AIDES to improving medication adherence in older adults

Barriers to Antiplatelet and Statin Adherence Following Major Vascular Intervention

BACKGROUND

Antiplatelets and statins therapies are associated with improved cardiovascular outcomes following major vascular intervention. Many vascular surgery institutions are reporting improved prescribing rates for aspirin (ASA), P2Y12 antagonists, and statins. Nevertheless, there remains limited publication describing rates and patient-perceived barriers for postoperative adherence. The purpose of this study is to investigate patient nonadherence to antiplatelet and statin therapies following major vascular intervention.

METHODS

A retrospective review of patients who underwent major vascular intervention at a single academic center was performed. The prescribing rates of ASA, P2Y12 antagonists, and statins were reviewed. Postoperative adherence, defined as consistent intake as prescribed, was evaluated at 1, 3, 6, 9, and 12 months using electronic documentation of both follow-up clinic appointments and phone call assessments, then corroborated with pharmacy fulfilment records. Patient-reported barriers to medication adherence were also examined.

RESULTS

A total of 101 subjects underwent major vascular intervention between January 2020 and July 2020, 98% of whom were discharged on at least 1 antiplatelet or statin agent. Approximately 90% of patients were discharged with ASA, 32% with a P2Y12 antagonist, and 96% with a statin. All patients who maintained adherence up to 6 months continued to report adherence at 9 and 12 months. Consistent adherence at 12 months was documented in 76% of patients on ASA, 81% on P2Y12 antagonism therapy, and 73% on statins. New adverse drug reactions represented the most common barrier to achieving adherence (37% [n = 20]). Preoperative therapy with ASA, P2Y12 antagonists, and statins were all independently predictive of postoperative adherence to the same regimen (P ≤ 0.001). The female gender was also associated with higher rates of adherence to postoperative P2Y12 antagonism therapy (P ≤ 0.05).

CONCLUSIONS

The current prescribing rates for antiplatelet and statin agents are promising, but postoperative nonadherence remains a multifaceted issue.

A cornerstone of healthy aging: do we need to rethink the concept of adherence in the elderly?

Worldwide, the population is aging and this trend will increase in the future due to medical, technological and scientific advancements. To take care of the elderly is highly demanding and challenging for the health care system due to their frequent condition of chronicity, multimorbidity and the consequent complex management of polypharmacy. Nonadherence to medications and to medical plans is a well-recognized public health problem and a very urgent issue in this population. For this reason, some considerations to identify a new shared approach to integrated care of older people are described. The concept of adherence should be considered as a complex and continuous process where family, caregivers and patients' beliefs come into play. Moreover, a new culture of adherence should contemplate the complexity of multimorbidity, as well as the necessity to renegotiate the medication regimen on the basis of each patient's needs.

Beliefs and practices of Greek doctors in relation to patients' adherence to antihypertensive medication

Although it has been proven that decreasing the arterial blood pressure decreases cardiovascular morbidity and mortality, <25% of hypertensive patients receiving antihypertensive treatment achieve target values, which are mainly attributed to failure of the patients to comply to treatment. Ensuring patient compliance to antihypertensive treatment, to prevent the development of hypertension-associated complications, has proven to be challenging in several countries. The aim of the present study was to investigate the knowledge, perceptions and practices applied by doctors treating hypertensive patients regarding patient compliance to the prescribed treatment. We also aimed to assess the possible barriers physicians face to using reinforcement methods and currently available guidelines. A total of 202 doctors from the Serres and Drama prefectures of Greece participated in this study. The data collection comprised a quantitative method questionnaire and the data were processed using Stata 8.0 statistical software. The results demonstrated that 84.7% of the participating doctors do not use the current guidelines for compliance, whereas only 10.1% have consultations lasting >15 min when discussing the medication with their patients. In addition, the majority (84.7%) of the doctors do not practice peer mentoring and consider the most effective interventions to be providing information and discussing the medication with their patients. In conclusion, the level of patient compliance to antihypertensive medication is unsatisfactory and the main reason is considered to be the non-use of guidelines by the treating physicians. Patients may benefit from further education of health professionals in this field.

Therapeutic intervention in oropharyngeal dysphagia

Oropharyngeal dysphagia is a frequent consequence of several medical aetiologies, and even considered part of the normal ageing process. Early and accurate identification provides the opportunity for early implementation of dysphagia treatments. This Review describes the current state of the evidence related to dysphagia therapies - focusing on treatments most clinically utilized and of current interest to researchers. Despite successes in select studies, the level of evidence to support the efficacy of these treatments remains limited. Heterogeneity exists across studies in both how interventions are administered and how their therapeutic value is assessed, thereby making it difficult to establish external validation. Future work needs to address these caveats. Also, to be most efficacious, dysphagia therapies need to account for influences from pre-morbid patient characteristics as these factors have potential to increase the risk of dysphagia and the resulting complications of aspiration, malnutrition and psychological burden. Dysphagia therapies therefore need to incorporate the medical aetiology that is at its root, the resulting swallow physiology captured from comprehensive clinical and/or instrumental assessments, and the existing needs and supports of patients.

Parent health literacy and adherence-related outcomes in children with epilepsy

BACKGROUND

The relationship between parent health literacy and adherence to treatment in children with epilepsy has not been fully explored. The purpose of this study was to determine whether parent health literacy and other variables predicted factors associated with adherence, such as missed medication doses, missed medical appointments, and seizure frequency, in children with epilepsy between 1 and 12 years old.

METHODS

It was hypothesized that parents with adequate parent health literacy would report fewer missed doses, missed appointments, and seizure occurrences. Using a nonexperimental, cross-sectional study design, interviews were conducted with 146 parents and guardians of children with epilepsy who resided in rural communities. Univariate analyses, including ANOVA, and multiple linear regressions were conducted.

RESULTS

Results indicated that parent health literacy was the strongest predictor of two of the adherence-related factors. Higher health literacy scores were associated with fewer missed medication doses and seizure occurrences. However, health literacy was not associated with missed medical appointments. Among other study variables, higher household income was also predictive of fewer missed doses.

CONCLUSION

The study findings suggest that inadequate health literacy among parents may serve as an independent risk factor for adherence-related outcomes among children with epilepsy. Further research, as well as effective, targeted parent health literacy strategies used to improve epilepsy management and care in children, is recommended.

Dropping the Ball and Falling Off the Care Wagon. Factors Correlating With Nonadherence to Secondary Fracture Prevention Programs

Health care systems and hospitals in several countries have implemented Fracture Liaison Services (FLSs). Success rates of FLSs with regard to osteoporosis assessment and treatment, fracture reduction, and adherence to osteoporosis medications have been reported by several groups including ours. A significant drop-out rate among patients in these programs may occur. This has not been evaluated before. We explored the factors correlating with nonadherence among a multiethnic population of patients in the FLS at our institution, the largest tertiary teaching hospital in South East Asia. Our secondary objective was to explore whether patients who defaulted follow-up visits continued to be compliant with medications. A retrospective analysis of our FLS's computerized database was performed. Of 938 patients followed up more than 2 years, 237 defaulted at various time points. A significant percentage of patients who dropped out of the program opined that it was because the follow-up visits were too time consuming. Non-Chinese patients were more likely than Chinese (adjusted hazard ratio [aHR] = 1.98, 1.33-2.94), patients with primary school education and below were more likely than those with secondary school and above education (aHR = 1.65, 1.11-2.45) and those with nonvertebral and/or multiple fractures were more likely than those with spine fractures (aHR = 1.38, 1.06-1.81) to be nonadherent. A fraction of patients who defaulted continued to fill osteoporosis medication prescriptions. Median medication possession ratio among the patients who defaulted was 12.3% (interquartile range: 4.1%-36.7%) at 2 years. Persistence ranged from 15.1% to 20.8% and from 1.9% to 7.5% at 1 and 2 years, respectively after defaulting from the program. Our study, which to the best of our knowledge is the first of its kind, provides insight into the factors correlating with nonadherence to FLSs. Knowledge of the challenges faced by patients may be of help to health care providers interested in developing FLSs.

What matters for patients with vasculitis?

Advances in clinical care for patients with vasculitis have improved survival rates and created new challenges related to the ongoing management of chronic disease. Lack of curative therapies, burden of disease, treatment-related side effects, and fear of relapse contribute to patient-perceived reduction in quality of life. Patient-held beliefs about disease and priorities may differ substantially from the beliefs of their health care providers, and research paradigms are shifting to reflect more emphasis on understanding vasculitis from the patient's perspective. Efforts are ongoing to develop disease outcome measures in vasculitis that better represent the patient experience. Health care providers who care for patients with vasculitis should be sensitive to the substantial burdens of disease commonly experienced by patients living with the disease and should strive to provide comprehensive care directed towards the medical and biopsychological needs of these patients.

Implementing evidence-based patient and family education on oral anticoagulation therapy: a community-based participatory project

AIMS AND OBJECTIVES

This study aimed at developing and implementing evidence-based patient and family education on oral anticoagulation therapy.

BACKGROUND

The number of persons with chronic diseases who live at home is increasing. They have to manage multiple diseases and complex treatments. One such treatment is oral anticoagulation therapy, a high risk variable dose medication. Adherence to oral anticoagulation therapy is jeopardised by limited information about the medications, their risk and complications, the impact of individual daily routine and the limited inclusion of family members in education. Hence, improved and tailored education is essential for patients and families to manage oral anticoagulation therapy at home.

DESIGN AND METHODS

A community-based participatory research design combined with the Precede-Proceed model was used including a systematic literature review, posteducation analysis, an online nurse survey, a documentation analysis and patient/family interviews. The study was conducted between April 2010-December 2012 at a department of general internal medicine in a teaching hospital in Switzerland. Participants were the department's nursing and medical professionals including the patients and their families.

RESULTS

The evidence-based patient and family education on oral anticoagulation therapy emerged comprising a learning assessment, teaching units, clarification of responsibilities of nurse professionals and documentation guidelines.

CONCLUSION AND CLINICAL RELEVANCE

The inclusion of the whole department has contributed to the development and implementation of this evidence-based patient family education on oral anticoagulation therapy, which encompasses local characteristics and patient preferences. This education is now being used throughout the department.

EMPOWER: an intervention to address barriers to pain management in hospice

CONTEXT

Concerns about pain medications are major barriers to pain management in hospice, but few studies have focused on systematic methods to address these concerns.

OBJECTIVES

The objective of this study was to test the preliminary efficacy of the Effective Management of Pain: Overcoming Worries to Enable Relief (EMPOWER) intervention, which included hospice staff education, staff screening of barriers to pain management at admission, and discussion about misunderstandings regarding pain management with family caregivers and patients.

METHODS

We conducted a pilot, cluster randomized, controlled trial with four hospices. One hundred twenty-six family caregivers (55 interventions and 71 controls) were interviewed at two weeks after admission. If patients survived three months after admission, caregivers were reinterviewed.

RESULTS

At two weeks, caregivers in the intervention group reported better knowledge about pain management (P = 0.001), fewer concerns about pain and pain medications (P = 0.008), and lower patient pain over the past week (P = 0.014) and trended toward improvement in most other areas under study. Exploratory analyses suggest that EMPOWER had a greater effect for black subjects (vs. whites) on reducing concern about stigma. At three months, the intervention group trended better on most study outcomes.

CONCLUSION

EMPOWER is a promising model to reduce barriers to pain management in hospice.

District nurses’ preventive home visits to 75-year-olds: An opportunity to identify factors related to unsafe medication management

Aims: To investigate factors related to unsafe medication management among 75-year-olds during preventive home visits, and to describe the interventions district nurses used. Methods: An explorative study. During a 9- to 12-month period, 36 DNs used the Safe Medication Assessment (SMA) tool during preventive home visits to 75-year-olds who used at least one drug ( n=113). Results: One or more factors related to unsafe medication management were identified in 84% of the 75-year-olds. More than 40% used five or more drugs, and 34.5% reported symptoms potentially indicative of adverse effects of their drugs. Nearly 30% had prescribers from more than two medical units, and 7.1% of the older persons were appraised as having reduced cognitive ability. DNs intervened in more than two-thirds of the cases and used a variety of nursing care interventions to improve the safety of medication management. Conclusions: Preventive home visits seem to provide a unique opportunity to promote safe medication management. Several factors related to unsafe medication management were identified, and several different nursing care interventions were carried out to ensure safe medication management. Use of the SMA tool in preventive home visits seems to be advantageous in improving the safety of medication management among older persons.

[Evaluation of a medication self-management education program for elders with hypertension living in the community]

PURPOSE

The purpose of this study was to examine the effect of a medication self-management education program on medication awareness, communication with health care provider, medication misuse behavior, and blood pressure in elders with hypertension.

METHODS

The research design for this study was a non-equivalent control group quasi-experimental design. Participants were 23 elders for the control group, and 26 elders for the experimental group. The experimental group participated in the medication self-management education program which included the following, verbal education, 1:1 consultation, practice in medication self-management, and discussion over 5 sessions. Data were analyzed using the SPSS 18.0 program.

RESULTS

There were statistically significant differences between the experimental and control group for medication awareness, medication misuse behavior, and communication with health care providers. However, no significant difference was found between the two groups for blood pressure.

CONCLUSION

The results indicate that the education program is effective in improving medication awareness and communication with health care providers and in decreasing medication misuse behavior. Therefore, it is recommended that this education program be used as an effective intervention for improving medication self-management for elders with hypertension.

The impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses

It is a challenge for rural health professionals to promote medication safety among older adults taking multiple medications. A volunteer coaching program to promote medication safety among rural elders with chronic illnesses was designed and evaluated. A community-based interventional study randomly assigned 62 rural elders with at least two chronic illnesses to routine care plus volunteer coaching or routine care alone. The volunteer coaching group received a medication safety program, including a coach and reminders by well-trained volunteers, as well as three home visits and five telephone calls over a two-month period. All the subjects received routine medication safety instructions for their chronic illnesses. The program was evaluated using pre- and post-tests of knowledge, attitude and behaviors with regard to medication safety. Results show the volunteer coaching group improved their knowledge of medication safety, but there was no change in attitude after the two-month study period. Moreover, the group demonstrated three improved medication safety behaviors compared to the routine care group. The volunteer coaching program and instructions with pictorial aids can provide a reference for community health professionals who wish to improve the medication safety of chronically ill elders.

Adherence and medication management by the elderly

AIMS AND OBJECTIVES

The purpose of this study was to explore the strategies used for medication management by elderly who live at home.

BACKGROUND

Non-adherence to chronic medication is a common problem among the elderly with chronic conditions. Many studies have been developed, but it did not progress in solving this multidisciplinary health care problem. The causes of non-adherence by the elderly are multiple and complex.

DESIGN

Descriptive qualitative design.

METHODS

Data were collected by two focus groups. The content of discussion was analysed from verbatim transcript and identifying categories and sub-categories emerged, leading to the construction of a diagram analysis.

RESULTS

The finding indicated the strategies and the interpretation of people aged 65 or more and with chronic illness, managing their medication. Four content categories emerged: to live with drugs, taking medication, belief about drugs and relationship with health professionals.

CONCLUSION

The study enabled us to identify and understand, by giving a 'voice' to the elderly, that living with drugs is a dynamic and complex process and that taking medication is perceived by older people as a consequence of their ageing, which requires them to include that process in their lives as a habit implying changes in their daily routines. The elderly suggest that the relationship with health professionals is essential in medication management and they reported that the information given by the nurse during consultation is very important.

RELEVANCE TO CLINICAL PRACTICE

The relationship with nurses in particular is an important issue for the older people. Understanding the factors of adherence and helping people are important areas of research in nursing. The quality of this relationship may be the key to increasing adherence in this group of people.

Predictors of adherence to medication in older Korean patients with hypertension

BACKGROUND AND RESEARCH OBJECTIVES

Adherence to a medication regimen is a major factor in achieving adequate blood pressure control for hypertensive patients. However, older adults often report having missed doses, which they attribute to forgetfulness. The purpose of this study was to identify significant factors, including socioeconomic variables, hypertension history, and cognitive functions, contributing to medication adherence among older Korean adults with hypertension.

SUBJECTS AND METHOD

This study involved 241 older patients with hypertension from a community senior center during the period from 2008 to 2009. Data were collected through face to face interviews. The association of medication adherence with socioeconomic characteristics, hypertension-related history, knowledge, antihypertensive lifestyle, and memory was assessed by computing odds ratios in logistic regressions.

RESULTS AND CONCLUSIONS

Of the 241 patients, 44% were aged 75 or older, and 60% were male. The rate of non-adherence with antihypertensive medication was 41%. Metamemory, adherence to an antihypertensive lifestyle, and employment status, were associated with participants' adherence to antihypertensive medication in both univariate and multivariate analyses. Results suggest that memory functions are a key factor to medication adherence among the Korean elderly population. In contrast to younger adults, unintentional non-adherence appears to be a major issue for older adults to keep medicating. Interventions focusing on memory ability, such as strategies for recalling and placing cues, are needed for implementation in the population of older Korean patients with hypertension. Unemployed older people who have hypertensive lifestyles should also be considered a high-risk group for non-adherence to medication.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Prescribing for older adults

Pharmacotherapy of the elderly is very complex due to age-related physiologic changes, multiple comorbidities, multiple medications (prescription, over-the counter, and herbal), and multiple providers (prescribers and pharmacies). Age-related physiologic changes and disease-related changes in organ function affect drug handling (pharmacokinetics) and response (pharmacodynamics). In addition, patients' cognitive impairment, functional difficulties, as well as caregiver issues play a large role in errors and compliance. Many older adults have several chronic conditions, and they stand to benefit the most from best practice guidelines. However, they are also at risk of toxicity given our increasingly complex pharmacopoeia and potential adverse effects that can cause morbidity and mortality. It is imperative that physicians learn how to minimize side effects and interactions. Potentially inappropriate medications (medications that pose more risk than benefit to the patient) are among the most important causes of adverse drug reactions, independent of the number of medications and other confounding factors. Many of these adverse drug reactions could be predicted from the known pharmacology of the drug and therefore could be potentially avoidable. To prescribe appropriately, we need to consider not only the pharmacological properties of the drugs, but also clinical, epidemiological, social, cultural, and economic factors. Elders' adherence to prescribed medications is also complex and depends on medical, personal, and economic factors; cognitive status; and relationship with the physician. Detection of nonadherence is a necessary prerequisite for adequate treatment, and patient education is a cornerstone in achieving medication adherence. Finally, appropriate prescribing should include a consideration of life expectancy and goals of care.

District nurses’ use for an assessment tool in their daily work with elderly patients’ medication management

Aim: To explore the capability of the Safe Medication Assessment (SMA) tool in identifying factors highly related to unsafe medication management among elderly patients and to investigate the district nurses’ (DNs) opinions of the SMA’s usefulness as a tool in their daily primary healthcare practice. Introduction: Elderly patients who experience many medical conditions often use multiple drugs. As well as the combined decline in physical and cognitive functions, the elderly are at high risk for medication-related problems. It is essential to develop a screening procedure to distinguish elderly at risk of an unsafe medication management. Methods: An explorative study. During a 3—6-month period, 25 voluntary DNs used SMA with 160 patients (consecutively chosen and meeting four specified criteria) in their daily practice. Furthermore, DNs responded to questions regarding SMA’s usefulness. Results: The result showed that SMA had the capability to identify factors highly related to unsafe medication management among the elderly included in the study. In 64% of assessments DNs identified areas of new information and in 23% of the assessments DNs intervened. They found SMA to be satisfactory regarding its level of simplicity, relevance, completeness, intelligibility, and time for implementation. Conclusions: SMA alerted the DNs to patients’ attitudes about medication and empowered them in identifying elderly patients who had unsafe medication management. SMA was also perceived as a useful assessment tool by the DNs.

Medication adherence is a partnership, medication compliance is not

Medication adherence is a complex phenomenon. As individuals assume greater responsibility for, and participation in, decisions about their health care, teaching and supporting adherence behaviors that reflect a person's unique lifestyle are the essence of a clinician-patient partnership-and it is a perfect fit with assisted living communities and nursing practice. The notion of compliance is an outdated concept and should be abandoned as a clinical practice/goal in the medical management of patient and illness. It connotes dependence and blame and does not move the patient forward on a pathway of better clinical outcomes. This article discusses the differences between compliance and adherence, identifies purposeful and unintentional reasons for nonadherence, and describes assessment tools for adherence, medication effect, and self-management capacity. Drawing on the scholarly work of others, we introduce a model for medication adherence, the ACE-ME Model: assessment, collaboration, education, monitoring, and evaluation. This model draws on the strengths and science of nursing and engages nursing participation in the continuing evolution of adherence strategies. For purposes of clarity in discussing these concepts, we use the word patient in this article rather than the word resident-that is, the older adult living in an assisted living community.

Anticancer drug therapy in the older cancer patient: pharmacology and polypharmacy

OPINION STATEMENT

Older patients currently are the largest group of oncology patients and their numbers will continue to expand. There has been minimal participation of older patients in clinical trials. This has resulted in a lack of data to make high-level evidence-based decisions with regard to chemotherapy. There has now been a number of clinical trials which have given information with regard to age-related changes and the spectrum of toxicity that occurs with older patients. There is also an expanding literature on organ dysfunction. The overall data seem to indicate that there are a very few age-related changes in the pharmacokinetics of chemotherapy. The small changes that are present have not been clinically significant. It seems that the pattern of toxicity is more reflective of patient selection (functional status, performance status), comorbidity, and drug scheduling. The large number of drugs with significant renal excretion requires careful evaluation of renal function. Future clinical trial design needs to be adapted to older patients. Therefore, drugs, which will be primarily used by older patients, should be studied in older patients. These studies should involve pharmacokinetics, and oral therapies should include measurements of compliance. Phase II trials of new agents should consider prospectively dividing groups of patients by age (i.e., <75 years vs. >or=75 years). Phase I trials should consider accruing older patients. The studies can be performed in the older group by using progressive degrees of functional impairment and increasing comorbidity as a surrogate for dose limiting toxicity. Functional independence as a clinical benefit of cancer treatment in older individuals should be considered as an endpoint. Overall survival may not be an appropriate endpoint in clinical trials in the oldest group. Clinical trials should consider studying long-term functional and medical consequences of cancer treatment in long-term older cancer survivors. Journal editors should encourage the inclusion of age-related analyses in the reporting of clinical trials to provide meaningful information for clinicians caring for older patients. Ideally, the clinical trial design should prospectively incorporate age analysis to maximize clinical benefit of data generated. A careful assessment of medication used in older patients needs to be part of routine evaluation to minimize the adverse effects of polypharmacy.

Education, psychology and 'compliance'

Those working with patients with diabetic foot wounds are well aware that individuals who take a considerable time to heal pose ongoing challenges for health care professionals and informal carers; cycles of breakdown, recurrent infections, pain management, and adherence to treatment all require regular reassessment, renegotiation of care goals, and review of care plans. Those patients with ulcers for many years are clearly hard-to-heal and often reach a state where the wound is 'static'-not always with any apparent reason. Whilst such scenarios lead professionals to feel exasperated by the lack of progress-how often do we fully consider what this must be like from the patient's point of view? This article will focus on aspects of educational research and health psychology that can lead to a clearer understanding of ways in which professionals can negotiate with patients and empower them to take more responsibility for their own health, within a framework that clearly distinguishes between 'compliance', 'adherence', and 'concordance'. Motivation is fundamental to adherence; the key to developing individual motivation is personal self-awareness and knowledge. However, education on its own will not lead to behaviour change. Readiness to change, confidence in having the necessary skills and family support are key factors when structuring behavioural change programmes.