Medication management capacity in relation to cognition and self-management skills in older people on polypharmacy

The development and evaluation of a medication diary to report problems with medication use

Purpose

The study aimed to develop and evaluate a medication diary for patients to report problems with medication use to enable shared-decision making and improve medication adherence.

Methods

Based on a search for existing diaries, a review of the content, and a list of medication self-management problems compiled from previous research, a paper and pencil version of a medication diary was developed. The diary was reviewed for clarity and overall presentation by five healthcare providers and nine patients. Afterwards, user-friendliness was evaluated by 69 patients with polypharmacy discharged from hospital during a quantitative prospective study.

Results

The medication diary consists of several parts: (1) a medication schedule allowing patients to list their medicines, (2) information sheets allowing patients to write down specific medication-related information, (3) a monthly overview to indicate daily whether medication-related problems were experienced, (4) problem sheets elaborating on the problems encountered, (5) space for specific medication-related questions for healthcare providers to facilitate shared-decision making. The review phase resulted in minor textual adjustments and one extra problem in the problem sheet. Most participants, who tested the medication diary for two months, found the diary user-friendly (80%) and easy to fill in (89%). About 40% of participants reported problems with medication use. Half of the patients indicated that the diary can facilitate discussing problems with healthcare providers.

Conclusion

The medication diary offers patients the opportunity to report problems regarding their medication use in a proven user-friendly manner and to discuss these problems with healthcare providers. Reporting and discussing problems with medication use can serve as a first step towards making shared decisions on how to address the problems encountered.

Medication self-management among older adults with cognitive frailty

BACKGROUND

Independent and safe medication self-management is essential for successful aging. Nevertheless, how older adults with cognitive frailty (CF) self-manage medications at their own homes remain elusive.

OBJECTIVE

This study aimed at assessing the medication self-management capability of home-dwelling older adults with CF and exploring the ways, perceived challenges and barriers in medication self-management.

METHODS

A convergent mixed-method study design was used. The medication management capability of 16 CF individuals aged ≥ 60 years on ≥ 1 long-term prescription drugs were assessed using the Drug Regimen Unassisted Grading Scale (DRUGS). Virtual in-depth interviews were also performed between July-August 2022 using a semi-structured interview guide. All interviews were audio-recorded and transcribed verbatim. Qualitative data were analysed using a thematic analysis approach guided by Bailey and colleagues' model of medication self-management.

RESULTS

The mean DRUGS summary score was 96.86 [standard deviation (SD) 3.74] with highest performance scores observed in medication access (100 %) and lowest performance score in medication identification (91.46 %). Informants were able to independently take their medications and they tended to organise their medication intakes according to mealtime even though some admitted missing medication doses due to forgetfulness. Informants had difficulties with recalling drug names, with little awareness of self-monitoring their own health conditions and the effects of medications. Misconceptions towards medications, difficulties in accessing medications, reduced mobility and worsening health conditions could potentially deter informants from safe and independent medication self-management. In contrast, trust in doctors and a desire to achieve treatment goal could motivate medication self-management.

CONCLUSION

The findings revealed knowledge gaps among older adults with CF in identifying their medications and self-monitoring which warrant reinforcement by healthcare professionals to ensure chronic safe medication use. Future studies should evaluate strategies to enhance medication safety in terms of self-monitoring in individuals with CF.

The Development of Recommendations for Healthcare Providers to Support Patients Experiencing Medication Self-Management Problems

Medication self-management problems such as the inability to correctly obtain, understand, organize, administer or monitor medication can result in negative patient outcomes. However, supportive tools for healthcare providers to assist patients with medication self-management problems are lacking. This study aimed to develop recommendations for healthcare providers to support patients with polypharmacy who experience medication self-management problems. A three-phase study was conducted starting with (1) the mapping of medication self-management problems, followed by (2) a scoping review providing a list of relevant interventions and actions for each respective problem and (3) a three-round modified e-Delphi study with experts to reach consensus on the relevance and clarity of the recommended interventions and actions. The cut-off for consensus on the relevance and clarity of the recommendations was set at 80% expert agreement. Experts could propose additional recommendations based on their professional experience and expertise. The experts (n = 23) involved were healthcare professionals (i.e., nurses, pharmacists, and physicians) with specific expertise in medication management of patients with polypharmacy. Simultaneous with the second e-Delphi round, a panel of patients with polypharmacy (n = 8) evaluated the usefulness of recommendations. Results obtained from the patient panel were fed back to the panel of healthcare providers in the third e-Delphi round. Descriptive statistics were used for data analysis. Twenty medication self-management problems were identified. Based on the scoping review, a list of 66 recommendations for healthcare providers to support patients with the identified medication self-management problems was composed. At the end of the three-round e-Delphi study, the expert panel reached consensus on the relevance and clarity of 67 recommendations, clustered according to the six phases of the medication self-management model by Bailey et al. In conclusion, this study resulted in a guidance document including recommendations that can serve as a resource for healthcare providers to support patients with polypharmacy in case of medication self-management problems. Future research should focus on the evaluation of the feasibility and user-friendliness of the guide with recommendations in clinical practice.

Parameters to Consider for Successful Medication Use in Older Adults - an AGePOP Review

Older adults are the main users of medicine and due to their multimorbidity are often faced/confronted with a complex medication management. This review article provides a brief overview on aspects of medication management such as maintaining a stock of the required medicine, understanding and following the instructions for use, coping with the primary and secondary packaging as well as preparation prior to use. The main focus however is on the drug intake itself and provides an overview about the current understanding of real life dosing conditions of older adults and geriatric patients. Furthermore, it elaborates the acceptability of dosage forms, in particular solid oral dosage forms as they represent the majority of dosage forms taken by these patient populations. An improved understanding of the needs of older adults and geriatric patients, their acceptability of various dosage forms and the circumstances under which they manage their medications, will make the design of more patient-centric drug products possible.

Development of a clinician guide for electronic medication adherence products in older adults

Background/objectives:

The ability to manage medications independently may be affected in older adults due to physical and cognitive limitations. Numerous electronic medication adherence products (eMAPs) are available to aid medication management. Unfortunately, there are no available guidelines to support clinicians in recommending eMAPs. The objective of this study was to create and validate a clinician tool to guide use of eMAPs.

Methods:

Pharmacists who previously tested the usability of the eMAPs participated in a focus group to provide feedback on 5 metrics of the clinician guide: unassisted task completion, efficiency, usability, workload and an overall eMAP score. Participants were asked semistructured questions on how they would use the tool to inform recommendations of medication aids to patients. The discussions were audio-recorded and transcribed verbatim and qualitatively analyzed. The clinician guide was modified to reflect feedback.

Results:

Five pharmacists (80% female, mean years of practice: 15.8) participated in the focus group. The clinician guide was modified by removing 2 metrics and adding an additional 8 metrics: maximum number of alarms, number of days the product can accommodate for based on a daily dosing regimen, price, monthly subscription, portability, locking feature, average time to set the device and number of steps required to set the device. The definition and calculation for unassisted task completion were modified. Additional instructions and specific patient case examples were also included in the final clinician guide.

Conclusion:

Since significant variability exists between eMAPs, it is imperative to have a tool for frontline clinicians to use when appropriately recommending the use of these products for medication management in older adults.

Integration of a smart multidose blister package for medication intake: A mixed method ethnographic informed study of older adults with chronic diseases

Smart adherence products are marketed to assist with medication management. However, little is known about their in-home integration by older adults. It is necessary to investigate the facilitators and barriers older adults face when integrating these products into their medication taking routines before effectiveness can be examined. The aim of this study was to (a) examine the integration of a smart multidose blister package and (b) understand medication intake behaviour of adults with chronic diseases using an integrated theoretical model comprised of the Technology Acceptance Model (TAM), Theory of Planned Behaviour (TPB) and Capacity, Opportunity, Motivation and Behaviour (COM-B) Model. An ethnographic-informed study was conducted with older adults using the smart multidose blister package to manage their medications for eight weeks. Data was collected quantitatively and qualitatively using in-home observations, photo-elicitation, field notes, semi-structured interviews, system usability scale (SUS) and net promoter scale (NPS). The interview guide was developed with constructs from the TAM, TPB and COM-B Model. Data were analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL) framework to generate themes and sub-themes which were mapped back to TAM, TBP and COM-B Model. Ten older adults with an average age of 76 years, of which 80% were female, participated in the study. On average, participants reported five medical conditions, while the average number of medications was 11.1. The mean SUS was 75.50 and overall NPS score was 0. Qualitative analysis identified three themes; (1) factors influencing medication intake behaviour (2) facilitators to the product use and, (3) barriers to the product use. The smart blister package was found to be easy to use and acceptable by older adults. Clinicians should assess an older adult’s medication intake behavior as well as barriers and facilitators to product use prior to recommending an adherence product for managing medications.

Older Patients' Perceptions of Medicines and Willingness to Deprescribe

Introduction Major barriers in deprescribing are the ambivalence of patients, resistance to change, and poor acceptance of alternative treatments. Objective To investigate older patients' beliefs, understanding and knowledge, satisfaction with medicine use, health outcome priorities, their attitude toward deprescribing, and to identify associated patient factors. Methods This multi-center cross-sectional, semistructured survey study involved older outpatients (70 years of age and older) with polypharmacy. The survey comprised three validated questionnaires: Beliefs about Medicines Questionnaire, Patients' Attitudes Towards Deprescribing questionnaire, and the Health Outcome Prioritization tool, with additional questions about understanding and satisfaction. The association between questionnaire outcomes and patient characteristics was investigated. Results Fifty participants were included; they used an average of 9 (+/- SD 2.7) medicines. For most participants (82%), the necessity of using medicines outweighed their concerns. Participants could name 35% of their medicines and 43% of the indications. Overall, 76% were satisfied with the effect of their medicines, but 94% would be willing to stop their medication if advised by their doctor. Maintaining independence (46%) and reducing pain (31%) were the most important health outcome priorities reported by the patients; staying alive had the lowest priority (51%). Participants with higher levels of educational attainment had better knowledge and had more concerns about harmful effects. Conclusions Patients are open to deprescribing but would probably not initiate the conversation themselves because they are generally very satisfied with their medicines. Knowledge about their medicines and their indications is poor. If doctors initiate deprescribing, patients are probably willing to follow their advice. Patients' life priorities should be discussed in deprescribing conversations.

Factors Influencing Administration, Recognition, and Compliance of Medicine among Community Residents from Jilin Province, China: A Questionnaire Study

INTRODUCTION

To identify and analyze factors that influence administration, recognition, and compliance of medicine among community residents in Jilin Province, China.

METHODS

A survey was carried out among 2417 community residents in Jilin Province, China, to study their administration (CRA), recognition (CRR), and compliance (CRC) of medicine. Multivariate logistic regression analyses and chi-squared tests were performed to assess factors influencing CRA, CRR, and CRC.

RESULTS

Logistic analyses showed that gender, educational level, and occupation were influencing factors on CRA; age, educational level, smoking status, and health condition were influencing factors on CRR; and gender, age, occupation, and health condition were influencing factors on CRC.

CONCLUSIONS

CRA, CRR, and CRC are associated with specific lifestyles and social economic statuses of community residents. Attention should be paid to influencing factors in order to facilitate community pharmaceutical care, promote the rational use of drugs, and ensure the safe use of medications. This study explores the type and extent of professional services provided through community pharmacies in Jilin Province, China, and provides evidence for optimizing the quality of community pharmacy services.

Development and Content Validation of an Instrument to Measure Medication Self-Management in Older Adults

BACKGROUND

For older adults, the capacity to self-manage medications may be limited by several factors. However, currently available tools do not permit a comprehensive assessment of such limitations. The Domain Specific Limitation in Medication Management Capacity (DSL-MMC) was developed to address this need. This study aimed to establish the face and content validity of the DSL-MMC.

METHODS

The DSL-MMC tool consisted of 4 domains and 12 sub-domains with 42 items including: 1. physical abilities (vision, dexterity, hearing); 2. cognition (comprehension, memory, executive functioning); 3. medication regimen complexity (dosing regimen, non-oral administration, polypharmacy); and 4. access/caregiver (prescription refill, new prescription, caregiver). Pharmacists assessed each item for relevance, importance, readability, understandability, and representation. Items with content validity index (CVI) scores of <0.80 for relevance were examined for revision or removal.

RESULTS

Twelve pharmacists participated in the study. CVI scores for relevance and importance of domains were 1.0; of the sub-domains, two were below 0.80. Among the 42 items, 35 (83%) and 30 (71%) maintained CVI scores above 0.80 for relevance and importance, respectively. Five items were removed, three were merged and seven were modified due to low CVI scores and/or feedback.

CONCLUSION

The DSL-MMC has been validated for content.

Difficulty with Taking Medications Is Associated with Future Diagnosis of Alzheimer's Disease and Related Dementias

BACKGROUND

Medication management requires complex cognitive functioning, and therefore, difficulty taking medications might be an early sign of cognitive impairment and could be a risk factor for Alzheimer's disease and related dementias (ADRD). Accordingly, people with difficulty taking medications may benefit from more detailed cognitive screening, potentially aiding in the diagnosis of ADRD, which is underdiagnosed. We are unaware of evidence on medication management difficulties that precede a real-world ADRD diagnosis in the USA.

OBJECTIVE

Examine the association between difficulty taking medications and subsequent real-world ADRD diagnoses.

DESIGN

Case-control study, using Health and Retirement Study (HRS) survey data linked to Medicare claims.

PARTICIPANTS

A total of 1461 HRS respondents with an ADRD diagnosis observed from 1993 to 2012 (cases), matched by year of birth, wave of HRS entry, and sex to 3771 controls with no ADRD diagnosis.

MAIN MEASURES

We examined the association between diagnosis of ADRD and self-reported difficulty taking medications in the preceding years (1-2 and 3-4 years prior to case definition). Control individuals were assigned the index date from their matched case. Conditional logistic regressions adjusted for age, sex, race, education, and comorbidities.

KEY RESULTS

Compared with matched controls, cases had higher prevalence of difficulty taking medications 1-2 years prior to diagnosis (11.0% versus 2.3%), and 3-4 years prior to diagnosis (5.8% versus 2.3%). Adjusted analyses showed that compared with individuals without ADRD, those with an ADRD diagnosis had more than four times higher odds of difficulty taking medications 1-2 years prior (OR = 4.56 (CI 3.30-6.31)), and more than two times higher odds of difficulty taking medications 3-4 years prior (OR = 2.41 (CI 1.61-3.59)).

CONCLUSIONS

Odds of medication difficulty 1-2 years prior were more than four times greater for individuals with ADRD diagnoses compared with those without ADRD. Medication management difficulties may prompt further cognitive screening, potentially aiding in earlier recognition of ADRD.

Home Care Patients' Experiences with Home Care Nurses' Support in Medication Adherence

PURPOSE

To describe nurses' support interventions for medication adherence, and patients' experiences and desired improvements with this care.

PATIENTS AND METHODS

A two-phase study was performed, including an analysis of questionnaire data and conducted interviews with members of the care panel of the Netherlands Patients Federation. The questionnaire assessed 14 types of interventions, satisfaction (score 0-10) with received interventions, needs, experiences, and desired improvements in nurses' support. Interviews further explored experiences and improvements. Data were analyzed using descriptive statistics and a thematic analysis approach.

RESULTS

Fifty-nine participants completed the questionnaire, and 14 of the 59 participants were interviewed. The satisfaction score for interventions was 7.9 (IQR 7-9). The most common interventions were: "noticing when I don't take medication as prescribed" (n = 35), "helping me to find solutions to overcome problems with using medications" (n = 32), "helping me with taking medication" (n = 32), and "explaining the importance of taking medication at the right moment" (n = 32). Fifteen participants missed ≥1 of the 14 interventions. Most mentioned the following: "regularly asking about potential problems with medication use" (33%), "regularly discussing whether using medication is going well" (29%), and "explaining the importance of taking medication at the right moment" (27%). Twenty-two participants experienced the following as positive: improved self-management of adequate medication taking, a professional patient-nurse relationship to discuss adherence problems, and nurses' proactive attitude to arrange practical support for medication use. Thirteen patients experienced the following as negative: insufficient timing of home visits, rushed appearance of nurses, and insufficient expertise about side effects and taking medication. Suggested improvements included performing home visits on time, more time for providing support in medication use, and more expertise about side effects and administering medication.

CONCLUSION

Overall, participants were satisfied, and few participants wanted more interventions. Nurses' support improved participants' self-management of medication taking and enabled patients to discuss their adherence problems. Adequately timed home visits, more time for support, and accurate medication-related knowledge are desired.

Opportunities for changes in the drug product design to enhance medication safety in older people: Evaluation of a national public portal for medication incidents

AIMS

Medication safety requires urgent attention in hospital pharmacy. This study evaluated the medication-related problems/errors as reported to the Dutch medication incident registry and disseminated for information to pharmacists. Through analysis by an expert panel we aimed to better understand which problems could have been mitigated by the drug product design. Additionally, the (wider) implications of the problems for current hospital/clinical practice were discussed.

METHODS

Items were extracted from the public Portal for Patient Safety. Items were included if relevant for older people and connected with the drug product design and excluded if they should reasonably have been intercepted by compliance to routine controls or well-known professional standards in pharmaceutical care. To explore any underreporting of well-known incidents, it was investigated if different medication-related problems could be observed in a regional hospital practise over a 1-month period. For 6 included items (cases), the implications for hospital/clinical practise were discussed in an expert panel.

RESULTS

In total, 307 items were identified in the Portal for Patient Safety; all but 14 were excluded. Six cases were added from daily hospital practice. These 20 cases commonly related to confusing product characteristics, packaging issues such as the lack of a single unit package for an oncolytic product, or incorrect or incomplete user instructions.

CONCLUSION

Medication registries provide important opportunities to evaluate real-world medication-related problems. However, underreporting of well-known problems should be considered. The product design can be used as an (additional) risk mitigation measure to support medication safety in hospital practice.

Medication self-management: Considerations and decisions by older people living at home

BACKGROUND

Medication self-management is complicated for older people. Little is known about older persons' considerations and decisions concerning medication therapy at home.

OBJECTIVE

(s): To explore how older people living at home self-manage their medication and what considerations and decisions underpin their medication self-management behavior.

METHODS

Semi-structured interviews with consenting participants (living at home, aged ≥65, ≥5 different prescription medications daily) were recorded and transcribed with supporting photographs. Content was analyzed with a directed approach and presented according to three phases of medication self-management (initiation, execution, and discontinuation).

RESULTS

Sixty people were interviewed. In the initiation phase, participants used different techniques to inform healthcare professionals and to fill and check prescriptions. Over-the-counter medication was seldom discussed, and potential interactions were unknown to the participants. Some participants decided to not start treatment after reading the patient information leaflets for fear of side effects. In the execution phase, participants had various methods for integrating the use of new and chronic medication in daily life. Usage problems were discussed with healthcare professionals, but side effects were not discussed, since the participants were not aware that the signs and symptoms of side effects could be medication-related. Furthermore, participants stored medication in various (sometimes incorrect) ways and devised their own systems for ordering and filling repeat prescriptions. In the discontinuation phase, some participants decided to stop or change doses by themselves (because of side effects, therapeutic effects, or a lack of effect). They also mentioned different considerations regarding medication disposal and disposed their medication (in)correctly, stored it for future use, or distributed it to others.

CONCLUSIONS

Participants' considerations and decisions led to the following: problems in organizing medication intake, inadequate discussion of medication-related information with healthcare professionals, and incorrect and undesirable medication storage and disposal. There is a need for medication self-management observation, monitoring, and assistance by healthcare professionals.

A Prospective Study of Usability and Workload of Electronic Medication Adherence Products by Older Adults, Caregivers, and Health Care Providers

Background

A decreased capacity to self-manage medications results in nonadherence, medication errors, and drug-related problems in older adults. Previous research identified 80 electronic medication adherence products available to assist patients with self-management of medications. Unfortunately, the usability and workload of these products are unknown.

Objective

This study aimed to examine the usability and workload of a sample of electronic medication adherence products.

Methods

In a prospective, mixed methods study, a sample of older adults, health care professionals, and caregivers tested the usability and workload of 21 electronic medication adherence products. Each participant tested 5 products, one at a time, after which they completed the system usability scale (SUS) and NASA-task load index (NASA-TLX), instruments that measure the usability and workload involved in using a product. Higher SUS scores indicate more user-friendliness, whereas lower NASA-TLX raw scores indicate less workload when using a product.

Results

Electronic medication adherence products required a mean of 12.7 steps (range 5-20) for the appropriate use and took, on average, 15.19 min to complete the setup tasks (range 1-56). Participants were able to complete all steps without assistance 55.3% of the time (103 out of the 186 tests were completed by 39 participants; range 0%-100%). The mean SUS and NASA-TLX raw scores were 52.8 (SD 28.7; range 0-100) and 50.0 (SD 25.7; range 4.2-99.2), respectively, revealing significant variability among the electronic medication adherence products. The most user-friendly products were found to be TimerCap travel size (mean 78.67, SD 15.57; P=.03) and eNNOVEA Weekly Planner with Advanced Auto Reminder (mean 78.13, SD 14.13; P=.049) as compared with MedReady 1700 automated medication dispenser (mean 28.63, SD 21.24). Similarly, MedReady (72.92, SD 18.69) was found to be significantly more work intensive when compared with TimerCap (29.35, SD 20.35; P=.03), e-pill MedGlider home medication management system (28.43, SD 20.80; P=.02), and eNNOVEA (28.65, SD 14.97; P=.03). The e-pill MedTime Station automatic pill dispenser with tipper (71.77, SD 21.98) had significantly more workload than TimerCap (P=.04), MedGlider (P=.03), and eNNOVEA (P=.04).

Conclusions

This study demonstrated that variability exists in the usability and workload of different electronic medication adherence products among older adults, caregivers, and clinicians. With few studies having investigated the usability and workload of electronic medication adherence products, no benchmarks exist to compare the usability and workload of these products. However, our study highlights the need to assess the usability and workload of different products marketed to assist with medication taking and provides guidance to clinicians regarding electronic medication adherence product recommendations for their patients. Future development of electronic medication adherence products should ensure that the target populations of patients are able to use these products adequately to improve medication management.

Home storage of biological medications administered to patients with rheumatic diseases

Background

The inadequate storage of biopharmaceuticals may result in an ineffective therapeutic response since poor conservation can lead to the emergence of protein aggregates and cause immunogenicity in patients, which can increase the risk of adverse events by inducing the production of anti-drug antibodies. This can also lead to significant economic losses for public health, given the high cost of these medicines. The aim of this study was to verify whether the home storage of biopharmaceuticals dispensed by the Unified Public System was in accordance with the manufacturers’ specified standards and whether external variables interfered with the correct home storage.

Methods

This was a prospective observational study. Patients with a confirmed diagnosis of rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis who were using a biologic exclusively dispensed by Unified Public System were included. Storage temperature was measured by digital thermometer inserted into the refrigerator of the participant’s home. Fisher’s exact test was performed to cross-reference the temperature data and the qualitative variables obtained using an epidemiologic questionnaire. Mean, minimum, maximum values and standard deviation were described in the quantitative data. Mann-Whitney non-parametric test was performed to the association between temperature excursion and the number of people in the house.

Results

A total of 81 participants were included and 67 (82.71%) did not maintain home storage correctly. The maximum temperature observed among all patients was 15.5 °C, the minimum was − 4.4 °C and the average was 5.6 °C (standard deviation 2.8); 10 (12.3%) had at least one negative temperature measured. The average time for participants who had an inadequate temperature record was 8 h and 31 min. Nine participants (90%) who stored the medication into the shelf/drawer below the freezer had a temperature excursion (p = 0.011). Most of the participants (88.5%) who stored their biopharmaceutical near the back side, close to the wall of the refrigerator had a negative temperature record (p < 0.001).

Conclusion

Most of the study participants (82.71%) did not maintain adequate home storage conditions for their biopharmaceutical. Intrinsic factors of household refrigerators may be involved in temperature deviations.

Evaluation of the Health Education Impact Questionnaire (heiQ), a Self-Management Skill Assessment Tool, in Italian Chronic Patients

Background

The Health Education Impact Questionnaire (heiQ) aims to evaluate eight self-management skills in people with chronic conditions. Knowledge about the relations between these self-management skills and different quality of life (QoL) outcomes has received little attention. It is also important to provide further evidence on its properties in non-English healthcare contexts, as the questionnaire is being used in cross-cultural research. Furthermore, in the Italian healthcare context, the relationship between the medical staff and the patients remains asymmetrical, with the latter having the role of passive recipients of medical prescriptions and services. The current study provided further evidence about the psychometric properties of the heiQ among Italian people with chronic conditions, specifically by assessing the factor structure, reliability, convergent/divergent and criterion validity (ie, the specific contribution of each of the self-management skills to QoL outcomes).

Methods

Two hundred ninety-nine individuals with a chronic condition (mean age = 61.4 years, 50% females) completed the heiQ and the Medical Outcomes Study-Short Form (MOS SF-36). Confirmatory factor analyses, Composite Reliability Indices (CRI), bivariate correlations and linear regression analyses were computed.

Results

A model with 8 correlated factors showed good fit, in a similar way to previous studies. CRI values were acceptable to good for all the subscales. Associations between some of the heiQ subscales and some of the MOS SF-36 subscales supported criterion validity. In particular, it was confirmed by the moderate associations between the constructive attitudes and approaches subscale and the MOS SF-36 vitality and perceived mental health and by the moderate correlations between the health directed activities subscale and the MOS SF-36 Vitality. In linear regressions, higher emotional distress predicted higher physical and mental QoL, while higher mental QoL was also associated with stronger constructive attitudes and approaches.

Conclusion

The heiQ has robust properties across translations and it can also be used routinely in Italian healthcare contexts. The evidence that all the other self-management skills did not predict either physical or mental QoL could suggest that the self-management model of chronic diseases is still not sufficiently developed in the Italian context, where patients are passive recipients of medical instructions.

Effect of multidose drug dispensing on the time in therapeutic range in patients using vitamin-K antagonists: A randomized controlled trial

BACKGROUND

A high number of vitamin K antagonist (VKA) users have a low proportion of time in therapeutic range (TTR) resulting in a high number of bleeding and thromboembolism events.

OBJECTIVE

Can the quality of anticoagulation be improved by dispensing VKAs via multidose drug dispensing (MDD).

METHOD

A randomized controlled trial in the Netherlands. Patients who used VKAs, ≥65 years of age with a TTR <65% were eligible for inclusion. All oral drugs were dispensed via MDD. In MDD systems, all oral chronic medication intended for one dosing moment is packed in plastic disposable pouches. Controls received VKAs by manual dispensing. The difference in TTR between the 6 months after- and 6 months before the index date. A mixed-effects model with the intervention, TTR before the index date, MDD system at baseline as covariates, and pharmacy as random effect. A per-protocol analysis was performed with all patients who completed the study as intended.

RESULTS

One hundred and seventy-nine patients were included. Mean age was 80.0 (SD 6.9) years. Mean TTR during the study was 79.2 ± 18.0% in the intervention group and 72.5 ± 20.1% in the control group. The intervention resulted in a 5.6% (95% CI: 0.1-11.1) increase in TTR compared to the control group. Per-protocol analysis resulted in an 8.3% (95% CI: 0.99-15.61) increase in TTR compared to the control group. No differences in reduction were observed between the intervention and control group.

CONCLUSION

The quality of anticoagulation can be improved with the use of MDD systems.

Associations between personality traits and adequate home storage of drugs in older patients

The objective of this study was to investigate the association between personality traits of older patients and adequate home storage of drugs. Forty-four participating Dutch community pharmacists randomly selected each up to four community-dwelling elderly patients (≥65 years) who were using at least one prescription drug. The Big Five Inventory was used to assess the personality traits - 'openness', 'conscientiousness', 'extraversion', 'agreeableness' and 'neuroticism' - of patients. An assessment of adequate home storage of drugs was made using a summed composite score for each patient ranging from zero (adequate storage) to three (inadequate storage) was based on storage criteria representing quality, information and level of storage organization. A 51.2% of the patients stored drugs adequately in accordance with all quality ("Q") and information ("I") criteria. A high level of drug storage organization was found in 70.8% of patients. Forty-three patients (31.4%) stored their drugs adequately based on all storage criteria (composite storage score 0). No associations between personality dimensions and adequate drug storage were found. Having a lower number of drugs was associated with adequate drug home storage (OR_adjusted 0.86; 95% CI: 0.77-0.96). In conclusion, this study suggests that personality is not associated with adequate home storage of drugs in older patients.

Factors influencing the attention to home storage of medicines in China

BACKGROUND

Medicines are stored in most households around the world for a range of different purposes including emergency use and the treatment of acute or chronic illnesses. The presence of medicines in households is becoming a significant risk factor for irrational medicine storage, disposal, and use in developing countries due to limited information and knowledge offered on safe storage. This study examined how patients store medicines and highlighted factors which influence home storage behaviours for medicines in China.

METHOD

A cross-sectional survey of 625 households was undertaken. In each household, data were collected from the head of household present at home. The study covered six provinces in China including the North, Central, and Southern regions. Respondents were interviewed by doctors. The doctors were study assistants and data collectors. "Attention" was taken as the research focus and a five-point Likert scale was used to measure attitudes to medicine storage at home. Factor analysis, variance analysis, and the multivariable logistic regression models were employed in the present study.

RESULTS

Of the households investigated in this study, cold medications were the medicine most commonly stored at home. The majority of the respondents gave more attention to the expiration date of medicines compared to other factors. Only a few respondents thought humidity was important factor influencing home storage of medicines. Despite some attention being given to the location of storage for home medicines, considerably more information is needed to improve awareness. In addition, our data revealed that some attention had been paid to elimination and recycling mechanisms but similarly, increased awareness is needed. There were obvious differences between the populations used in the study, due to differences in socio-demographic characteristics of the study participants. Age is the most important factor influencing the attention paid to home storage of medicines in China.

CONCLUSION

A major improvement in the awareness of correct storage conditions of medicines for home use can be realized by increased education, and highlighting the importance of correct medicine storage, disposal methods and usages, which has high potential to deliver public health benefits in China. Some suggestions were provided to health care providers.

Feasibility of a Texting Intervention to Improve Medication Adherence Among Older HIV+ African Americans: A Mixed-Method Pilot Study

Antiretroviral therapy (ART) is the primary treatment for HIV, and adherence to it is crucial to addressing health disparities. Approximately half of individuals in the United States living with HIV are African Americans, and those over 45 years of age are more likely to die early from HIV/AIDS than their White counterparts. This mixed-method pilot study evaluated the feasibility of a text-based mobile phone intervention designed to improve ART adherence among older African Americans with HIV. Feasibility was assessed via implementation, participant adherence, acceptability, and satisfaction, as well as short-term impact on medication adherence, adherence-related self-efficacy, and positive affect. The intervention utilized pill reminder, motivational, and health educational texts. Participants (N = 21) ranged in age from 50 to 68 years. Outcomes were evaluated via quantitative results from self-report measures and qualitative data from four focus groups. Attrition to the study was 100%. After 8 weeks, participants reported statistically significant improvements in medication adherence, but not in self-efficacy or affect scores. Qualitative findings highlight the psychologically supportive potential of the intervention, challenges to adherence, as well as suggestions for improvement. The study demonstrates that a text messaging intervention may be feasible for older African Americans with HIV, and helpful in supporting ART adherence.

Older Patients' Compliance with Drug Storage Recommendations

Background

Whereas storage conditions are regulated and closely monitored in every stage of the drug supply chain before drug dispensing, it is unknown if patients store drugs at home according to storage recommendations.

Objective

The objective of this study was to investigate how older patients store their prescription drugs at home and to what extent they comply with drug storage recommendations.

Methods

We conducted a cross-sectional study between October 2015 and March 2016. Forty-four participating Dutch community pharmacies selected four home-dwelling patients (aged ≥ 65 years) using at least one prescription drug. A complete drug inventory at patients’ homes was performed. Drugs were considered to fulfill the storage recommendation when these met all drug quality (Q) and information (I) criteria: adequately stored according to drug product label storage recommendations for temperature, light, humidity (Q1); expiry date not passed (Q2); integer primary package (Q3); drug identifiability (I1); drug package insert or information leaflet availability (I2).

Results

One hundred and seventy patients [53.5% female, mean age 74.9 (standard deviation 7.3) years] were included and 1133 prescription drugs stored at home were registered. More than half of the patients (51.2%) complied with all storage quality and information criteria. Assessment of the individual criteria showed that 76.4% of patients were compliant with criterion Q1 while 90.6, 95.3, 97.1 and 71.2% of patients complied with criteria Q2, Q3, I1 and I2, respectively. 53.2% of drugs that should be kept refrigerated according to storage criterion Q1 were not stored between 2 and 8 °C.

Conclusion

This study illustrates that more than half of the older patients comply with general drug storage recommendations.

Electronic supplementary material

The online version of this article (10.1007/s40266-018-0524-8) contains supplementary material, which is available to authorized users.

Cannabinoids for the treatment of neuropsychiatric symptoms, pain and weight loss in dementia

PURPOSE OF REVIEW

Efficacious treatment for neuropsychiatric symptoms (NPS), pain and weight loss for dementia patients is desperately needed. This review presents an up-to-date look at the literature investigating the use of cannabinoid for these symptoms in dementia.

RECENT FINDINGS

We searched electronically for publications regarding cannabinoid use in dementia, with a focus on Alzheimer's disease. Seven studies and one case report have been conducted to examine the use of cannabinoids for the treatment of NPS of dementia, and three of these trials reported on the effect of cannabinoids on weight. Five studies reported decreased agitation or improvements in sleep with cannabinoid use. One crossover trial found that cannabinoids positively impacted weight, whereas a chart review study found no impact on weight with cannabinoids, but an increase in food intake. There were no trials examining the use of cannabinoids for pain in dementia.

SUMMARY

Findings from trials with small sample sizes and various clinical populations suggest that cannabinoid use may be well tolerated and effective for treatment of NPS such as agitation as well as weight and pain management in patients with dementia. Additional studies are necessary to further elucidate the relative risks and benefits of this treatment.

Prevalence and Co-Occurrence of Geriatric Syndromes in People Aged 75 Years and Older in France: Results From the Bordeaux Three-city Study

Background

Geriatric syndromes (GSs) are often the result of cumulative insults to multiple organ systems and are considered common in older adults. However, their frequency and co-occurrence are not well known in the elderly population. This study aimed to determine the prevalence of several GSs and to analyze the co-occurrence of these syndromes in a general population of elderly individuals.

Methods

A cross-sectional analysis of 630 adults aged 75 years or older participating in the 10-year follow-up of the Bordeaux sample of the French Three-City Study was conducted. The following 10 GSs were assessed: physical frailty, dementia and cognitive impairment, depressive symptoms, polymedication, social isolation, thinness, falls, dependence, sensory deficit, and incontinence. The prevalence of the 10 GSs was estimated, and multiple correspondence analysis (MCA) models were used to explore the mutual associations between these GSs.

Results

The mean age of the participants was 83.3 years; 69% were women, and 80.5% [95% confidence interval (CI) = 76.3-82.7] had at least one GS. The most frequent GSs were polymedication (50.6% 95%CI = 46.7-54.5) and falls (43.1% 95%CI = 38.4-46.1). The MCA models identified two major dimensions of the 10 GSs: "Dementia-Dependence-Incontinence" and "Frailty-Depression-Isolation."

Conclusions

GSs were very common in this French elderly population and were grouped into two major dimensions: the "Dementia-Dependence-Incontinence" and "Frailty-Depression-Isolation."

A New Method of Identifying Characteristics of Needing Help to Take Medications in an Older Representative Community-Dwelling Population: The Older Adults Medication Assist Scale

OBJECTIVES

To determine the sociodemographic characteristics, health conditions, and cognitive and functional status associated with baseline prevalence and new need for help taking medication 3 years later and to construct a brief scale indicative of need for help taking medications.

DESIGN

Retrospective cross-sectional and 3-year longitudinal study.

SETTING

Five-county area in north-central Piedmont, North Carolina.

PARTICIPANTS

Representative community-dwelling sample of black and white individuals aged 65 and older (N = 4,136).

MEASUREMENTS

Information was obtained in person in participants' homes using structured questionnaires. Health conditions included sensory impairment and self-report of physician-diagnosed conditions. Cognitive status was assessed using the 10-item Short Portable Mental Status Questionnaire. Functional status was assessed using the three-item Rosow-Breslau scale, the five-item Katz activity of daily living scale, and a modified six-item Older Americans Resources and Services instrumental activities of daily living scale.

RESULTS

Characteristics associated with need for help taking medications were aged 80 and older, being male, living with others, having four or more chronic conditions, and impaired cognitive or functional status (c-statistic 0.94, 77.1% sensitivity, 87.9% specificity). Predictors of new need for help with medications 3 years later included aged 75 and older at baseline, being male, and impaired cognitive and functional status (c-statistic 0.75).

CONCLUSION

This brief scale can help identify persons needing help with medications and could be useful in assisting clinicians with medication management.

Medication self-management skills and cognitive impairment in older adults hospitalized for heart failure: A cross-sectional study

Background:

Cognitive impairment is highly prevalent among older adults (aged ≥65 years) hospitalized for heart failure and has been associated with poor outcomes. Poor medication self-management skills have been associated with poor outcomes in this population as well. The presence and extent of an association between cognitive impairment and poor medication self-management skills in this population has not been clearly defined.

Objective:

We assessed the cognition of consecutive older adults hospitalized for heart failure, in relation to their medication self-management skills.

Methods:

We conducted a cross-sectional study of older adults (aged ≥65 years) who were hospitalized for heart failure and were being discharged home. Prior to discharge, we assessed cognition using the Mini-Cog. We also tested patients’ ability to read a pill bottle label, open a pill bottle safety cap, and allocate mock pills to a pill box. Pill allocation performance was assessed quantitatively (counts of errors of omission and commission) and qualitatively (patterns suggestive of knowledge-based mistakes, rule-based mistakes, or skill-based slips).

Results:

Of 55 participants, 22% were found to have cognitive impairment. Patients with cognitive impairment tended to be older as compared to those without cognitive impairment (mean age = 81 vs 76 years, p = NS). Patients with cognitive impairment had a higher prevalence of inability to read pill bottle label (prevalence ratio = 5.8, 95% confidence interval = 3.2–10.5, p = 0.001) and inability to open pill bottle safety cap (prevalence ratio = 3.3, 95% confidence interval = 1.3–8.4, p = 0.03). While most patients (65%) had pill-allocation errors regardless of cognition, those patients with cognitive impairment tended to have more errors of omission (mean number of errors = 48 vs 23, p = 0.006), as well as more knowledge-based mistakes (75% vs 40%, p = 0.03).

Conclusion:

There is an association between cognitive impairment and poor medication self-management skills. Medication taking failures due to poor medication self-management skills may be part of the pathway linking cognitive impairment to poor post-discharge outcomes among patients with heart failure transitioning from hospital to home.

Documentation of Functional Medication Management in Older Adults: A Retrospective Chart Review in Acute Care Hospitalization

Background

Functional skills can affect the ability of older adults to appropriately manage their medication regimens. Research evaluating a patient’s functional ability or the assessment of medication management is limited.

Objectives

Our objective was to describe the documented components of functional medication management (FMM) in adults aged ≥65 years during an acute hospital stay. The secondary objective was to describe the characteristics of the healthcare providers (HCP) who document FMM.

Methods

This study was a retrospective chart review of a sample of patients aged ≥65 years admitted to medical units in a tertiary hospital from January 2013 to October 2014. FMM was defined as the steps required to take medications—including ordering, picking up, organizing, preparing, administering, and monitoring medications—and the functional abilities necessary to perform these tasks.

Results

The mean (standard deviation [SD]) age of patients was 78.9 (8.4) years; 72 (52 %) were female. Of the 190 charts screened, 140 were eligible for inclusion. The mean (SD) number of documented scheduled oral medications was eight (3.1) per patient, and 108 (77.1 %) charts contained documented FMM-related information. Commonly documented FMM components included whether the patient could administer medications independently (73 [52 %]) or schedule medication (46 [33 %]). These activities were most frequently documented by physicians (124 [39 %]) and occupational therapists (108 [34 %]).

Conclusion

FMM assessments for older adult inpatients with multiple comorbidities and complex medication regimens were not documented comprehensively or frequently. Given the complexity of medication regimens and the functional skills required to manage medications at home, failing to document these assessments when evaluating patients in hospital reflects a lost opportunity.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-016-0092-3) contains supplementary material, which is available to authorized users.

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.

Factors associated with appropriate knowledge of the indications for prescribed drugs among community-dwelling older patients with polypharmacy

BACKGROUND

polypharmacy contributes to patients' non-adherence with physicians' prescriptions. Patients' knowledge about the indications for their medicines is one of the factors influencing adherence.

OBJECTIVE

to identify factors associated with appropriate knowledge about the indications for drugs prescribed to older patients with polypharmacy.

METHODS

in a primary care setting, using home interviews and postal questionnaires, patients aged 60 and over who were taking five or more prescribed drugs simultaneously were asked about their medication. Multiple logistic regression analysis was used to evaluate the association (odds ratio, OR) between medication knowledge and explanatory variables like medication use, sex, age, living situation and educational level.

RESULTS

seven hundred and fifty-four participants (mean age 73.2 years) reported an average daily intake of nine (SD 3.0) prescribed drugs. Only 15% of the patients were able to recall the indication for each of their prescribed drugs. Variables that were negatively associated with correct reporting of all indications were taking many prescribed drugs (e.g. ≥10 versus ≤5: OR 0.05), age 80 years or over (versus 60-69 years: OR 0.47) and male sex (OR 0.53). Patients living with a partner were more knowledgeable than patients living alone (OR 2.11). We did not find an association with educational level.

CONCLUSION

among older patients using five or more prescribed drugs, there was little understanding of the indications for their drugs, especially among patients taking the highest number of drugs, patients aged 80 or over, and men. Patients living independently with a partner were more knowledgeable than others.

Specific cognitive functions and depressive symptoms as predictors of activities of daily living in older adults with heterogeneous cognitive backgrounds

Cognitive functioning influences activities of daily living (ADL). However, studies reporting the association between ADL and neuropsychological performance show inconsistent results regarding what specific cognitive domains are related to each specific functional domains. Additionally, whether depressive symptoms are associated with a worse functional performance in older adults is still under explored. We investigated if specific cognitive domains and depressive symptoms would affect different aspects of ADL. Participants were 274 older adults (96 normal aging participants, 85 patients with mild cognitive impairment, and 93 patients probable with mild Alzheimer's disease dementia) with low formal education (∼4 years). Measures of ADL included three complexity levels: Self-care, Instrumental-Domestic, and Instrumental-Complex. The specific cognitive functions were evaluated through a factorial strategy resulting in four cognitive domains: Executive Functions, Language/Semantic Memory, Episodic Memory, and Visuospatial Abilities. The Geriatric Depression Scale measured depressive symptoms. Multiple linear regression analysis showed executive functions and episodic memory as significant predictors of Instrumental-Domestic ADL, and executive functions, episodic memory and language/semantic memory as predictors of Instrumental-Complex ADL (22 and 28% of explained variance, respectively). Ordinal regression analysis showed the influence of specific cognitive functions and depressive symptoms on each one of the instrumental ADL. We observed a heterogeneous pattern of association with explained variance ranging from 22 to 38%. Different instrumental ADL had specific cognitive predictors and depressive symptoms were predictive of ADL involving social contact. Our results suggest a specific pattern of influence depending on the specific instrumental daily living activity.

Factors affecting family physicians' drug prescribing: a cross-sectional study in Khuzestan, Iran

BACKGROUND

Rational prescription is a considerable issue which must be paid more attention to assess the behavior of prescribers. The aim of this study was to examine factors affecting family physicians' drug prescribing.

METHODS

We carried out a retrospective cross-sectional study in Khuzestan province, Iran in 2011. Nine hundred eighty-six prescriptions of 421 family physicians (including 324 urban and 97 rural family physicians) were selected randomly. A multivariate Poisson regression was used to investigate potential determinants of the number of prescribed drug per patient.

RESULTS

The mean of medication per patient was 2.6 ± 1.2 items. In the majority (91.9%) of visits a drugs was prescribed. The most frequent dosage forms were tablets, syrups and injection in 30.1%, 26.9%, and 18.7% of cases respectively. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and antibiotics were 29.7% and 17.1% of prescribed drugs respectively. The tablets were the most frequent dosage forms (38.6% of cases) in adult's patients and syrups were the most frequent dosage forms (49% of cases) in less than 18 years old. Paracetamols were popular form of NSAIDs in two patients groups. The most common prescribed medications were oral form.

CONCLUSION

In Khuzestan, the mean of medication per patient was fewer than national average. Approximately, pattern of prescribed drug by family physicians (including dosage form and type of drugs) was similar to other provinces of Iran.