of the patient's control. This paper presents the results of a review of the literature on medical compliance to determine whether iron supplementation is different from other medications, to assess the known levels of compliance, and to synthesize recommendations for improving compliance relevant to iron supplementation. The review showed that compliance with iron therapy is a specific case of medical compliance. Reasons for non-compliance with iron deficiency treatment include: inadequate program support (lack of political commitment and financial support); insufficient service delivery (poor provider-user dynamics; lack of supplies, access, training, and motivation of health care professionals); and patient factors (misunderstanding instructions, side effects, frustration about the frequency and number of pills taken, migration, fear of having big babies, personal problems, nausea that accompanies pregnancy, and the subtlety of anemia which makes demand for treatment low). Much has been made about the side effects (nausea, constipation, etc.) that women might experience during iron therapy as the cause of poor compliance with iron supplementation without justification according to this review. Instead, unavailability of iron supplements was the most common reason why women did not take iron supplements. Women bear a disproportionate burden from iron deficiency anemia even though the technology exists to address the problem at low cost. Governments and health care professionals must renew their commitment to iron therapy by monitoring and improving compliance. We can significantly improve compliance by: making sure that iron supplements are available at all times; providing advanced warning about the possibility of side effects; involving the patient in the therapeutic strategy; and providing reminders, such as posters and calendars, about taking supplements.

Medication use by the elderly

Medication use is correlated with the age-associated onset of chronic diseases for which drug therapy offers symptomatic relief, and assists in preventing the onset of disabling and life-threatening complications. However, high rates of medication use by older people raise a number of issues, ranging from concerns with rising expenditures for individuals and third-party insurers; increased risk of adverse drug reactions; toxic or interaction effects from concomitant use of multiple pharmaceutical agents, both physician and self-prescribed; and poor compliance with complex medication regimens by the more physically and mentally impaired. Although existing data do not support the theory of age as an independent predictor of drug-specific adverse reactions, older people have typically been excluded from clinical trials in the dynamic and changing field of pharmacotherapy. Furthermore, ingestion of a greater number of different agents clearly exposes individuals to higher risk of adverse reactions and interactions. Recent advances in information technology have facilitated multicenter clinical trials and post-marketing epidemiological surveillance studies of specific and concomitant medication use by individuals of all ages. The employment of such technology by insurers to determine appropriate prescribing or to control costs in the present limited state of knowledge is, however, premature. Furthermore, such techniques will not replace the need for careful clinical review of symptoms and total drug therapy by prescribing physicians, with modification of regimens and provision of appropriate information and instructions to older individuals and their caregivers.

Reducing financial barriers enhances the return rate of stool Hemoccult packets

Patient compliance in returning fecal-hemoccult card packets has been studied in recent years but no specific interventions have been shown consistently to improve the return rate. It was wondered whether removing a small financial barrier for indigent patients would positively affect compliance. Therefore, the effect of prepaid postage on the rate of return was studied. Pre-prepared packets containing hemoccult cards with return envelopes were distributed in a randomized fashion to indigent and private insurance patients in outpatient clinics. On half of the return envelopes return postage was applied. The main outcome measure was the rate of return of stamped and unstamped packets stratified between indigent and private insurance patients. The overall rates of return were 117 of 159 (74%) for the stamped packets and 102 of 166 (61%) for unstamped packets (p < 0.02). After stratification, in the indigent patients (n = 177), 73 of 95 (77%) stamped packets were returned compared to 46 of 82 (56%) unstamped packets (p < 0.006). In the private insurance patients (N = 148), 44 of 64 stamped packets (69%) and 52 of 84 unstamped packets (62%) were returned (p > 0.10). Removing even small financial barriers (eg, providing a postage stamp) can enhance compliance for indigent patients.

Failure to have prescriptions filled among Black elderly

Despite extensive research on drug consumption and compliance with drug regimens within the geriatric population, little attention has been given to the failure to have prescriptions filled among elderly in general and Black elderly in particular. The prevalence and correlates of patients' failure to have prescriptions filled were investigated for a sample of 571 Black elderly. In terms of prevalence, 12.8% of this sample asserted that they had received a prescription from a physician and not had it filled during the 6 months period prior to interview. Multivariate logistic regression was employed to detect the significant predictors of this type of noncompliance. According to our data, failure to have prescriptions filled was significantly greater among Black elderly with higher levels of anxiety, those with lower levels of internal health locus of control, those who did not have prescription medication coverage through Medicaid, those who were currently using prescription medications, those who consumed greater numbers of over-the-counter medications, and those who reported more financial problems. Implications of these findings are discussed.

Polypharmacy: the cure becomes the disease

Polypharmacy occurs when a medical regimen includes at least one unnecessary medication. Factors that contribute to this problem include: patient characteristics of increasing age, multiple medical problems, therapy expectations, and decisions to self-treat; physician factors such as excessive prescribing; and system problems of multiple providers and lack of a coordinating provider. Complications include increased adverse drug reactions and noncompliance, which can lead to increased hospitalization and associated costs. Polypharmacy can be avoided by patient education and sharing the decisions for making the treatment goals and plan. The medication regimen can be simplified by eliminating pharmacologic duplication, decreasing dosing frequency, and regular review of the drug regimen. The goal should be to prescribe the least complex drug regimen for the patient as possible, while considering the medical problems and symptoms and the cost of therapy.

Evaluation of the effectiveness of lipid-lowering therapy (bile acid sequestrants, niacin, psyllium and lovastatin) for treating hypercholesterolemia in veterans

Veterans are frequently older, have more chronic illnesses, and take more medications than subjects volunteering for clinical trials. Because these factors may impair the effectiveness of lipid-lowering drug therapy, the effectiveness of drug therapy in veterans may differ from that measured in randomized controlled trials. In 297 patients with type IIa hyperlipidemia attending a large Veterans Administration Medical Center lipid clinic, adverse effects, compliance, lipid and lipoprotein responses to drug therapy were prospectively monitored. Bile acid sequestrants (4 packets/day) were associated with a high rate of adverse effects, and had the highest drug discontinuance rate (37%) and poorest compliance (73 +/- 3% of the doses prescribed reported ingested) of all agents. Patients aged > 60 years tolerated therapy with bile acid sequestrants less well than did younger veterans (p < 0.01). Niacin (1.5 g/day) also had a high drug discontinuance rate (27%). Lovastatin (20 mg/day) had the lowest drug discontinuance rate (2%) and the highest compliance (90 +/- 2%). Lovastatin also reduced low-density lipoprotein (LDL) cholesterol the most (-21.6 +/- 2.0%), whereas niacin produced the largest increase in high-density lipoprotein (HDL) cholesterol (+/- 14.3 +/- 2.2%); both niacin and lovastatin produced similar reductions in the LDL/HDL ratio. However, psyllium (10.4 g/day) reduced LDL cholesterol by only 2%, and had no effect on the LDL/HDL ratio. Psyllium produced larger LDL cholesterol reductions in patients aged < 60 years than in older patients (p < 0.01). Niacin and lovastatin are effective drugs for hypercholesterolemia management in the Veterans Administration Medical Center setting.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of drug compliance by continuous electronic monitoring: a pilot study in elderly patients discharged from hospital

OBJECTIVE

A pilot study to assess patient compliance with medication by using a new measurement technique, continuous electronic monitoring.

DESIGN

Survey. Compliance monitors were provided to eligible patients at discharge from the hospital to measure drug intake behavior prospectively for a period of 3 weeks.

SETTING

Ambulant patient care after discharge from a geriatric hospital, Krankenhaus Bethanien, which is affiliated with the University Clinic, Heidelberg.

PATIENTS

A consecutive convenience sample of 18 independently living elderly patients (median age 76 years) completed the study. The patients were on maintenance therapy with cardiac glycosides and/or potassium-sparing diuretics prescribed to be taken once daily.

INTERVENTION

The monitoring method provides information about patients' real timing of drug use by continuously recording date and time of openings and closings of the medication containers (monitors). In addition to a standard measure, the percentage of prescribed doses taken, information about regularity of drug use is obtained.

RESULTS

Compliance, percentage of prescribed doses taken, was remarkably variable; it ranged from 24% to 100%, 95% CI: 62%-84%. Mean compliance declined from the first to the third week after discharge, 85% vs 69%, 95% CI: 74%-95% and 56%-81%, respectively (P < 0.05). Omissions of doses, the predominant pattern of non-compliance, were observed in 17 of 18 patients. Regularity of dose timing, as defined by the number of interdose intervals within 24 h +/- 15%, varied from 10% to 100%, 95% CI: 46%-76%.

CONCLUSIONS

Continuous electronic monitoring revealed highly variable compliance in patients prescribed maintenance therapy. Even with a once-daily regimen, persistent and high compliance cannot be assumed. The monitoring technique may be of great value to research and, possibly, to practical therapeutic management.

Counseling in special populations: the elderly patient

This seventh installment in the series on value-added services provides pharmacists with a systematic approach to identifying and meeting the special counseling-related needs of the ambulatory elderly patient. The article describes the physical, mental, and social changes that characteristically accompany the aging process and that create special problems for pharmacists and their elderly patients during the delivery of pharmaceutical care. It also describes a systematic approach that pharmacists can use to evaluate whether their elderly patients need special counseling. Finally, it illustrates how the principles that are discussed can be applied in the practice setting.

Medication compliance in elderly people: influencing variables and interventions

This paper describes a study in which 70 elderly patients were assessed for risk factors in their medication regimen. They were separated into three study groups, including two levels of teaching intervention focused on the home medication administration system, and a control group. The intervention utilizing a follow-up telephone call demonstrated a significant change in risk-related behaviours such as verbalization of the regimen, congruence between instructions and usage of medications, and taking of medicines not currently prescribed or over-the-counter.

Compliance aids--do they work?

The decision to use a compliance aid will depend on the motivation of the patient, their specific medication regimen, and their physical and cognitive ability. The administration of oral medicines may be facilitated through the appropriate use of 'organisers' which act as aides memoire. 'Medidos' and 'Dosett' are the most frequently studied compliance aids and both have been shown to be beneficial to the elderly and to community-based psychiatric patients. Adherence to a medication regimen may be improved without the use of proprietary compliance aids by ensuring that the most appropriate traditional container is used and by paying attention to the highest standard of labelling on the medicine container. Gadgets that are designed to improve physical dexterity can be useful when applying topical preparations, administering insulin injections, operating pressurised inhalers or administering eyedrops. The accurate administration of eyedrops is particularly important when treating glaucoma and may be facilitated by using devices that are designed to help with aiming of the eyedrops ('Easidrop', 'Mumford Auto-drop,' 'Opticare'). If squeezing the eyedrop container is a problem the 'Opticare' device may be particularly suitable. There may be value in the use of the compliance aids to provide assistance to carers who become involved with preparing medication for patients. Selection of an appropriate compliance aid is not likely to be the total solution to inadequate adherence and most patients will require a combination of strategies to facilitate adherence to treatment with medicines.