Can elderly people take their medicine?

Is polypharmacy associated with difficulty taking medicines in people aged ≥85 living at home? Findings from the Newcastle 85+ Study

It is unclear whether polypharmacy is associated with difficulty taking medications amongst people aged ≥85 living at home. This is despite the projected decline in availability of family carers, who may support independent living. Using Newcastle 85+ Study data and mixed-effects modelling, we investigated the association between polypharmacy and difficulty taking medications amongst 85-year-olds living at home, over a 10-year time period. Polypharmacy was not associated with difficulty taking medications as either a continuous (OR = 0.99 [0.91-1.08]) or categorical variable (5-9 medications, OR = 0.69 [0.34-1.41]; ≥10 medications, OR = 0.85 [0.34-2.07]). The significant predictors included disability, visual impairment and cognitive impairment. Our results suggest that people aged ≥85 living at home with disability, visual impairment and/or cognitive impairment will have difficulty taking their medications, regardless of how many they are prescribed. Therefore, healthcare professionals should routinely ask about, assess and address problems that these patient groups may have with taking their medicines, independent of the number of drugs taken.

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.

Treatment Strategies for Chronic Pruritus and Eczema/Dermatitis in Older Adults Under the Category of Chronic Eczematous Eruptions of Aging (CEEA)

Chronic eczematous eruptions of aging (CEEA) refers to a heterogenous group of longstanding, pruritic eczematous dermatoses with an unidentified etiology, or those which do not meet strict disease criteria. The literature has not yet established a single ubiquitous disease or term for these eruptions in adults over the age of 65 years. Instead, CEEA is attributed various names, including immunologic eruption of aging, and eruption of immunosenescence. Atopic dermatitis in the elderly, eczema in the elderly, and late- or adult-onset atopic dermatitis or eczema likely also fall under the umbrella of CEEA, given that older patients often do not meet strict criteria for atopic dermatitis. As a reflection of such terminological heterogeneity, CEEA does not have a standardized workup algorithm. This lack of uniformity can obscure the ability to study and understand appropriate treatments for this condition. Yet, as providers become increasingly aware of CEEA and more comfortable in making this diagnosis in older adults, it is necessary that dermatologists understand the safety and efficacy of common CEEA treatments in this population. Here, we discuss special considerations, challenges, and recommendations for treating older adults with CEEA with topical and systemic therapeutics. We provide an overview of therapeutic strategies and potential barriers to treatment and discuss the essential role of shared decision making when caring for this patient population.

Difficulties in the use of medications by elderly people followed up in a cohort study in Southern Brazil

OBJECTIVE

This study aimed to assess the need for help by elderly people to take their medications, the difficulties related to this activity, the frequency of forgotten doses, and factors associated.

METHODS

Cross-sectional study conducted with a cohort of elderly people (60 years and over - "COMO VAI?" [How do you do?] study), where the need for help to properly take medication and the difficulties faced in using them were evaluated. The Poisson regression model was used to estimate the crude and adjusted prevalence ratios (PR) of the outcomes and respective 95% confidence intervals according to the characteristics of the sample.

RESULTS

In total, 1,161 elderly people were followed up. The prevalence of participants who reported requiring help with medication was 15.5% (95%CI 13.5-17.8), and the oldest subjects, with lower educational levels, in worse economic situations, on four or more medications and in bad self-rated health were the ones who needed help the most. Continuous use of medication was reported by 83.0% (95%CI 80.7-85.1) of the sample and most participants (74.9%; 95%CI 72.0-77.5) never forgot to take their medications.

CONCLUSION

The need for help to use medications was shown to be influenced by social and economic determinants. Studies assessing the difficulties in medication use by the elderly are important to support policies and practices to improve adherence to treatment and the rational use of medications.

Developing a novel tool to assess the ability to self-administer medication - A systematic evaluation of patients' video recordings in the ABLYMED study

Background

Older people often experience medication management problems due to multimorbidity, polypharmacy and medication complexity. There is often a large gap between patients’ self-reported and actual abilities to handle the self-administration of their medication. Here we report on the development and evaluation of a new tool to assess the ability of non-demented hospitalized patients to self-administer medication in different dosage forms. To this end, we video-recorded the patients’ medication management performance and implemented a novel assessment scheme, which was applied by several independent raters.

Methods

Sixty-seven in-patients ≥70 years of age and regularly taking ≥5 different drugs autonomously of the ABLYMED study agreed to the video recording of their medication management performance with five different dosage forms. All raters underwent a training and applied a standardized assessment form and written guide with rating rules for evaluation. In a pilot phase, video recordings of three patients were rated by 19 raters (15 medical students, two expert raters to determine a reference standard, and two main raters who later rated the total sample). In the rating phase, based on the ratings obtained from the two main raters, we determined interrater (assessed every section of 20 patients as agreement between the raters at one point of time) and intrarater (assessed as consistency within each rater across three points of time) agreement by intraclass correlation analysis.

Results

In the pilot phase we obtained an overall sufficient agreement pattern, with an adjustment of the rating rules for patches. In the rating phase we achieved satisfactory agreement between the two raters (interrater reliability) and across different points of time (intrarater reliability). For two dosage forms (eye-drops and pen), rater training needed to be repeated to reach satisfactory levels.

Discussion

Our novel rating procedure was found to be objective, valid and reproducible, given appropriate training of the raters. Our findings are an important part of a larger research project to implement a novel assessment for the ability to self-administer medication in different dosage forms. Further, they can support the development of patient trainings to improve medication management and secure independent living.

Difficulties in the use of medications by elderly people followed up in a cohort study in Southern Brazil

Objective:

This study aimed to assess the need for help by elderly people to take their medications, the difficulties related to this activity, the frequency of forgotten doses, and factors associated.

Methods:

Cross-sectional study conducted with a cohort of elderly people (60 years and over — “COMO VAI?” [How do you do?] study), where the need for help to properly take medication and the difficulties faced in using them were evaluated. The Poisson regression model was used to estimate the crude and adjusted prevalence ratios (PR) of the outcomes and respective 95% confidence intervals according to the characteristics of the sample.

Results:

In total, 1,161 elderly people were followed up. The prevalence of participants who reported requiring help with medication was 15.5% (95%CI 13.5–17.8), and the oldest subjects, with lower educational levels, in worse economic situations, on four or more medications and in bad self-rated health were the ones who needed help the most. Continuous use of medication was reported by 83.0% (95%CI 80.7–85.1) of the sample and most participants (74.9%; 95%CI 72.0–77.5) never forgot to take their medications.

Conclusion:

The need for help to use medications was shown to be influenced by social and economic determinants. Studies assessing the difficulties in medication use by the elderly are important to support policies and practices to improve adherence to treatment and the rational use of medications.

Comprehensibility of a personalized medication overview compared to usual-care prescription drug labels

Poor understanding of prescription drug label (PDL) instructions can lead to medication errors, suboptimal treatment (side) effects, and non-adherence. A personalized medication hard-copy overview listing PDL instructions and visual information may support patients in their medication use. This study aimed to investigate the comprehensibility of PDL instructions on a personalized medication overview compared to usual-care PDL instructions presented on a medication box. A hypothetical-online-experiment was set up, comparing groups of respondents exposed vs not exposed to the medication overview and who received PDL instructions for three, five, or eight medications. Participants were divided randomly in six groups. Online questionnaires were sent to a stratified sample of 900 members from the Nivel Dutch Healthcare Consumer Panel. Outcome measures included comprehension of instructions for medication use, e.g. how often, dose timing, usage advice and warnings for a medication with simple use instructions (omeprazol) and more complex use instructions (levodopa/carbidopa (L/C)). To analyze differences between experimental conditions ANOVA testing was used. 604 respondents (net response 67%) completed the questionnaires. Respondents exposed (E) to the overview gave a higher proportion of correct answers compared to non-exposed (NE) respondents for usage advice (L/C: mean 0.83, SD 0.4 E; 0.03, SD 0.2 NE, p < 0.001; omeprazol: mean 0.85, SD 0.4 E; 0.10, SD 0.3 NE, p < 0.001). Both groups gave the same proportion of correct answers (mean 0.80, SD 0.4, p = 1.0) for dose timing of omeprazol. More NE respondents gave correct answers for how often (mean 0.85, SD 0.4 NE; mean 0.76, SD 0.4 E, p = 0.02) and dose timing (mean 0.92, SD 0.3 NE; mean 0.86, SD 0.4 E, p = 0.04) of L/C. No differences were found regarding number of medications nor were interaction effects found between the number of medications and information type. As a medication overview contains additional information, it can be a good addition in supporting patients in their medication use compared to usual-care PDLs. Future research should focus on identifying patient groups who might benefit more from a medication overview, by testing the effect of such overview on this group.

The neglected barrier to medication use: a systematic review of difficulties associated with opening medication packaging

Difficulty opening medication packaging can have serious consequences that can lead to patient harm via medication mismanagement or poor adherence. However, the quality of literature pertaining to these issues has yet to be collated and critiqued. This systematic review examined cross-sectional studies that objectively examined the ability of participants to open different medication packaging. Of the 8,692 studies identified, 12 met the inclusion criteria, all of which were direct observational studies given that prior research has identified a mismatch between self-report and actual ability. Scoring via the Appraisal Tool for Cross Sectional Studies revealed that the methodological quality of included studies was typically low. Study samples mostly consisted of older adults. All studies reported a non-negligible proportion of participants unable to open packaging, with the most difficulty associated with child-resistant containers. Several studies examined associations; however, no factor was consistently found to be significantly associated with the ability to open packaging. Despite these studies spanning >40 years, the packaging types examined remained largely the same. This suggests that, despite decades of research demonstrating that packaging is problematic, there has been a stagnation in medication packaging development. Whether this is attributed to a paucity of high-quality research, and therefore a lack of strong evidence that change is needed, is unclear. Future research should strive for better methodological quality, with generalisable cohorts assessed via observation in their home. If the problems identified in prior research persist, this may provide the impetus for change that is overdue in the medication packaging industry.

In search of disambiguation: development of eye drop bottle sleeves to aid in identification and survey among possible users. A cross-sectional study

BACKGROUND

Considerable numbers of individuals present low vision, blindness, illiteracy and other conditions that could possibly impair their identification of medications, such as eye drops. Through helping these individuals to identify their eye drops, they can achieve greater autonomy. Misidentification can be avoided through use of multisensory sleeves that can be adapted to most eye drop bottles. Correct use of eye drops is important for preventing progression of diseases like glaucoma that could potentially lead to blindness.

OBJECTIVE

To develop bottle sleeves to aid in identification of eye drops and then interview a group of possible users to evaluate the acceptance of the solution.

DESIGN AND SETTING

Cross-sectional survey performed at an ophthalmological clinic in São Paulo (SP), Brazil.

METHODS

We describe the development of multisensory sleeves to assist in identification of eye drops. To assess the acceptance of this solution, we interviewed 18 patients who were currently using three or more types of eye drops.

RESULTS

We developed four prototypes for eye drop bottle sleeves and conducted an acceptance test on them. Most of the patients who answered the survey about the sleeves were elderly. Most (95%) reported believing that the sleeves would help reduce the risk of mixing up eye drops with other medications that also dispense drops. They also believed that these would increase their autonomy in using eye drops.

CONCLUSION

The solution presented was well accepted and may help increase safety in using eye drops through preventing misidentification.

Key factors of the functional ability of older people to self-manage medications

Daily medication use can be affected by the gradual loss of functional ability. Thus, elderly patients are at risk for nonadherence due to functional decline, namely, decreases in cognitive skills and visual and manual dexterity. The main objective was to assess the ability of older people to self-manage their medication and to identify the main predictors for unintentional nonadherence. A cross-sectional study was conducted (2014-2017) in community centers and pharmacies. Functional assessment was performed with the Portuguese versions of the Drug Regimen Unassisted Grading Scale (DRUGS-PT) and the Self-Medication Assessment Tool (SMAT-PT). A purposive sample including 207 elderly patients was obtained. To identify the main predictors, binary logistic regression was performed. The average DRUGS-PT score was slightly lower than that in other studies. On the SMAT-PT, the greatest challenge for patients was identifying medications by reading labels/prescriptions. The main difficulties identified were medication memorization and correct schedule identification. The scores were higher with the real regimen than with the simulated regimen, underlining the difficulties for patients in receiving new information. Regarding the predictors of an older individual's ability to self-manage medications, two explanatory models were obtained, with very high areas under the curve (> 90%). The main predictors identified were cognitive ability, level of schooling and daily medication consumption.

Web-based education of the elderly improves drug utilization literacy: A randomized controlled trial

The aim of this study was to explore the effects of web-based education in the field of drug utilization on elderly individuals' knowledge of, concerns about and self-assessed understanding of drug utilization. The 260 included participants were randomized to a control group or an intervention group. To assess drug utilization literacy, we used a questionnaire containing 20 multiple-choice questions on drug utilization and ten statements about drug utilization (to which participants graded their response using a Likert scale: two about common concerns and eight about their self-assessed understanding of drug utilization). The Beliefs about Medicines Questionnaire-General was also used. The intervention group scored higher on the knowledge questions (p < 0.001) and on six of the eight statements about self-assessed understanding of drug utilization at the first check after 2 weeks (p < 0.05). At a second check 6 months later, the difference remained for the knowledge questions, but there was no difference in self-assessed understanding of drug utilization between the groups. There were no differences in the concerns about drug utilization or beliefs about medication at any time. We conclude that a web-based education can improve drug utilization literacy in elderly individuals and might contribute to the safer use of medications.

The impact of textual elements on the comprehensibility of drug label instructions (DLIs): A systematic review

INTRODUCTION

Correct interpretation of drug labels instructions (DLIs) is needed for safe use and better adherence to prescribed drugs. DLIs are often too difficult for patients, especially for those with limited health literacy. What is yet unknown, is how specific textual elements in DLIs (e.g., the presentation of numbers, or use of medical jargon) and patients' health literacy skills are related to the comprehension of DLIs. In order to provide concrete directions for health professionals on how to optimize drug prescriptions, we performed a systematic review to summarize the available research findings on which textual elements facilitate or hinder the correct interpretation of DLIs in relation to patients' health literacy.

METHOD

A systematic search was performed in PubMed, EMBASE, PsychINFO, and Smartcat (until April 2019) to identify studies investigating textual elements that facilitate or hinder the correct interpretation of DLIs in relation to patients' health literacy.

RESULTS

A total of 434 studies were identified of which 28 studies met our inclusion criteria. We found that textual elements contributing to the correct interpretation of DLIs were: using explicit time periods in dosage instructions, using plain language, presenting numbers in a numerical format, and providing DLIs in patients' native language. Multistep instructions per instruction line, using abbreviations and medical jargon seem to hinder the correct interpretation of DLIs. Although health literacy was taken into account in a majority of the studies, none of them assessed the effectiveness of specific textual elements on patients' comprehensibility of DLIs.

CONCLUSION

Based on our findings, we provide an overview of textual elements that contribute to the correct interpretation of DLIs. Optimizing the textual instruction on drug labels may increase the safety and adherence to prescribed drugs, taking into account that a significant proportion of patients has low health literacy.

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.

Development of a Community-Based Integrated Service Model of Health and Social Care for Older Adults Living Alone

The number of elderly people living alone worldwide is increasing, and the responsibility of the state in this context is emerging. This study aimed to develop a community-based integrated service (CBIS) model of health and social care for older adults living alone. The model was designed based on a literature review of previous community care models and per older adults’ health and daily life needs. Thereafter, feedback on the integrated model was taken from older adults living alone by conducting a survey (n = 1023) and focus group interviews, after which the opinions of the Public type Health Management Promotion Council were considered and content validity was confirmed. The model, comprising eight healthcare services and five social care services, was tested on 22 older adults for two weeks to assess its feasibility and preliminary efficiency. Each service included screening, assessment, providing service, evaluation, and quit. Participants rated their overall satisfaction with the services as 9 out of 10. Care navigators reported feeling comforted and discovered their own sense of being while providing the services. We believe that the CBIS model may foster independence among community-dwelling older adults living alone, thereby improving their quality of life through “aging in place”.

Measuring Medication Self-Management Capacity: A Scoping Review of Available Instruments

BACKGROUND

Managing a medication regimen is a complex self-care activity that requires a high level of integration and coordination between cognitive and physical skills. This scoping review aims to identify available instruments designed to assess an adult individual's ability to manage a medication regimen independently and to identify reliable and valid tools to be used in clinical practice and research.

METHODS

Five databases (PubMed/MEDLINE, CINAHL Complete, PsycINFO, Embase, and International Pharmaceutical Abstracts) were searched to identify articles reporting the development of an instrument to assess medication self-management capacity in adults. The process included a broad initial search of the databases, followed by screening of titles and abstracts, and full review of relevant articles. For each instrument identified, characteristics, including validity and reliability assessments, were summarized.

RESULTS

Sixteen papers were identified that reviewed or described the development and/or validation of 26 instruments designed to assess medication self-management capacity. Most instruments were designed to identify cognitive and physical barriers to successful medication management, but there was inconsistency across instruments in the specific skills assessed and the assessment method used. Most instruments were validated by testing at least one related construct, such as cognitive function, activities of daily living or instrumental activities of daily living performance, or medication adherence.

CONCLUSION

Development of standardized instruments to quantify medication self-management capacity is still growing. The choice of instrument for use in a specific clinical or research setting will depend on the purpose for making the assessment and the population that it will be applied to. Results of this review can assist in selecting an appropriate instrument or guiding the development of new instruments for assessment of medication self-management capacity for specific clinical or research purposes.

Development of Comprehensible Prescription Label Instructions: A Study Protocol for a Mixed-Methods Approach

Introduction

Patients receive information about their medication from different sources, including prescription labels. These labels are physically attached to each package dispensed to patients and contain the most important instructions on how to use the medication correctly. However, many patients experience difficulties in understanding and applying the instructions on these labels correctly, especially patients with limited health literacy. The aim of this study is to investigate the comprehensibility of prescription label instructions among patients with adequate and limited health literacy skills, and to implement improvements in primary health care.

Methods

We used a mixed-methods approach, which consisted of four phases. Phase 1 (desk research) was divided into a systematic literature review on the comprehensibility of prescription label instructions (1a) and a content analysis of the textual elements in Dutch prescription label instructions (1b). In phase 2 (patient studies), semi-structured interviews were conducted to investigate the comprehensibility of seven prescription labels among patients with different health literacy skills (2a), and a quantitative study in which the comprehensibility of six optimized prescription labels was compared among patients with different health literacy skills (2b). Patient studies were conducted in eight Dutch pharmacies. In phase 3 optimized prescription label instructions were implemented in national medication databases which has been supported by a guideline (3a), and education of pharmacy workers (3b). Phase 4 consists of evaluating the optimized prescription label instructions by experiences from patients and pharmacists.

Anticipated Results

This mixed-methods approach will result in scientific publications of the individual studies, and a guideline on how to compose comprehensible prescription label instructions to be put on medication packages. Optimized prescription label instructions will be implemented in national medication databases.

Discussion

This protocol describes a mixed-method research to compose and implement comprehensible prescription label instructions and will lead to knowledge about the comprehensibility of textual elements in these labels, with specific attention for patients with limited health literacy. Implementation of optimized prescription label instructions will lead to a better understanding of them, which may contribute to improved medication adherence. A limitation is that non-textual aspects of prescription labels are not investigated.

The package barrier to user adherence: Comparative analysis of various types of opening instructions on the ease of opening comprising effectiveness, efficiency and user satisfaction

AIMS

Adequate user access to drug therapy can only be ensured when the drug can be removed from its package. The aim of this study was to investigate the influence of a variety of opening instructions on the ease of opening a user package and user satisfaction.

METHODS

This experiment was conducted according to CEN/TS 15945. Ease of opening was defined as the ability to open a package within a defined time frame (effectiveness) and the learning effect by repeated opening (efficiency). (Dis)satisfaction ranged from -2 to +2. Empty bottles with left threat screw caps (rather than the standard right) were studied following 4 different types of instructions: none, arrow in the screw cap, package leaflet, video. Each instruction was studied in a group of 20 different healthy older adult volunteers (65-80 years). No opening aid was permitted. Data were captured in forms and on video.

RESULTS

Nine (45%) participants could open the package without any instruction, 19 (95%) with an arrow marked bottle and 20 (100%) with a package leaflet or video. No notable differences were observed in median times for first and repeated opening. Participants were most often (n = 11) dissatisfied (score -2) without any instruction and neutral to most satisfied (0-2) with a video (n = 17).

CONCLUSION

The effectiveness, efficiency and user satisfaction to open a package is strongly influenced by the type of opening instruction. This conclusion requires further consideration in drug product packaging and labelling.

Patient behaviour in medication management: Findings from a patient usability study that may impact clinical outcomes

Aims

Adequate medication management is a key condition to ensuring effective pharmacotherapy. However, it is well acknowledged that older people may encounter difficulties self‐administering medicines in a correct manner.

Methods

A mixed method pilot study was performed to investigate medication self‐management in older and multimorbid patients with polypharmacy. The pilot study involved medication management tasks followed by semi‐structured interviews in 20 patients. The tasks and interviews were based on the patients' individual medication plans, which had been prepared earlier by the pharmacy for each patient on basis of all their prescriptions.

Results

The patients' self‐reported medication management skills differed from their actual observed medication management performance. In addition, the routines and coping strategies used by the patients to deal with the complexity of their overall medication regimen were not in accordance with the medication plan and the instructions for use on the product labels. Issues were observed on all stages of the medication process that can be considered relevant to patient adherence, especially medication plan recall, product identification, product selection, product handling and product recognition in a multicompartment compliance aid.

Conclusions

The pilot study suggested that medication management issues by older and multimorbid patients remain widely undetermined and unrecognized in primary care. Further investigation and interdisciplinary collaboration will be required to resolve the user problems and ensure adequate patient adherence.

A scoping review of the pharmaceutical care needs of people with sensory loss

OBJECTIVES

This scoping review collated evidence of the pharmaceutical care needs of people with sensory loss (SL).

METHODS

Electronic databases were searched with no limit on year of publication: Medline (1946); Embase; Cinahl (1979); and Web of Science (1985). Search terms included the following: pharmacy; sight/hearing/dual impairment. Studies were included if they involved people with SL requiring pharmaceutical care and/or pharmacists/pharmacy support staff providing pharmaceutical care for people with SL. All study designs were eligible. This was a scoping review, and as such, the quality of studies was not formally evaluated.

KEY FINDINGS

Eleven studies were included. People with SL had lower levels of medication knowledge than their peers without SL. People with SL were identified as being at higher risk of iatrogenic harm than people without SL. Communication was a barrier to the provision of pharmaceutical care for people with hearing loss, with pharmacists relying on the provision of written information. The prevalence of SL increases with age, yet only two studies included older people. No studies involved family or carers of people with SL, people with dual loss or people with SL receiving polypharmacy.

CONCLUSIONS

There is a paucity of data regarding the pharmaceutical care needs of people with SL. Unmet pharmaceutical care needs put people with SL at increased risk of harm from their medicines. A detailed understanding of the needs of people with SL is required which will inform future delivery of pharmaceutical care for this vulnerable population.

Divide and conquer: improving parental understanding of health-related instructions using sequential pictorial instructions

Patient misunderstandings of healthcare-related instructions result in significant health, social and economic consequences. Pushing the boundaries of traditional academic methods may offer strategies that promote new ways to improve communication and understanding between healthcare providers, caregivers and patients. Comics can be an educational tool, offering an innovative strategy to communicate health-related information. Our study objective was to compare parents' understanding of health-related instructions (i.e. prescription labels, medical instructions and emergency situation scenarios) that were presented using two different formats-sequential pictorial instructions (SPIs) versus written text instructions (WRIs).This was a cross-sectional study to compare parents' understanding of health-related instructions for pediatric patients using structured SPIs versus WRIs. Parents (n = 359, 18-82 years old) of pediatric patients were given a card with instructions that were presented as SPIs (n = 195, 54.3%) or WRIs (n = 164, 45.7%), and then they completed a questionnaire. Total (14 questions) and grouped scores (10 questions) for parental comprehension of prescription and medical emergency instructions were significantly higher among participants viewing the SPIs than those viewing the WRIs in both English and Spanish. The mean understanding of instructions significantly increased from 6% to 12.2% when comparing the WRI versus the SPI.Our initial findings indicate that parents and caregivers of pediatric patients had significantly better understanding and recall of instructions delivered using SPIs than using WRIs.

Evaluating practical support stroke survivors get with medicines and unmet needs in primary care: a survey

OBJECTIVES

To design a questionnaire and use it to explore unmet needs with practical aspects of medicine taking after stroke, predictors of medicine taking and to estimate the proportion of survivors who get support with daily medication taking.

DESIGN

Four workshops with stroke survivors and caregivers to design the questionnaire.A cross-sectional postal questionnaire in primary care.

SETTING

18 general practitioner practices in the East of England and London. Questionnaires posted between September 2016 and February 2017.

PARTICIPANTS

1687 stroke survivors living in the community outside institutional long-term care.

PRIMARY OUTCOME MEASURES

The proportion of community stroke survivors receiving support from caregivers for practical aspects of medicine taking; the proportion with unmet needs in this respect; the predictors of experiencing unmet needs and missing taking medications.

RESULTS

A five-item questionnaire was developed to cover the different aspects of medicine taking. 596/1687 (35%) questionnaires were returned. 56% reported getting help in at least one aspect of taking medication and 11% needing more help. 35% reported missing taking their medicines. Unmet needs were associated with receiving help with medications (OR 5.9, P<0.001), being on a higher number of medications (OR 1.2, P<0.001) and being dependent for activities of daily living (OR 4.9, P=0.001). Missing medication was associated with having unmet needs (OR 5.3, P<0.001), receiving help with medications (OR 2.1, P<0.001), being on a higher number of medicines (OR 1.1, P=0.008) and being older than 70 years (OR 0.6, P=0.006).

CONCLUSIONS

More than half of patients who replied needed help with taking medication, and 1 in 10 had unmet needs in this regard. Stroke survivors dependent on others have more unmet needs, are more likely to miss medicines and might benefit from focused clinical and research attention. Novel primary care interventions focusing on the practicalities of taking medicines are warranted.

[Oral administration of medicines in elderly patients and adaptation of galenic forms]

Physiological ageing and pathologies can have an influence on the pharmacology of numerous medicines, leading to serious iatrogenic accidents, polypharmacy and incorrect use of a medicine in elderly people. An observational study carried out in a short-stay geriatric unit focused on the issues surrounding the difficulties the elderly may encounter when taking medicines and the prevalence of the manipulation of galenic forms.

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.

Aids for eye drop administration

One aspect to eye drop adherence is successful instillation of the drops; however, it is well known that many patients struggle with this task. Difficulties may include aiming their drops, extending their neck, preventing excess drop leakage, avoiding contamination of the bottle tip, and generating enough force to expel a drop from the bottle. Instillation aids are devices that aim to ameliorate one or more of these barriers. We review the literature on instillation aids to describe the options available to patients and to report evaluations of their efficacy. Most instillation aids studied improved objective or subjective outcomes of eye drop instillation, including improved rates of successful administration and increased patient satisfaction compared with standard eye-drop bottles. Although further research is warranted, instillation aids may be an underutilized resource for the many patients who struggle to administer their own eye drops.

Assessment of the elderly's functional ability to manage their medication: a systematic literature review

Background The evaluation of the elderly's ability to manage medication through the use of a validated tool can be a significant step in identifying inabilities and needs, with the objective of increasing their self-care skills, and promoting successful aging. Aim of the review To identify studies assessing the elderly's functional ability to manage their own medication. Method For the search strategy, the PICO method was used: P-Population (elderly), I-Instruments (tools for assessing medication management ability), C-Context (community) and O-Outcomes (functional ability to manage medication). The final search query was run in MEDLINE/PubMed, CINAHL Plus, ISI Web of Science and Scopus. The whole process was developed according to the PRISMA statement. Results The search retrieved 8051 records. In each screening stage, the selection criteria were applied to eliminate records where at least one of the exclusion criteria was verified. At the end of this selection, we obtained a total of 18 papers (17 studies). The results allow the conclusion to be drawn that studies use several different instruments, most of them not validated. The authors agree that medication management abilities decrease as cognitive impairment increases, even if a lot of studies assess only the physical dimension. DRUGS was the instrument most often used. Conclusion Older adults' ability to manage their medication should be assessed using tools specifically built and validate for the purpose. DRUGS (which uses the real regimen taken by the elderly) was the most widely used assessment instrument in the screened studies.

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.

Pillbox use, satisfaction, and effectiveness among persons with chronic health conditions

The purpose of this study was to understand how persons with chronic health conditions use pillboxes, their satisfaction with current devices, and the impact of pillbox use on medication adherence. We used convergent parallel mixed methods approach to explore the experiences of 13 regular, 3 occasional, and 5 non-pillbox users. Medication consumers completed the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0), an interview about their medication routines, and a medication adherence diary to describe their experiences with their pillboxes. Results demonstrated most participants use pillboxes to help manage their medications, and pillbox users tended to have better medication adherence than nonusers. Participants used a variety of pillboxes differing in size, shape, and color. Users reported selecting pillboxes based on their needs in addition to the demands of their habits and medication regimens. Users were generally satisfied with their pillboxes with an average QUEST score of 4.33. However, participants also identified areas for an improved design of pillboxes. Pillboxes can be an effective strategy to improve medication adherence. Improvements in device prescription, training, research, and design are needed to understand the mechanisms and size of effects of this intervention.

Medication adherence in Alzheimer's disease: The mediator role of mindfulness

BACKGROUND

Medication adherence is often assessed based on compliance to the dosage and frequency of physician's prescription. Cognitive impairment is one of the biggest barriers in elderly patients with Alzheimer's disease (AD), who are usually polymedicated with different oral drugs. Transdermal drug delivery, also requires mobility abilities, reinforcing the role of patients' caregivers.

OBJECTIVE

To evaluate the relationship between psychological variables such as social support, family satisfaction, psychological morbidity, awareness of the disease, coping, mindfulness and medication adherence, in patients with AD, taking in consideration the patient's perspective.

DESIGN

Cross-sectional and quantitative study including 128 patients with mild AD.

RESULTS

Medication adherence showed a positive relationship with social support, mindfulness, family satisfaction and awareness of the disease. Mindfulness was a mediator in the relationship between awareness of the disease and medication adherence.

CONCLUSIONS

This study reinforces the importance of psychological assessment in medication adherence in mild AD patients, specially the role of mindfulness. Intervention programs to promote mindfulness may have a potential dual benefit, preserving cognitive skills and promoting medication adherence.

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.

Insights into inpatients with poor vision: A high value proposition

BACKGROUND

Vision impairment is an under-recognized risk factor for adverse events among hospitalized patients, yet vision is neither routinely tested nor documented for inpatients. Low-cost ($8 and up) nonprescription "readers" may be a simple, high-value intervention to improve inpatients' vision. We aimed to study initial feasibility and efficacy of screening and correcting inpatients' vision.

METHODS

From June 2012 through January 2014 we began testing whether participants' vision corrected with nonprescription lenses for eligible participants failing a vision screen (Snellen chart) performed by research assistants (RAs). Descriptive statistics and tests of comparison, including t tests and χ(2) tests, were used when appropriate. All analyses were performed using Stata version 12 (StataCorp, College Station, TX).

RESULTS

Over 800 participants' vision was screened (n = 853). Older (≥65 years; 56%) participants were more likely to have insufficient vision than younger (<65 years; 28%; P < 0.001). Nonprescription readers corrected the majority of eligible participants' vision (82%, 95/116).

DISCUSSION

Among an easily identified subgroup of inpatients with poor vision, low-cost readers successfully corrected most participants' vision. Hospitalists and other clinicians working in the inpatient setting can play an important role in identifying opportunities to provide high-value care related to patients' vision.

"It's MAGIC"--development of a manageable geriatric assessment for general practice use

Background

Geriatric assessments are established tools in institutional care since they enable standardized detection of relevant age-related disorders. Geriatric assessments could also be helpful in general practice. However, they are infrequently used in this setting, mainly due to their lengthy administration. The aim of the study was the development of a “manageable geriatric assessment – MAGIC”, specially tailored to the requirements of daily primary care.

Methods

MAGIC was developed based on the comprehensive Standardized Assessment for Elderly People in Primary Care (STEP), using four different methodological approaches: We relied on A) the results of the PRISCUS study by assessing the prevalence of health problems uncovered by STEP, the importance of the respective problems rated by patients and general practitioners, as well as the treatment procedures initiated subsequently to the assessment. Moreover, we included findings of B) a literature analysis C) a review of the STEP assessment by experienced general practitioners and D) focus groups with general practitioners.

Results

The newly created MAGIC assessment consists of 9 items and covers typical geriatric health problems and syndromes: function, falls, incontinence, cognitive impairment, impaired ears and eyes, vaccine coverage, emotional instability and isolation.

Conclusions

MAGIC promises to be a helpful screening instrument in primary care consultations involving elderly multimorbid patients. Applicable within a minimum of time it still covers health problems highly relevant with regard to a potential loss of autonomy. Feasibility will be tested in the context of a large, still ongoing randomized controlled trial on “reduction of potentially inadequate medication in elderly patients” (RIME study; DRKS-ID: DRKS00003610) in general practice.

Recommendations to prescribe in complex older adults: results of the CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project

The occurrence of several geriatric conditions may influence the efficacy and limit the use of drugs prescribed to treat chronic conditions. Functional and cognitive impairment, geriatric syndromes (i.e. falls or malnutrition) and limited life expectancy are common features of old age, which may limit the efficacy of pharmacological treatments and question the appropriateness of treatment. However, the assessment of these geriatric conditions is rarely incorporated into clinical trials and treatment guidelines. The CRIME (CRIteria to assess appropriate Medication use among Elderly complex patients) project is aimed at producing recommendations to guide pharmacologic prescription in older complex patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes, and providing physicians with a tool to improve the quality of prescribing, independent of setting and nationality. To achieve these aims, we performed the following: (i) Existing disease-specific guidelines on pharmacological prescription for the treatment of diabetes, hypertension, congestive heart failure, atrial fibrillation and coronary heart disease were reviewed to assess whether they include specific indications for complex patients; (ii) a literature search was performed to identify relevant articles assessing the pharmacological treatment of complex patients; (iii) A total of 19 new recommendations were developed based on the results of the literature search and expert consensus. In conclusion, the new recommendations evaluate the appropriateness of pharmacological prescription in older complex patients, translating the recommendations of clinical guidelines to patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes. These recommendations cannot represent substitutes for careful clinical consideration and deliberation by physicians; the recommendations are not meant to replace existing clinical guidelines, but they may be used to help physicians in the prescribing process.

Expectations and user experience of a multimodal medicine management system for older users

Purpose

– The purpose of this paper is to analyse the adoption of a multimodal medication management system (MMS) targeted on older people and home care professionals. The paper aims to describe the expectations of the system and the user experience findings from an empirical qualitative field trial. The field trial results are used to discuss how MMSs should be designed in order to improve adherence to medications.

Design/methodology/approach

– The paper suggests that building a multimodal medicine management system targeted on both older users and home care professionals brings many benefits over electronic medicine dispenser systems or general reminder systems. The research process uses an iterative prototyping approach including phases of requirements analysis and concept design, prototype building and evaluation in a field trial.

Findings

– The study demonstrates how a system that merely satisfied users during the prototype building phase does not necessarily succeed as well as expected in the field trials. It would be important to consider reasons for medication non-adherence and non-technology factors influencing willingness to adopt new assistive devices in order to promote diffusion of new MMSs at home. The paper also discusses how the different persuasive functionalities of the system addressed patient-centred factors influencing non-adherence and how they could be addressed.

Research limitations/implications

– This study has some limitations. The actual adherence to medications was not measured. However, in the future, it will be important to study how the MMSs influence medication adherence. Also, the user experiences of the home care professionals were not studied in the field trials. Home care professionals who were involved in the user studies and trials merely estimated the value for their patients and not for themselves.

Originality/value

– This paper analyses design issues relevant when designing systems to help older people manage their medications.

Self-Management of Wellness and Illness in an Aging Population

In this chapter, we review the last 10 years of literature on self-management of illnesses (acute/episodic and chronic) and wellness (e.g., health promotion). We focus on health self-management in the context of an aging population, wherein middle-aged adults are more likely to be managing wellness activities and older adults are often managing both maintenance of health and chronic illnesses. The critical issues related to self-management of health are discussed, including those imposed by health care demands and those stemming from individual differences in general abilities (e.g., motor, perception, cognition) and socioemotional characteristics. The dynamic relationship between theory and practice is highlighted. Health care demands reflect the nature of the illness or wellness activity and include managing comorbidities, symptoms, and medications; engaging in health promotion activities (e.g., exercise, diet); the required use of health technologies; the need for health-related information; and coordination of the care network. Individual differences in motor, perceptual, and cognitive abilities, as well as in the severity and complexity of the illness and the consequent demands, also impact how a person self-manages health. Cognitive abilities, such as decision making, knowledge, literacy (i.e., general, health, and e-health literacy), and numeracy are particularly implicated in the process of managing one’s own health and are especially important in the context of an aging population; therefore we give these cognitive abilities special attention in this chapter. Socioemotional characteristics, and attitudes and beliefs about one’s health, impact an individual’s self-management of health as well, impacting his or her motivation and goal-setting behaviors. Moreover, we discuss literature on interventions that have been used to improve self-management of health, and we examine the potential for technology. We conclude with guidelines for technology design and instruction, and discuss emerging themes.

Testing the validity, reliability and utility of the Self-Administration of Medication (SAM) tool in patients undergoing rehabilitation

BACKGROUND

Determination of patients' ability to self-administer medications in the hospital has largely been determined using the subjective judgment of health professionals.

OBJECTIVES

To examine the validity, reliability and utility of the Self-Administration of Medication (SAM) tool as an objective means to determine patients' ability to self-administer in a rehabilitation unit of a public teaching hospital in Melbourne, Australia.

METHODS

To assess validity of the SAM tool, associations were examined between the total SAM tool score and of the patients' competence to self-administer from the perceptions of the tool administrator, patients and nurses. Validity also was determined from a principal component analysis. Pearson correlations were calculated for how SAM scores related to scores obtained from the Functional Independence Measure (FIM) and Barthel Score Index (BSI). To assess the SAM tool's reliability, a Cronbach's alpha coefficient was calculated. Utility of the SAM tool was evidenced by documenting its administration time.

RESULTS

One hundred patients participated in this study. The SAM tool had a Cronbach's alpha coefficient of 0.75 and took a mean time of 5.36 min to complete. The capability to self-medicate section of the SAM tool had strong correlations with the FIM (r = 0.485) and BSI (r = 0.472) data, respectively, and the total SAM tool had moderate and strong correlations with the nurses' (r = 0.315) and tool administrator's (r = 0.632) perceptions of patients' ability to self-administer, respectively. Bland-Altman and ROC curve analyses showed poor agreement between the total SAM tool score and the nurses' perceptions.

CONCLUSIONS

The SAM tool demonstrated acceptable overall internal consistency. It only requires a short time to be completed and is more objective than seeking out health professionals' perceptions. Additional research is needed to further validate this approach to determining patients' ability to self-medicate.

Characterizing caregiver-mediated medication management in patients with memory loss

Increasingly, family members are assisting with the complex task of medication management when patients are experiencing cognitive decline. To date, limited published research addresses caregiver-mediated medication management of patients with impaired cognition. Thus, the purpose of this study was to describe the characteristics and correlates of caregiver-mediated medication management in community-dwelling patients with memory loss. We used baseline data from the 91 patient-caregiver dyads participating in a randomized controlled trial designed to assist caregivers of patients with memory loss with medication management. The patient's level of cognitive impairment was not related to medication errors; however, the number of medications that patients were prescribed and taking was related to medication errors. Important factors to consider when discussing medication management with caregivers of patients with memory loss include the caregiver's age, cognitive ability, and depressive symptoms, as well as the caregiver's perception of the impact of the patient's behavioral problems.

Influence of blister package design on usability among older adults

BACKGROUND

Blisters packs are commonly used as packaging for oral drug products. Utilization problems among older adults with pharmaceutical packaging are well known from investigations of multi-unit dose containers, but there is a lack of studies focusing on blister packaging. This study was performed to identify design parameters that should be considered when developing blister packaging for drug products intended to be used by older adults.

OBJECTIVES

To investigate the relationship between blister pack design and utilization problems among older adults.

SETTING

Community-based study including 141 volunteers (age 80+) living at home and in assisted-living facilities.

METHOD

In random order 5 blister packs of uniform shape but with different opening characteristics (variation of the force required to open the blisters and different mechanisms of opening) were tested by each participant.

MAIN OUTCOME MEASURE

Opening was evaluated (difficulty, pain perception and overall assessment) by questioning of the participants. Additionally, data were collected as to whether participants managed to take out 4 tablets within 4 min test duration and whether they gave up opening. Reasons for utilization problems were examined by subgroup analysis, frequently made observations, and technological characterization of blisters. Results Blisters with thicker push-through foils were assessed as being inferior. Anyhow, most of participants (>84 %) were capable of opening each type of push-through blister within 4 min. By contrast, many of the participants were unable to open peel (30 %) and child-resistant peel-off push-through blisters (44 %) or gave up trying before the end of the test. In addition to medical conditions, vision and age of participants correlated with utilization problems.

CONCLUSION

Blister pack design, including opening force and opening mechanism, can have significant impact on the usability of blister packs by older adults. The study identified several parameters that should be considered with respect to older adults when developing blister packaging for drug products.

[Coping with chronic illness and multiple medicines in older age: self-management support as an obligation in nursing]

In later stages of chronic disease and especially in older age, chronically ill people are often dependent on multiple medicines. Coming to terms with complex medication regimes in everyday life is a challenging task. To provide the support actually needed, patient-centered interventions are essential, not only taking into account the patients' needs and preferences, but also promoting their ability to self manage their disease(s) and their medication regime. This paper outlines the results of a research project aimed at developing and evaluating an intervention to integrate self-management support into primary care, based on a qualitative exploration of the patients' and professionals' views. The findings stress that home care nurses should take an active part in self-management support but need to be prepared adequately. Therefore, a two-tier intervention was developed and evaluated in a prospective control study, consisting of a qualified training and guidelines for practice. The intervention serves to expand the nurses' professional competence to provide the needed individually tailored self-management support in home care.

Force requirements in topical medicine use--the squeezability factor

INTRODUCTION

Patient compliance is essential to ensure efficacious treatment. The ease of topical drop delivery is of paramount importance. At least 50% of patients report difficulty in self-administration of topical ocular medicine. The two most frequently reported causes of difficulty include aiming the bottle and squeezing the bottle.

PURPOSE

The aims of this study were to identify (I) the force required to deliver a single drop from a bottle (the squeezability factor), (II) are some bottle designs easier to use than others? (III) Do compliance aids reduce the finger strength required to deliver an eye drop?

METHOD

We measured the force required to deliver a single drop from a variety of commonly used ophthalmic preparations. Force was slowly applied at the midpoint along the bottle until a drop fell from the tip. Compliance aids were also tested with this technique.

RESULTS

We report a wide variation in the force requirements needed to use topical medicines. Three of the four compliance aids tested increased force requirements but may have had other beneficial effects by altering the grip on the medicine bottle.

CONCLUSION

This study highlights the large variability in force required to deliver a single drop using the ophthalmic preparations and compliance aids tested. We feel our results will be of interest and relevant to prescribing physicians and manufactures alike.

A review of medication reconciliation issues and experiences with clinical staff and information systems

Medication reconciliation was developed to reduce medical mistakes and injuries through a process of creating and comparing a current medication list from independent patient information sources, and resolving discrepancies. The structure and clinician assignments of medication reconciliation varies between institutions, but usually includes physicians, nurses and pharmacists. The Joint Commission has recognized the value of medication reconciliation and mandated implementation in 2006; however, a variety of issues have prevented simple, easy, and universal implementation. This review references issues related to the development and the implementation of medication reconciliation including: - the need of a system or standard for accurate drug identification to create a definitive 'gold standard' patient medication list, - identifying stakeholders of medication reconciliation within the institution and contrasting staff interest and participation with institutional resources, - observations and opportunities of integrating medication reconciliation with the electronic patient health record, and - summarizing a series of institutions experiences developing and implementing medication reconciliation. Last, as medication reconciliation becomes a regular process within medical centers, key concepts for effective implementation are discussed.

Geriatric drug therapy: neglecting the inevitable majority

Demographic evolution will considerably increase the number of people aged 65 years and beyond in the coming decades. The elderly not only represent the most heterogeneous population, but also are a major user group for prescribed medicines, a predominance that will continue to further increase. Medicines and medication management are much more complex and challenging in the elderly and can only be addressed through a multidisciplinary approach. There is strong evidence that the elderly are able to properly manage their medication; however, their medications require different features than the standard medications used by adults. The elderly are exposed to several chronic disease conditions and their treatments, as well as experience age-related changes and limitations that need to be reflected in their medication management strategies. Geriatric drug therapy remains a multidisciplinary task. The health care industry, physicians, pharmacists, nurses and care givers provide and guide the patient's therapy according to individual needs, while the health care system and regulatory authorities build the necessary framework of support and resources.Any realistic and significant enhancement to the elderly patients' medicines and medication management needs to be addressed by all disciplines and stakeholders involved since the absence of any of the stakeholders in the overall process negatively impacts the achievable enhancement in geriatric drug therapy.

Designing packaging to support the safe use of medicines at home

In the light of a number of serious incidents in the UK resulting from accidental overdoses of methotrexate, this study investigated how the design of methotrexate packaging can influence patient safety, and aimed to collect evidence to provide a basis for the development of new concepts for revised designs by the pharmaceutical industry. The research found that patients using methotrexate experience a number of difficulties in using their medicines packaging, and as a result, resourcefully adopt a variety of "coping strategies" which may increase the risk of dosing errors. By investigating both the practice of methotrexate users, and the design of the system that supports methotrexate use, additional problems were observed across the healthcare system, meaning that the function of medicines packaging in ensuring safety may be even more critical than first suspected. As a result of this research the National Patient Safety Agency responded with a UK-wide programme of work to improve safety for patients, and continues to work with the pharmaceutical industry to develop more user-friendly packaging and labelling.