Medication Adherence in Older Adults With Cognitive Impairment: A Systematic Evidence-Based Review

Subclinical Mood and Cognition Impairments and Blood Pressure Control in a Large Cohort of Elderly Hypertensives

BACKGROUND

Blood pressure (BP) control in the elderly is often limited by poor compliance with prescribed regimen. Both can be influenced by clinical cognitive or mood impairments; however, the impact of subclinical alterations of cognition or mood remains unknown.

OBJECTIVES

To assess the relation between cognition, mood, and BP control in treated older hypertensive patients.

DESIGN

Cross-sectional association study.

SETTING

Predefined substudy to the POLFOKUS nationwide survey investigating the correlates of poor BP control in patients randomly drawn from primary and specialist practices across Poland.

PARTICIPANTS

1988 outpatients ≥65 years of age treated for hypertension for at least 1 year.

MEASUREMENTS

BP was mean of at least 2 office measurements. We assessed adherence to antihypertensive medications using a questionnaire and performed screening tests for cognitive deficits [Abbreviated Mental Test Score (AMTS)] and mood disorders [Geriatric Depression Scale (GDS)]. In all patients, we used a unified (BP <140/90 mm Hg) and in ≥80 years old a unified or age-specific (<150 mm Hg systolic BP) definition of BP control. We fitted logistic regression models to assess the probability of poor BP control in association with cognitive and mood disturbances.

RESULTS

The mean [standard deviation (SD)] age of 1988 (65.6% women) patients was 73.9 (6.0) years (19.3% ≥80 years old). Cognitive and mood impairments were observed in 8.0% and 37.2%, respectively. Mean systolic and diastolic BP were 141.8 (16.4) and 83.6 (9.5) mm Hg, respectively. According to age-stratified and unified definition of proper BP control, goal BP was achieved in 65.4% and 38.5% patients ≥80 years of age, respectively. In younger patients, the control reached 46%. Globally, 66% patients adhered to antihypertensive medications. Poor compliance was related to cognitive and mood impairments. When unified goal was applied, there was a 15.0% higher risk of finding poor BP control per 1 score lost in AMTS and an 8.0% increase per 1 score gained in GDS (all P < .001).

CONCLUSION

Poorer BP control is related to subclinical worsening of cognition and mood, which supports widespread use of the Comprehensive Geriatric Assessment even in apparently self-dependent older patients with hypertension.

Medication use and adherence among multi-ethnic community-dwelling older adults in Malaysia

AIM

The present study assessed adherence, barriers, belief and awareness towards the use of medications among multi-ethnic community-dwelling older adults in Malaysia. Medication accessibility, expenditure and perceptions towards medicine labeling among older adults were also evaluated.

METHODS

A cross-sectional study was carried out in the central region of Malaysia from January to August 2015. The older adults enrolled in an ongoing prospective community-based geriatric cohort study and prescribed with medicines were interviewed using a 50-item validated questionnaire.

RESULTS

Of the 79 older adults interviewed, 39.2% had ≥4 prescribed medications. Most obtained their medications free-of-charge from government hospitals (66, 83.5%). Nearly half (35, 44.3%) had trouble reading labels for medicines that they had received. Chinese older adults (P = 0.001) and those with lower monthly household income (P < 0.001) expressed difficulty in reading medication labels. Most (59, 75.0%) were unable to differentiate between generic and brand names of the medications, and 49.4% of the older adults did not know that all medicines had to be registered with the Ministry of Health, Malaysia. Most older adults had positive beliefs about the necessity of their medications, and 50.6% (n = 40) reported high medication adherence. The medication adherence score was negatively correlated with the concerns score (r = -0.5, P < 0.001).

CONCLUSIONS

The findings from the present study provide a unique insight into the diversity of medication use among multiethnic community-dwelling older adults. Although high adherence to medications and positive beliefs about the necessity of medications were reported by the older adults, their knowledge about medications remained insufficient and they had difficulty in reading medication labels. Geriatr Gerontol Int 2017; 17: 1214-1220.

Persons With Advanced Alzheimer’s Disease Engage in Mild Leg Exercise Supported by Technology-Aided Stimulation and Prompts

This study assessed whether nine persons with advanced Alzheimer’s disease would learn to engage in leg responses (exercise) with the support of a technology-aided program, which provided (a) preferred stimulation contingent on the leg responses and (b) verbal reminders/prompts in case of no responding. The study was conducted according to a non-concurrent multiple baseline design across participants and involved sessions of 5 min. During the baseline, the participants’ mean frequencies of leg responses ranged from zero to slightly above two per session. During the intervention, those frequencies ranged from nearly 10 to nearly 17 per session. The mean frequencies of prompts varied across participants from about two to more than seven per session. In addition to the increase in leg responses, participants showed an increase in signs of positive personal involvement (e.g., smiles and positive verbalizations) during the intervention sessions as compared with the baseline sessions. The applicability and potential benefits of the program in daily contexts are discussed.

Ability of older people with dementia or cognitive impairment to manage medicine regimens: a narrative review

Impaired cognition has a significant impact on a person’s ability to manage their medicines. The aim of this paper is to provide a narrative review of contemporary literature on medicines management by people with dementia or cognitive impairment living in the community, methods for assessing their capacity to safely manage medicines, and strategies for supporting independent medicines management. Studies and reviews addressing medicines management by people with dementia or cognitive impairment published between 2003 and 2013 were identified via searches of Medline and other databases. The literature indicates that as cognitive impairment progresses, the ability to plan, organise, and execute medicine management tasks is impaired, leading to increased risk of unintentional non-adherence, medication errors, preventable medication-related hospital admissions and dependence on family carers or community nursing services to assist with medicines management. Impaired functional capacity may not be detected by health professionals in routine clinical encounters. Assessment of patients’ (or carers’) ability to safely manage medicines is not undertaken routinely, and when it is there is variability in the methods used. Self-report and informant report may be helpful, but can be unreliable or prone to bias. Measures of cognitive function are useful, but may lack sensitivity and specificity. Direct observation, using a structured, standardised performance-based tool, may help to determine whether a person is able to manage their medicines and identify barriers to adherence such as inability to open medicine packaging. A range of strategies have been used to support independent medicines management in people with cognitive impairment, but there is little high-quality research underpinning these strategies. Further studies are needed to develop and evaluate approaches to facilitate safe medicines management by older people with cognitive impairment and their carers.

Cognition in People With End-Stage Kidney Disease Treated With Hemodialysis: A Systematic Review and Meta-analysis

BACKGROUND

Cognitive impairment is associated with poorer quality of life, risk for hospitalization, and mortality. Cognitive impairment is common in people with end-stage kidney disease treated with hemodialysis, yet the severity and specific cognitive deficits are uncertain.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING & POPULATION

Adults receiving hemodialysis compared with the general population, people with non-dialysis-dependent chronic kidney disease (NDD-CKD), people receiving peritoneal dialysis, or people with nondialyzed chronic kidney failure.

SELECTION CRITERIA FOR STUDIES

Randomized controlled trials, cohort or cross-sectional studies without language restriction.

INDEX TESTS

Validated neuropsychological tests of cognition.

OUTCOMES

Cognitive test scores, aggregated by cognitive domain: orientation and attention, perception, memory, language, construction and motor performance, concept formation and reasoning, and executive functions.

RESULTS

42 studies of 3,522 participants. Studies were of high or uncertain risk of bias, assessed by the Newcastle-Ottawa Scale. People treated with hemodialysis had worse cognition than the general population, particularly in attention (n=22; standardized mean difference [SMD], -0.93; 95% CI, -1.18 to -0.68). Hemodialysis patients performed better than nondialyzed patients with chronic kidney failure in attention (n=6; SMD, 0.70; 95% CI, 0.45 to 0.96) and memory (n=6; SMD, 0.36; 95% CI, 0.08 to 0.63), but had poorer memory than the general population (n=16; SMD, -0.41; 95% CI, -0.91 to 0.09) and people with NDD-CKD (n=5; SMD, -0.40; 95% CI, -0.60 to -0.21). There were insufficient data to show other differences among people receiving hemodialysis and those receiving peritoneal dialysis or with NDD-CKD.

LIMITATIONS

Potentially biased studies, not wholly adjusted for education. High heterogeneity, mainly due to the large variety of tests used to assess cognition.

CONCLUSIONS

People treated with hemodialysis have impaired cognitive function compared to the general population, particularly in the domains of orientation and attention and executive function. Cognitive deficits in specific domains should be further explored in this population and should be considered when approaching education and chronic disease management.

Self-Reported Medication Adherence Barriers Among Ambulatory Older Adults with Mild Cognitive Impairment

STUDY OBJECTIVE

To compare the frequencies of barriers to medication adherence reported by ambulatory older adults with a diagnosis of mild cognitive impairment (MCI) and ambulatory older adults with normal cognition.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinics within a safety-net health care system.

PARTICIPANTS

Ambulatory older adults (≥ 65 yrs) with a diagnosis of MCI (96 participants) or normal cognition (104 participants).

MEASUREMENTS AND MAIN RESULTS

Self-reported beliefs and barriers to medication nonadherence were assessed by items from the Morisky Medication Adherence Survey, the Adherence Estimator, and barriers derived from a systematic review of studies in older adults with cognitive impairment. Participants with a diagnosis of MCI had a mean age of 72 years, 77% were female, and 37% were African-American. Participants with normal cognition had a mean age of 76 years, 79% were female, and 47% were African-American. Among all participants, 83% reported the presence of at least one barrier to medication adherence, and 62.5% reported two or more barriers to medication adherence. The most commonly reported barriers were difficulty remembering the amount or time of each medication to take (49%), difficulty opening or reading prescription bottles (42%), feeling worse when taking medications (29%), and trouble affording medications (26%). Considering the multiple comparisons made in this analysis, few significant differences in barrier frequencies were identified between the groups with MCI and normal cognition.

CONCLUSION

Multiple medication adherence barriers were identified among all participants, including cognitive, physical, and financial barriers, although few significant differences were identified between those with and without MCI. Interventions capable of addressing multiple barriers are required to improve medication adherence in older adults with and without MCI.

An intervention to maximize medication management by caregivers of persons with memory loss: Intervention overview and two-month outcomes

Overseeing medication-taking is a critical aspect of dementia caregiving. This trial examined a tailored, problem-solving intervention designed to maximize medication management practices among caregivers of persons with memory loss. Eighty-three community-dwelling dyads (patient + informal caregiver) with a baseline average of 3 medication deficiencies participated. Home- and telephone-based sessions were delivered by nurse or social worker interventionists and addressed basics of managing medications, plus tailored problem solving for specific challenges. The outcome of medication management practices was assessed using the Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) and an investigator-developed Medication Deficiency Checklist (MDC). Linear mixed modeling showed both the intervention and usual care groups had fewer medication management problems as measured by the MedMaIDE (F = 6.91, p < .01) and MDC (F = 9.72, p < .01) at 2 months post-intervention. Reduced medication deficiencies in both groups suggests that when nurses or social workers merely raise awareness of the importance of medication adherence, there may be benefit.

Interventional tools to improve medication adherence: review of literature

Medication adherence and persistence is recognized as a worldwide public health problem, particularly important in the management of chronic diseases. Nonadherence to medical plans affects every level of the population, but particularly older adults due to the high number of coexisting diseases they are affected by and the consequent polypharmacy. Chronic disease management requires a continuous psychological adaptation and behavioral reorganization. In literature, many interventions to improve medication adherence have been described for different clinical conditions, however, most interventions seem to fail in their aims. Moreover, most interventions associated with adherence improvements are not associated with improvements in other outcomes. Indeed, in the last decades, the degree of nonadherence remained unchanged. In this work, we review the most frequent interventions employed to increase the degree of medication adherence, the measured outcomes, and the improvements achieved, as well as the main limitations of the available studies on adherence, with a particular focus on older persons.

[Assessment of cognitive functions in internal medicine]

The evaluation of cognitive functions can be performed using two approaches: a quantitative one, based on screening tools; a qualitative one, based on the examination of specific cognitive functions. The quantitative approach offers a pragmatic process: to screen rapidly for a cognitive dysfunction that may require assistance or treatments. We will present three screening tools and their diagnostic value: the clock test, the Mini Mental State Examination and the Montreal Cognitive Assessment. They help select patients who require a more detailed examination to precisely diagnose their cognitive dysfunction. We propose a way to perform a detailed cognitive examination at the bedside, including the examination of alertness, attention, memory, language, frontal functions, praxis and hemi-neglect. This simple examination indicates the location of the cerebral lesion and sometimes suggests the underlying disease.

Informal Caregiver Disability and Access to Preventive Care in Care Recipients

INTRODUCTION

Many informal caregivers of dependent midlife and older adults suffer from their own functional limitations. The impact of caregiver functional limitations on care recipient receipt of preventive services is unknown. The purpose of this study is to examine the association between caregiver functional limitations and decreased access to recommended preventive services in dependent care recipients.

METHODS

Dependent adults (those receiving assistance with activities of daily living or instrumental activities of daily living) and their primary informal caregiver were identified from pooled alternate years (2000-2008) of the nationally representative Medical Expenditure Panel Survey (data analyzed February-October 2014). The impact of caregiver limitations (cognitive, mobility, sensory, emotional health) on care recipient's receipt of up to seven different preventive services was assessed via survey-weighted linear and logistic regression.

RESULTS

Of the 5-year weighted estimate of 14.2 million caregiver-care recipient dyads, 38.0% of caregivers reported at least one functional limitation. The percentage of recommended preventive services received by care recipients was significantly lower if the caregiver had cognitive, mobility, or emotional health limitations. Each type of caregiver functional limitation was negatively associated with at least four different preventive services.

CONCLUSIONS

Informal caregivers burdened by their own functional impairments may face challenges in facilitating access to preventive care in dependent midlife and older adults. Policies and interventions designed to prevent or mitigate the impact of caregiver functional impairments are critical to the success of community-based models of care for dependent adults.

Cognitive screening in persons with chronic diseases in primary care: challenges and recommendations for practice

An integrative literature review was performed to identify the challenges in current cognitive screening. The aim of the review was to serve as an evaluative resource to guide clinicians in the selection of the best available cognitive screening measures for early assessment of mild cognitive impairment (MCI) in people with chronic diseases. The review classified the available cognitive screening measures according to purpose, time to administer, and cognitive domains assessed as: 1) simple/ brief cognitive screening measures, 2) disease specific screening measures, 3) domain specific screening measures, 4) self-administered screening measures, and 5) technology-based screening measures. There is no single optimal cognitive measure for all patient populations and settings. Although disease specific cognitive screening measures are optimal, there is a lack of validated screening measures for many chronic diseases. Technology-based screening measure is a promising avenue for increasing the accessibility of cognitive screening. Future work should focus on translating available screening measures to mobile technology format to enhance the utility in busy primary care settings. Early cognitive screening in persons with chronic disease should enhance appropriate referrals for detailed neurocognitive examination and cognitive interventions to preserve and or minimize cognitive decline.

Adjuvant Systemic Therapy in Older Breast Cancer Women: Can We Optimize the Level of Care?

Defining optimal adjuvant treatment for older women with breast cancer is challenged by the lack of level-1 clinical evidence and the heterogeneity of the older population. Nevertheless, recommendations based on reviews of available evidence mainly from retrospective subgroup analyses and extrapolation of study results from younger patients, and expert opinions, may be useful to guide treatment decisions in fit patients. But how can we properly define a "fit" older patient? In clinical practice, age by itself and clinical impression generally drive treatment decision, although the appropriateness of this judgment is under-documented. Such an approach risks overtreatment or, more frequently, undertreatment. A geriatric assessment can be valuable in oncology practice to address this issue. In this review article, we will focus only on systemic treatment and will discuss "standard" adjuvant systemic treatment strategies for fit older breast cancer patients and the role of "personalized" systemic therapy in unfit patients. The concepts conveyed in this review cannot be extrapolated to locoregional therapy.

Adesão ao uso de medicamentos entre idosos hipertensos

INTRODUÇÃO: O crescimento da população idosa está associado à elevada prevalência de doenças crônicas. Tal fato favorece a exposição dessa população ao uso de múltiplos medicamentos, e também ao aumento de incapacidades físicas e mentais, trazendo desafios para as famílias e sociedade. OBJETIVO: Descrever a adesão ao uso de medicamentos em idosos hipertensos com déficit cognitivo, assistidos pela Estratégia Saúde da Família (ESF), e identificar fatores relacionados. MÉTODO: Estudo transversal com abordagem quantitativa, realizado em oito ESFs de Dourados-MS. Amostra constituída por 124 idosos, de ambos os sexos, com diagnóstico de hipertensão arterial. Instrumentos utilizados: questionário para dados sociodemográficos, Miniexame de Estado Mental e Autorrelato de Adesão ao Medicamento, composto de oito itens. RESULTADOS: Predomínio de idosos do sexo feminino, baixa escolaridade, com pouco rendimento financeiro, residiam acompanhados e autoavaliaram a saúde como muito boa, boa ou regular. Houve diferença significativa entre adesão ao tratamento farmacológico com a faixa etária (p<0,001) e idosos com algum grau de déficit cognitivo (p=0,033). Dos idosos que possuíam algum grau de déficit cognitivo, 76,3% residiam acompanhados e 23,7%, sozinhos. Destaca-se que, dos idosos que moravam acompanhados, 29,0% aderiram à terapêutica medicamentosa, e dos que viviam sós, apenas 9,2%. CONCLUSÃO: As variáveis "renda per capita", "escolaridade" e "arranjo familiar" não influenciaram na adesão à terapêutica medicamentosa; em contrapartida, "idade" e "déficit cognitivo", sim. Ressalta-se a possível influência positiva dos familiares na adesão ao tratamento farmacológico, principalmente se o idoso apresentar distúrbios das funções cognitivas.

Communication Vulnerabilities in Working-age Australians with Musculoskeletal Conditions: A Cross-sectional Analysis

Objective.

To estimate the prevalence of communication vulnerability (CV) and its association with various health measures among working-age Australians with musculoskeletal conditions (MSK). The various vulnerability characteristics may lead to inadequate communication between consumers and healthcare professionals.

Methods.

Prevalence of CV among 18–64 year olds, with or without MSK, was analyzed using the Australian Bureau of Statistics’ National Health Survey 2007–08 data. Associations between CV and measures of health complexity (accumulating multimorbidity and risk factors) and health burden (poorer self-rated health, psychological distress, and pain restricting work) in the MSK population were estimated using logistic regression. Further analyses were conducted for each vulnerability characteristic to determine the degree of association (crude and adjusted) with measures of interest.

Results.

CV were more prevalent in working-age Australians with MSK (65%) than those without (51%). Adjusted for age and sex among working-age Australians with at least 1 MSK, those with 1 or more CV were more likely to have multimorbidity [adjusted OR (aOR) = 1.8, 95% CI 1.5–2.2], lifestyle risk factors (aOR = 2.1, 95% CI 1.5–2.8), poorer self-rated health (aOR = 3.4, 95% CI 2.7–4.2), greater psychological distress (aOR = 2.9, 95% CI 2.3–3.7), and pain restricting employment (aOR = 1.7, 95% CI 1.4–2.1) compared with those without CV.

Conclusion.

For working-age people, there is an association between MSK and CV. For those with MSK, CV were associated with increased likelihood of health complexity and burden. These findings have policy and clinical relevance. Research is needed to determine whether interventions that address these specific CV characteristics reduce the burden of disease within these populations.

Adherence to therapy and adverse drug reactions: is there a link?

INTRODUCTION

Advances in biomedical technology and access to effective medications have resulted in significant improvements in patient survival and quality of life. Patient adherence is crucial to quality healthcare outcomes; however, achievement of consistent adherence remains difficult. Patient non-adherence represents an important health problem, from a clinical/economic viewpoint, being associated with reduced treatment benefits and significant financial burden. Non-adherence potentially leads to adverse drug events (ADEs), which are generally responsible for poorer health outcomes and avoidable resource misuse. Further, adverse drug reactions (ADRs) exemplify one of the most significant barriers to patients' medication-taking behavior with further detrimental clinical/economic outcomes.

AREAS COVERED

The authors review adherence definitions and its measurement, emphasizing the consequences of the New European Pharmacovigilance Legislation on ADR definition. They analyzed the causes and the clinical/economic consequences of non-adherence and ADEs/ADRs in order to highlight a possible causal link.

EXPERT OPINION

Careful assessment of this harmful relationship is crucial in planning for the interventions needed to improve effectiveness of pharmacological care and to safeguard the sustainability of healthcare systems. Finally, through the 'deactivation' of this link, there will be more chance that advances in healthcare technologies will realize their potential to reduce the burden of chronic illness.

Cognitive impairment six months after ischaemic stroke: a profile from the ASPIRE-S study

Background

Cognitive impairment commonly occurs in the acute phase post-stroke, but may persist with over half of all stroke survivors experiencing some form of long-term cognitive deficit. Recent evidence suggests that optimising secondary prevention adherence is a critical factor in preventing recurrent stroke and the incidence of stroke-related cognitive impairment and dementia. The aim of this study was to profile cognitive impairment of stroke survivors at six months, and to identify factors associated with cognitive impairment post-stroke, focusing on indicators of adequate secondary prevention and psychological function.

Methods

Participants were assessed at six months following an ischaemic stroke as part of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke study (ASPIRE-S), which examined the secondary preventive and rehabilitative profile of patients in the community post-stroke. Cognitive impairment was measured using the Montreal Cognitive Assessment (MoCA).

Results

Two-hundred and fifty-six stroke patients were assessed at six months. Over half of the sample (56.6%) were found to have cognitive impairment, with significant associations between cognitive impairment and female sex (odds ratio (OR) = 1.6, 95% CI 1.01-2.57) and history of cerebrovascular disease (OR = 2.22, 95% CI 1.38-3.59). Treatment with antihypertensive medications (OR = .65, 95% CI .44-.96) and prescription of anticoagulant therapy (OR = .41, 95% CI .26-.68) were associated with reduced likelihood of cognitive impairment, however increasing number of total prescribed medications was moderately associated with poorer cognitive impairment (OR = 1.12, 95% CI 1.04-1.19).

Conclusions

Findings reveal levels of cognitive impairment at 6 months post-stroke that are concerning. Encouragingly, aspects of secondary prevention were identified that may be protective in reducing the incidence of cognitive impairment post-stroke. Neuropsychological rehabilitation post-stroke is also required as part of stroke rehabilitation models to meet the burden of post-stroke cognitive impairment.

Update on Pharmacotherapy for Prevention and Treatment of Post-operative Delirium: A Systematic Evidence Review

Delirium is highly prevalent among elderly post-operative patients with no pharmacological intervention approved by the Food and Drug Administration for prevention or treatment. We conducted a systematic evidence review to critically appraise literature related to the pharmacotherapy of post-operative delirium. Ten studies fulfilled our inclusion criteria with two interventions for delirium treatment and eight interventions for delirium prevention in post-operative patients. The quality of evidence of delirium treatment studies was poor, whereas the quality of evidence in delirium prevention studies ranges from moderate to high. Delirium treatment studies find similar delirium duration and length-of-stay outcomes between haloperidol and either morphine or ondansetron. Risperidone was found to reduce the conversion of sub-syndromal delirium to delirium in one study compared to placebo. Haloperidol, olanzapine, and ketamine were each found to reduce delirium incidence, whereas rivastigmine had no impact on delirium incidence or duration. Lighter anesthesia as monitored by bi-spectral index led to a decreased delirium incidence. Considering results from studies conducted prior to the dates of this review, the current evidence suggests that certain pharmacologic classes and lighter sedation using BIS monitoring may prevent post-operative delirium, although a conclusive recommendation for clinical practice must await further research.

Persons with Alzheimer's disease engage in leisure and mild physical activity with the support of technology-aided programs

Three studies were conducted to assess technology-aided programs to promote leisure engagement and mild physical activity in persons with Alzheimer's disease. Specifically, Study I assessed a program aimed at enabling three patients with mild or moderate Alzheimer's disease to choose among different music options and activate the preferred ones. Studies II and III were directed at patients in the low moderate or severe stages of the Alzheimer's disease who were no longer capable of ambulating and spent their time generally inactive, sitting in their wheelchairs. In particular, Study II used a program to help three patients exercise an arm-raising movement. Study III used a program to help three patients exercise a leg-foot movement. Each study was carried out according to a nonconcurrent multiple baseline design across patients. Results were very encouraging. The patients of Study I learned to choose and activate their preferred music pieces. The patients of Studies II and III enhanced their performance of the target movements and increased their indices of positive participation (e.g., smiles and verbalizations) during the sessions. The applicability of the programs in daily contexts and their implications for the patients involved are discussed.

Older adults receiving assistance with physician visits and prescribed medications and their family caregivers: prevalence, characteristics, and hours of care

OBJECTIVES

To profile older adults receiving assistance with physician visits and prescribed medications and the time demands associated with their care.

METHODS

Observational study of 7,197 community-dwelling adults ages 65+ responding to the 2011 National Health and Aging Trends Study.

RESULTS

More than one third of older adults receive assistance with either physician visits or prescribed medications (26.3%), or both (9.9%). The 3.3 million older adults who receive assistance with both physician visits and prescribed medications are a high-need subgroup: 3 in 5 have possible (16.5%) or probable (46.1%) dementia and three quarters (76.6%) receive help with mobility, self-care, or household activities. These 3.3 million older adults receive more than twice as many weekly hours of help with all activities (60.5 hr) as those receiving help with either physician visits or prescribed medications (26.5 hr), or neither (18.6 hr). Older adults receiving help with both physician visits and prescribed medications are assisted by 7.2 million helpers, most often adult children (46.6%), or spouses (23.6%). The 3.1 million helpers who assist with both physician visits and prescribed medications provide an average of 45.4 hr of help per week; nearly two thirds (64.3%) also assist with mobility or self-care.

DISCUSSION

Older adults receiving help with both physician visits and prescribed medications typically have high health and functioning needs that involve significant time demands for caregivers.

Medication adherence in patients with Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder, after Alzheimer's disease, affecting the elderly worldwide. Current therapy for PD is largely based on prescription of drugs that act as either dopamine precursors, dopamine agonists or agents that inhibit key enzymes in the dopamine catabolic pathways. Most of these drugs are administered in tablet or capsule form and can involve multiple daily doses in complex dosing regimens, which contributes to sub-optimal compliance amongst patients. There is evidence to suggest that non-compliance with medications results in perceived poor response to therapy and may ultimately increase direct and indirect health care costs. Medication compliance in PD assumes a particularly important role, given that PD is a progressive, debilitating condition, and once medication is instituted for ameliorating the symptoms of PD, it is lifelong. We included nine research studies in our review of the medical literature, which report the prevalence of significant medication non-compliance in PD, using standard definitions, varies between 10 and 67%. This variation partly reflects differences in defining what clinically significant medication adherence is, the methods used to estimate the scale of the problem and the underlying population heterogeneity. Nevertheless, medication adherence is related to health costs and to the quality of life of patients affected by PD and, indirectly, their carers. Educating patients and their carers is one method of improving patient adherence to therapy. Simplifying drug regimens can also aid in this effort.

Persistence and adherence with dementia pharmacotherapy: relevance of patient, provider, and system factors

This paper provides a comprehensive review of studies examining adherence and (or) persistence with dementia pharmacotherapy during the past decade, including a summary of the key patient-, drug-, system-, and provider-level factors associated with these measures. Estimates of adherence and 1-year persistence to these drugs have ranged from 34% to 94% and 35% to 60%, respectively. Though many studies reported nonsignificant associations, there are data suggesting that patient age, sex, ethnoracial background, socioeconomic status, and region-specific reimbursement criteria, as well as the extent and quality of interactions among patients, caregivers, and providers, may influence persistence with pharmacotherapy. As many studies relied on administrative data, limited information was available regarding the relevance of patient's cognitive and functional status or the importance of caregiver involvement or assistive devices to adherence or persistence.

Towards a better understanding of readmissions after stroke: partnering with stroke survivors and caregivers

AIMS AND OBJECTIVES

To describe the experience of readmission from the perspective of the stroke survivor and family caregiver.

BACKGROUND

Older stroke survivors are at an increased risk for readmission with approximately 40% being readmitted in the first year after stroke. Patients and their families are best positioned to provide information about factors associated with readmission, yet their perspectives have rarely been elicited.

DESIGN

Descriptive qualitative study.

METHODS

This study included older stroke survivors who were readmitted to acute care from home in the six months following stroke, and their family caregivers. Participants were interviewed by telephone at approximately two weeks after discharge and a sub-set was also interviewed in person during the readmission. Interviews were audio-taped and content analysis was used to identify themes.

RESULTS

From the 29 semi-structured interviews conducted with 20 stroke survivors and/or their caregivers, the following themes were identified: preparing to go home after the stroke, what to expect at home, complexity of medication management, support for self-care in the community and the influence of social factors.

CONCLUSIONS

This study provides the critical perspective of the stroke survivor and family caregiver into furthering our understanding of readmissions after stroke. Participants identified several areas for intervention including better discharge preparation and the need for support in the community for medication management and self-care. The findings suggest that interventions designed to reduce readmissions after stroke should be multifaceted in approach and extend across the continuum of care.

RELEVANCE TO CLINICAL PRACTICE

The hospital level has been the focus of interventions to reduce preventable readmissions, but the results of this study suggest the importance of community-level care. The individual nature of each situation must be taken into account, including the postdischarge environment and the availability of social support.

Diabetes self-care and the older adult

The prevalence of diabetes is highest in older adults, a population that is increasing. Diabetes self-care is complex with important recommendations for nutrition, physical activity, checking glucose levels, and taking medication. Older adults with diabetes have unique issues that impact self-care. As people age, their health status, support systems, physical and mental abilities, and nutritional requirements change. Furthermore, comorbidities, complications, and polypharmacy complicate diabetes self-care. Depression is also more common among the elderly and may lead to deterioration in self-care behaviors. Because of concerns about cognitive deficits and multiple comorbidities, adults older than 65 years are often excluded from research trials. Thus, little clinical evidence is available and the most appropriate treatment approaches and how to best support older patients' self-care efforts are unclear. This review summarizes the current literature, research findings, and expert and consensus recommendations with their rationales.

Formal and informal support of family caregivers managing medications for patients who receive end-of-life care at home: a cross-sectional survey of caregivers

BACKGROUND

Managing medications is a complex responsibility of family caregivers caring for end-of-life patients. This study characterizes caregivers with and without formal/informal support managing medications for patients who receive end-of-life care at home.

AIM

To explore factors related to caregivers' support with managing medications for end-of-life home hospice patients.

DESIGN

A convenience-sampled, cross-sectional telephone survey.

SETTING/PARTICIPANTS

Computer-assisted telephone interviews were administered to 120 caregivers managing medications, who were referred by five Chicago-based home hospice services. We measured caregivers' additional formal (paid) and informal (unpaid) support with managing medications, and caregiver/patient socio-demographic, relational, and health characteristics.

RESULTS

While 47 (39%) had no additional support with managing medications, 27 (22.5%) had formal support, 37 (31%) informal, and 9 (7.5%) both. Seven caregivers (19%) with formal and 13 (31%) with informal support reported disagreements concerning treatment plans. Caregivers lacking formal support tended to be racial/ethnic minorities, live with the patient in their home, or report greater emotional burden. Caregivers with formal support tended to report higher education/income, lower mutuality, or care for a patient with over 6 months' hospice enrollment. Caregivers lacking informal support tended to be spousal caregivers, live with the patient, or have experience caring for another dying person.

CONCLUSION

Our study suggests that high proportions of caregivers may not have support managing medications for patients receiving hospice care at home. More research should examine whether the observed variations in obtaining support indicate disparities or unmet needs among caregivers. Disagreement about treatment with formal/informal support also warrants further investigation.

Persons with moderate Alzheimer's disease use simple technology aids to manage daily activities and leisure occupation

Two studies assessed technology-aided programs to support performance of daily activities and selection/activation of music items with patients with moderate Alzheimer's disease. In Study I, four patients were presented with activity-related pictorial instructions via a computer fitted with inexpensive, commercial software. In Study II, four patients were (a) presented with different music options and (b) allowed to select and activate the preferred option via a microswitch response. Study I showed that each patient learned to perform the two activities available with percentages of correct responses exceeding 85 by the end of the intervention. Study II showed that all patients learned to choose and activate music options. Psychology students, employed in a social validation check, scored the patients' behavior within the program better than their behavior in a control situation. The relevance and usability of simplified pictorial-instruction programs and music choice programs for patients with moderate Alzheimer's disease were discussed.

Cognitive impairment and risk of future stroke: a systematic review and meta-analysis

BACKGROUND

Several studies have assessed the link between cognitive impairment and risk of future stroke, but results have been inconsistent. We conducted a systematic review and meta-analysis of cohort studies to determine the association between cognitive impairment and risk of future stroke.

METHODS

We searched MEDLINE and Embase (1966 to November 2013) and conducted a manual search of bibliographies of relevant retrieved articles and reviews. We included cohort studies that reported multivariable adjusted relative risks and 95% confidence intervals or standard errors for stroke with respect to baseline cognitive impairment.

RESULTS

We identified 18 cohort studies (total 121 879 participants) and 7799 stroke events. Pooled analysis of results from all studies showed that stroke risk increased among patients with cognitive impairment at baseline (relative risk [RR] 1.39, 95% confidence interval [CI] 1.24-1.56). The results were similar when we restricted the analysis to studies that used a widely adopted definition of cognitive impairment (i.e., Mini-Mental State Examination score < 25 or nearest equivalent) (RR 1.64, 95% CI 1.46-1.84). Cognitive impairment at baseline was also associated with an increased risk of fatal stroke (RR 1.68, 95% CI 1.21-2.33) and ischemic stroke (RR 1.65, 95% CI 1.41-1.93).

INTERPRETATION

Baseline cognitive impairment was associated with a significantly higher risk of future stroke, especially ischemic and fatal stroke.

Characteristics associated with postdischarge medication errors

OBJECTIVE

To examine the association of patient- and medication-related factors with postdischarge medication errors.

PATIENTS AND METHODS

The Vanderbilt Inpatient Cohort Study includes adults hospitalized with acute coronary syndromes and/or acute decompensated heart failure. We measured health literacy, subjective numeracy, marital status, cognition, social support, educational attainment, income, depression, global health status, and medication adherence in patients enrolled from October 1, 2011, through August 31, 2012. We used binomial logistic regression to determine predictors of discordance between the discharge medication list and the patient-reported list during postdischarge medication review.

RESULTS

Among 471 patients (mean age, 59 years), the mean total number of medications reported was 12, and 79 patients (16.8%) had inadequate or marginal health literacy. A total of 242 patients (51.4%) were taking 1 or more discordant medication (ie, appeared on either the discharge list or patient-reported list but not both), 129 (27.4%) failed to report a medication on their discharge list, and 168 (35.7%) reported a medication not on their discharge list. In addition, 279 participants (59.2%) had a misunderstanding in indication, dose, or frequency in a cardiac medication. In multivariable analyses, higher subjective numeracy (odds ratio [OR], 0.81; 95% CI, 0.67-0.98) was associated with lower odds of having discordant medications. For cardiac medications, participants with higher health literacy (OR, 0.84; 95% CI, 0.74-0.95), with higher subjective numeracy (OR, 0.77; 95% CI, 0.63-0.95), and who were female (OR, 0.60; 95% CI, 0.46-0.78) had lower odds of misunderstandings in indication, dose, or frequency.

CONCLUSION

Medication errors are present in approximately half of patients after hospital discharge and are more common among patients with lower numeracy or health literacy.

Testing a novel pictorial medication sheet to improve adherence in veterans with heart failure and cognitive impairment

OBJECTIVES

(a) To evaluate efficacy of a pictorial medication sheet to improve adherence in veterans with heart failure (HF) and cognitive impairment (CI); (b) to describe acceptance of the intervention.

BACKGROUND

CI is prevalent in HF and is associated with worsened medication adherence. The Veteran's Administration has developed a medication image library; however, use of images to improve adherence has not been tested.

METHODS

Thirty-six veterans with HF and CI were enrolled and provided pictorial medication sheets and an optional alarmed pillbox. Adherence pre-and post-intervention was determined by 30-day pill counts. Acceptance was assessed from interviews.

RESULTS

Twenty-seven veterans (75%) completed the study. Overall medication adherence was poor, however there was significant improvement from pre-intervention (M = 79.74, SD = ±16.98) to post-intervention (M = 84.74, SD = ±10.00) adherence (t(26) = 2.16, p < .05, Cohen's d = .42).

CONCLUSIONS

This pilot study provides preliminary evidence that medication images improve adherence with complex medication regimens. The intervention was well received by patients.

Glycemic control in a 79-year-old female with mild cognitive impairment using a medication reminder device: a case report

A 79-year-old female with type 2 diabetes and mild cognitive impairment (Clinical Dementia Rating score of 0.5) was supported with medication with regard to the daily requirements using a medication reminder device. Use of this device not only improved her medication adherence, hemoglobin A1c level, and self-confidence but also reduced caregiver's burden. For elderly patients with such diseases, loading the device with medication, providing advance notice before mechanical reminders for a short period after the device's activation, monitoring unused medication, and adjusting the timing of reminders according to users' daily routine, seemed to facilitate daily use of the device.

Effect of dementia on the use of drugs for secondary prevention of ischemic heart disease

Background. Dementia and cardiovascular disease (CVD) are frequently comorbid. The presence of dementia may have an effect on how CVD is treated. Objective. To examine the effect of dementia on the use of four medications recommended for secondary prevention of ischemic heart disease (IHD): angiotensin-converting enzyme inhibitors, beta-blockers, lipid-lowering medications, and antiplatelet medications. Design. Retrospective analysis of data from the Cardiovascular Health Study: Cognition Study. Setting and Subjects. 1,087 older adults in four US states who had or developed IHD between 1989 and 1998. Methods. Generalized estimating equations to explore the association between dementia and the use of guideline-recommended medications for the secondary prevention of IHD. Results. The length of follow-up for the cohort was 8.7 years and 265 (24%) had or developed dementia during the study. Use of medications for the secondary prevention of IHD for patients with and without dementia increased during the study period. In models, subjects with dementia were not less likely to use any one particular class of medication but were less likely to use two or more classes of medications as a group (OR, 0.60; 95% CI, 0.36-0.99). Conclusions. Subjects with dementia used fewer guideline-recommended medications for the secondary prevention of IHD than those without dementia.

Aging society and gerontechnology: a solution for an independent living?

Recent studies report that the majority of older adults wish to live in their own homes, for as long as possible. This creates a growing interest in technologies to enable older people to remain living independently at home. The purpose of this article is to provide a narrative review of current technology appropriate for older adults' home use. The key research questions were as follow: 1- What is the evidence demonstrating that gerontechnologies are effective in enabling independent living? 2- What are devices designed specifically for frail elderly persons ? Several publications were identified about devices targeting social isolation (videophonic communication, affective orthotic devices or companion-type robots, personal emergency response systems [security]), autonomy loss (technologies for maintenance of autonomy in the activities of daily living) and cognitive disorders (cognitive orthotics, wandering management systems, telemonitoring). Very few articles dealt specifically with the frail older person. In particular, there was extremely limited evidence on use and efficacy of these devices within this population. There is a need to obtain a consensus on definition of the technologies, and also to revisit work strategies and develop innovative business models. To meet this goal, we need to create a network of technological companies, aging services organizations, end-users, academics, and government representatives to explore the real needs of the frail older population and to develop and validate new devices promoting aging at home.

The economic burden of inappropriate drug prescribing, lack of adherence and compliance, adverse drug events in older people: a systematic review

Adverse drug events (ADEs) are an increasingly relevant issue for healthcare systems as they are associated with poorer health outcomes and avoidable misuse of resources. The rates of ADEs are higher in the elderly population, as many older patients have comorbidities, multiple drug prescriptions and deteriorated physical and cognitive functioning. The occurrence of ADEs can lead to a perceived lack of therapy efficacy and further underuse or suboptimal adherence in elderly people, with detrimental clinical outcomes. The present article systematically reviews the studies evaluating the economic impact of ADEs occurring as consequence of poor therapy adherence, inappropriate drug use, underuse of effective treatments and poor adherence, medication errors, drug-drug and drug-disease interactions.A Medline systematic literature review of studies evaluating the economic consequences of inappropriate drug prescribing, lack of adherence and compliance, ADEs in older people was performed. English-language articles were screened through a three-step approach (title review, abstract review, full article review) to select pertinent studies quantitatively evaluating costs. We systematically reviewed evidence from767 articles. After title, abstract and full text review, 21 articles were found to measure economic implications ofADEs, inappropriate drug prescribing and poor adherence in elderly patients. Studies suggested that the economic impact of these undesired effects is substantial: hospital costs were the main cost driver, with a relevant part of them being preventable (consequences of inappropriate prescribing). Healthcare costs for unused drug wastage and destruction were also surprisingly high.Although economic evidence in elderly patients is still limited, all studies seemed to confirm that the financial burden due to pharmacological treatment issues is relevant in elderly people. Including economic effects of adverse events in pharmacoeconomic analysis would be beneficial to improve the reliability of results. Preliminary evidence suggests that programmes aimed at comprehensively assessing geriatric conditions, detecting 'high-risk' prescriptions and training patients to comply with prescribed therapies could be costeffective measures to reduce the burden of ADEs.

Medication adherence: a complex behavior of medication and illness beliefs

Medication nonadherence is a public health issue costing an estimated US$290 billion in the USA. The paper discusses the key facts known about medication nonadherence based on past research including predictors, measurements and interventions; and the recent research developments in medication nonadherence. Recent research has shown the need to approach medication adherence as a complex behavior of a patient’s beliefs regarding illnesses and medications; and how it varies across each medication for each patient. The paper concludes with the call to develop tailored interventions that match with the reasons for nonadherence for each medication.

Poststroke dementia is associated with recurrent ischaemic stroke

OBJECTIVE

To investigate whether poststroke dementia (PSD) diagnosed after ischaemic stroke predicts recurrent ischaemic stroke in long-term follow-up.

METHODS

We included 486 consecutive patients with ischaemic stroke (388 with first-ever stroke) admitted to Helsinki University Central Hospital who were followed-up for 12 years. Dementia was diagnosed in 115 patients using the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III) criteria. The effects of risk factors and  PSD on survival free of recurrent stroke were estimated using Kaplan-Meier log-rank analyses, and the HRs for stroke recurrence were calculated using Cox proportional hazards models.

RESULTS

In the entire cohort, patients with PSD had a shorter mean time to recurrent stroke (7.13 years, 95% CI 6.20 to 8.06) than patients without dementia (9.41 years, 8.89 to 9.92; log rank p<0.001). This finding was replicated in patients with first-ever stroke (6.89 years, 5.85 to 7.93 vs 9.68 years, 9.12 to 10.24; p<0.001). In Cox univariate analysis, PSD was associated with increased risk for recurrent stroke both in the entire cohort (HR 2.02; 95% CI 1.47 to 2.77) and in those with first-ever stroke (2.40; 1.68 to 3.42). After adjustment for the significant covariates of age, atrial fibrillation, peripheral arterial disease and hypertension, PSD was associated with increased risk for recurrent stroke both in the entire cohort (1.84; 1.34 to 2.54) and in those with first-ever stroke (2.16; 1.51 to 3.10).

CONCLUSIONS

Poststroke dementia predicts recurrence of ischaemic stroke in long-term follow-up and should be considered when estimating prognosis.

Older adults and mobile phones for health: a review

OBJECTIVE

To report on the results of a review concerning the use of mobile phones for health with older adults.

METHODS

PubMed and CINAHL were searched for articles using "older adults" and "mobile phones" along with related terms and synonyms between 1965 and June 2012. Identified articles were filtered by the following inclusion criteria: original research project utilizing a mobile phone as an intervention, involve/target adults 60 years of age or older, and have an aim emphasizing the mobile phone's use in health.

RESULTS

Twenty-one different articles were found and categorized into ten different clinical domains, including diabetes, activities of daily life, and dementia care, among others. The largest group of articles focused on diabetes care (4 articles), followed by COPD (3 articles), Alzheimer's/dementia Care (3 articles) and osteoarthritis (3 articles). Areas of interest studied included feasibility, acceptability, and effectiveness. While there were many different clinical domains, the majority of studies were pilot studies that needed more work to establish a stronger base of evidence.

CONCLUSIONS

Current work in using mobile phones for older adult use are spread across a variety of clinical domains. While this work is promising, current studies are generally smaller feasibility studies, and thus future work is needed to establish more generalizable, stronger base of evidence for effectiveness of these interventions.