Elder and caregiver solutions to improve medication adherence

Association of polypharmacy with all-cause mortality and adverse events among elderly colorectal cancer survivors

BACKGROUND

The risk of inappropriate drug exposure in elderly colorectal cancer (CRC) survivors after the initial cancer treatment has not been well studied. This study investigated the association of polypharmacy (PP) with overall survival, hospitalization, and emergency room (ER) visits among older CRC survivors.

METHODS

A retrospective cohort study was conducted using the Korean National Health Insurance claims data follow-up from 2002 to 2017. Participants comprised those aged ≥65 years who were hospitalized with a diagnosis of CRC received cancer treatment and survived at least 2 years from the initial CRC diagnosis between 2003 and 2012. PP was defined based on the number of individual drugs during the third year, after 2 years of survival since the initial cancer treatment. PP was categorized as follows: non-PP (zero to four prescribed drugs); PP (five to nine drugs), and excessive PP (≥10 drugs). Main outcomes are all-cause mortality, hospitalization, and ER visits.

RESULTS

Of the 55,228 participants, 44.5% died, 83.1% were hospitalized, and 46.1% visited the ER. The PP and excess PP groups showed increased risk of all-cause mortality, hospitalization, and ER visit compared with the low PP group, and was highly associated among groups including patients aged 65 to 74 years and those in low-level frailty groups.

CONCLUSIONS

These risks can be minimized by increasing awareness and enhancing behaviors among health care professionals, especially clinician and pharmacists, to be aware of potential drug interactions, review, and ongoing monitoring.

PLAIN LANGUAGE SUMMARY

The risk of inappropriate drug exposure in older colorectal cancer (CRC) survivors after the initial cancer treatment has not been well studied. Polypharmacy was associated with adverse outcomes, including all-cause mortality, hospitalization, and emergency room visits among older CRC survivors and it was particularly associated with those who were 65 to 75 years and those with low risk of frailty. When prescribing drugs, physicians should be mindful of finding a balance between adequate treatment of diseases and avoiding adverse drug effects in survivors of CRC.

A Systematic Review of Compensation and Technology-Mediated Strategies to Maintain Older Adults' Medication Adherence

Elderly medication adherence is a challenge in health care. The elderly are often at higher risk for non-adherence, and more likely to be on multiple prescription medications for many comorbidities. This systematic review aimed to explore the current strategies for maintaining older adults' medication adherence with compensation and technology-mediated strategies. We conducted a systematic review to examine related articles published in the PubMed, Web of Science, and Scopus databases, as well as Google Scholar for additional reference sources by cross-reference review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to guide this review. A total of 217 articles were screened, and 27 studies fulfilled the inclusion criteria. Older adults applied a variety of methods to maintain or enhance their medication adherence. Three studies indicated compensation strategies, 19 studies reported technological assistance, two studies used other strategies (community-offered help or caregivers help), and three studies used a combination of compensation with another strategy or technology. Studies identified various compensation- and technology-based strategies carried out by older adults to help remind them to take medication. This review identified potential benefits of technology and compensation strategy implementation in older adults to increase medication adherence. Although we are conscious of the heterogeneity of the included studies, it remains challenging to determine which elements underpin the most effective approaches.

Prevalence and reasons influenced medication non-adherence among diabetes patients: A mixed-method study

Objectives

This study aimed to identify the prevalence of medication non-adherence (MNA) and to explore the reasons that influenced MNA among diabetes patients.

Design

This study used the explanatory mixed-method design. Phase one comprised of a cross-sectional study followed by phase two of a qualitative study.

Setting

This study took place at two public hospitals in the Klang Valley, Malaysia.

Participants

About 427 diabetes patients were recruited and 399 of them completed the study. The inclusion criteria were those with age more than 18 years and above, Malaysian citizen, able to understand Malay or English, and were diagnosed with diabetes mellitus for more than one year. The exclusion criteria were those with an intellectual disability and pregnant women. Phase two involved 12 participants recruited from non-adherent patients in phase one of the study.

Results

About 46.6% of the patients failed to adhere to the medication. Malays (OR: 1.66, 95%CI: 1.09 to 2.51, p = 0.017), single/widow or divorced (OR: 1.79, 95%CI: 1.05 to 3.05, p = 0.031) and poor HbA1c (OR: 2.57, 95% CI: 1.61 to 4.10, p =  < 0.01) were associated with medication non-adherence. Five main categories emerged as the reasons for medication non-adherence, including perceived benefit of Complementary and Alternative medicine, attitude towards drawback of western medication, poor healthcare providers and patients' relationship, undesirable emotional response towards medication intake, as well as restraints in daily routine and cognitive function.

Conclusions

There are many reasons for patients' non-adherence to their anti-diabetes medication. These findings are important in identifying the factors that influenced non-adherence to recommend reliable patient-centred care strategies in improving medication non-adherence among patients with diabetes.

Collaborative medication management for older adults after hospital discharge: a qualitative descriptive study

BACKGROUND

Safe medication management for older adults after hospital discharge requires a well-coordinated, interprofessional, patient-centered approach. This study aimed to describe the perceived needs for collaborative medication management for older adults taking several different medications at home after hospital discharge.

METHODS

A qualitative descriptive study was conducted using semi-structured interviews with older adults (n = 28), informal (n = 17), and professional caregivers (n = 13).

RESULTS

Findings revealed four main needs: older adults and informal caregivers' perceived needs for greater involvement in discharge planning; older adults' perceived needs to be informed, listened to, and to be actively involved in decision-making; informal caregivers' perceived needs for help in supporting and coordinating medication management; and older adults' and informal and professional caregivers' perceived needs for better communication and coordination between professional caregivers.

CONCLUSION

This study revealed two underutilized pathways towards improving collaborative medication management: medication follow-up involving a community healthcare professional taking an overarching responsibility and empowering older adults and their informal caregivers in medication management after hospital discharge.

Medication management in Minority, Asian and Black ethnic older people in the United Kingdom: A mixed-studies systematic review

WHAT IS NEW AND OBJECTIVES

Older people from ethnic minorities experience the intersectionality of age and ethnicity in relation to complex medication management and polypharmacy. Minority ethnic groups in the United Kingdom are at risk of poor medication management because factors such as cultural beliefs, language barriers, lack of knowledge of how the healthcare system works may affect their ability to safely manage their medications. The aim of this systematic review was to review the literature focussing on medication management in the older population amongst ethnic minority communities in United Kingdom.

METHODS

The review was conducted and reported according to methods in the Cochrane Handbook and in the PRISMA 2020 statement using databases such as EMBASE, ASSIA, MEDLINE, PsychINFO and others. Studies conducted in the United Kingdom on individuals over 60 years of age and from a minority ethnic background were included. A thematic analysis was used to synthesize the results.

RESULTS AND DISCUSSION

Nine studies (eight from initial searches, one from a search update in 2021) met the inclusion criteria. Three main themes were identified: misbeliefs around medications, poor health literacy, communication and education as possible intervention to improve medication management. Misbeliefs around long-term illnesses exert a negative impact on medication management. Poor health literacy around medications influences patients' adherence to treatments. Poor communication is perceived as barrier to successful medication management. Despite extensive searching, the team identified a limited number of studies and a lack of intersectional studies focussing on minority ethnic groups and the older population.

WHAT IS NEW AND CONCLUSION

Our findings suggest tailored education as a possible intervention to improve medication management amongst these minority groups. Future research should look at recruiting participants from specific ethnic groups and from rural as well as urban areas to explore how medication management operates in different areas of the United Kingdom.

Safe Medication Management for Polymedicated Home-Dwelling Older Adults after Hospital Discharge: A Qualitative Study of Older Adults, Informal Caregivers and Healthcare Professionals’ Perspectives

Safe medication management is particularly challenging among polymedicated home-dwelling older adults after hospital discharge. This study aimed to identify and categorise the stressors experienced and reconstitution strategies adopted by older adults, their informal caregivers, and healthcare professionals as they manage older adults’ medications after hospital discharge. A primary study collected the perspectives of 28 older adults, 17 informal caregivers, and 13 healthcare professionals using a qualitative descriptive design. The Neuman Systems Model was used as the basis for a secondary deductive content analysis. Findings revealed that post-discharge medication management at home involved numerous stressors, often including dysfunctions in communication, collaboration, and coordination between the multiple stakeholders involved. Reconstitution strategies for safe medication management were not always successful or satisfactory and were sometimes identified as stressors themselves. Older adults, informal caregivers, and healthcare professionals’ perspectives highlighted several potential opportunities for improving safe medication management through nurse-led, interprofessional, patient-centred practices.

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

Background/objectives:

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

Methods:

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

Results:

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

Conclusion:

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

[Medication management in home care-The medication use process from the perspective of clients and their caregivers]

BACKGROUND

Professional home care nurses are often tasked with the medication management of older, polymedicated clients. The medication use process is often complex and prone to medication errors. From the perspective of professional caregivers, the interprofessional interfaces of care as well as the integration of clients and informal caregivers are a major challenge.

AIM

With this study, we explored the perspective of home care clients and their informal caregivers on the medication use process supported by professional caregivers with a focus on medication safety.

METHOD

We chose a qualitative research approach, using guideline-based interviews with eight clients and five caregivers. Data were analyzed applying the topical analysis according to Braun and Clarke.

RESULTS AND DISCUSSION

Before engaging professional home care nurses in the medication use process, clients reached their physical, psychological and social limits. They were relieved when the professional home care organization took care of the overall coordination of the medication use process and felt safe. They trust professional caregivers and see limited need to be preoccupied with medication safety themselves, despite risks inherent in self-medication, adherence and transition of care.

CONCLUSION

Through the relief provided by professional caregivers, home care clients and their informal caregivers no longer perceive themselves as active partners in maintaining medication safety. Healthcare professionals should keep an eye on self-medication as well as adherence and support the use of the medication plan.

Medication Adherence in Patients With Glaucoma and Disability

Importance

People with disabilities tend to have lower medication adherence. Glaucoma medication adherence has been scantly studied for people with disability.

Objective

To determine whether disability leads to reduced glaucoma medication adherence and whether this decrease varies by type of disability.

Design, Setting, and Participants

This population-based case-control study enrolled individuals with glaucoma and without disability, who were followed up until they received disability certification. All patients in Taiwan with confirmed glaucoma in 1 or both eyes were identified using National Health Insurance claims data. All patients with glaucoma who required glaucoma medication adherence (confirmed glaucoma, suspected glaucoma, and patients with ocular hypertension) and had newly obtained disability status after December 31, 2013, were identified and matched to counterparts without disability based on age and sex. The study period was January 1, 1997, to December 31, 2017. Data were analyzed from May 2021 to August 2021.

Exposures

All patients were followed up until they obtained confirmed disability status, which was identified using the National Disability Registry in Taiwan.

Main Outcomes and Measures

Secondary adherence was measured using frequencies of glaucoma medication refills and outpatient visits at 1-year and 2-year intervals.

Results

A total of 46 468 patients with glaucoma (23 234 with disability and 23 234 without disability; 24 508 men [52.7%]; 21 960 women [47.3%] mean [SD] age, 72.5 [14.3] years) were included in the study. Overall, the frequency of glaucoma outpatient visits was higher in people with disabilities than those without disabilities both before the index dates (difference, 0.64 [95% CI, 0.57-0.72]; P < .001) and after the index dates (difference, 0.34 [95% CI, 0.27-0.41]; P < .001) when using 1-year intervals. However, when stratified by the type of disability, having limb disability, being in a vegetative state, and having dementia were associated with fewer outpatient visits and lower medication adherence (at a maximum of 17.60 [95% CI, 8.90-26.30] percentage points lower; P < .001) compared with people without disability. Adjusted regression results revealed that people with visual disability had a mean of 2.50 (95% CI, 2.34-2.67) times more glaucoma outpatient visits than their matches who were disability free (P < .001).

Conclusions and Relevance

Certain types of disability can reduce glaucoma medication adherence by up to 17.60%. Policies targeting medication adherence should consider these disability types.

Medication adherence among the elderly: applying grounded theory approach in a developing country

BACKGROUND

Medication adherence is an important concept particularly among the elderly that can, directly and indirectly, affect the health system's costs and the elderly's health, quality of life, and functional abilities. This study aimed to determine the model of medication adherence among the Iranian elderly using the grounded theory approach.

METHODS

The concept of medication adherence and the determination of its process among the elderly is a multidisciplinary social issue that can be affected by many contextual factors. Grounded theory with the approach of Strauss and Corbin (2004) was applied to determine the customized model. Data triangulation occurred through semi-structured interviews, observation, field notes, and memoing. Open coding, selective coding, and axial coding were applied to analyze the data.

RESULTS

Delinquency in the medication use among the elderly was caused by factors such as doubtfulness, fear of complications, not following the patients by the physicians, and negative others and medical staff's impacts. During the process of medication adherence, the patient's lack of knowledge, lack of sufficient education, inappropriate and restricted lifestyle, difficult living conditions, and social pressures imposed on individuals could exacerbate and worsen the delinquency in medication adherence. It should not be neglected that some other factors such as lack of an effective supervision system, lack of supportive organizations, stakeholders' market-based behaviors, consumption inconvenience, consumption stress, hopelessness, and misunderstanding could also aggravate the delinquency.

CONCLUSIONS

Although the proposed theory and model were customized and context-based for the Iranian elderly, in general, making positive changes in the process of adherence to the medication use among the elderly requires scientific and basic management and planning of its factors. It should be noted that making these changes requires some interventions in and cooperation of all levels of the country's health system, from the Ministry of Health and Medical Education to the individual level of the elderly.

Medication adherence: Importance, issues and policy: A policy statement from the American Heart Association

Medications do not work in patients who do not take them. This true statement highlights the importance of medication adherence. Providers are often frustrated by the lack of consistent medication adherence in the patients they care for. Today with the time constraints that providers face, it becomes difficult to discover the extent of non-adherence. There are certainly many challenges in medication adherence not only at the patient-provider level but also within a healthy system and finally in insurers and payment systems. In a cross-sectional survey of unintentional nonadherence in over 24,000 adults with chronic illness, including hypertension, diabetes and hyperlipidemia, 62% forgot to take medications and 37% had run out of their medications within a year. These sobering data necessitate immediate policy and systems solutions to support patients in adherence. Medication adherence for cardiovascular diseases (CVD) has the potential to change outcomes, such as blood pressure control and subsequent events. The American Heart Association (AHA)/American Stroke Association (ASA) has a goal of improving medication adherence in CVD and stroke prevention and treatment. This paper will explore medication adherence with all its inherent issues and suggest policy and structural changes that must happen in order to transform medication adherence levels in the U.S. and achieve the AHA/ASA's health impact goals.

What influences the selection of contextual cues when starting a new routine behaviour? An exploratory study

BACKGROUND

Contextual cues play an important role in facilitating behaviour change. They not only support memory but may also help to make the new behaviour automatic through the formation of new routines. However, previous research shows that when people start a new behaviour, they tend to select cues that lack effectiveness for prompting behaviour. Therefore, it is important to understand what influences cue selection, as this can help to identify acceptable cues, which in turn could inform future behaviour change interventions to help people select cues that best fit their context and so ensure continued repetition.

METHODS

We conducted a qualitative study to investigate what cues people select, how, and what influences their decisions. We recruited 39 participants and asked them to take vitamin C tablets daily for 3 weeks and later interviewed them about their experience. Quantitative habit strength and memory measures were taken for descriptive purposes.

RESULTS

Cue selection was primarily influenced by a desire to minimise effort, e.g. keeping related objects at hand or in a visible place; prior experience with similar behaviours (regardless of whether the cues used in the past were reliable or not); and beliefs about effective approaches. In addition, we found that suboptimal remembering strategies involved reliance on a single cue and loosely defined plans that do not specify cues. Moreover, for many participants, identifying optimal cues required trial and error, as people were rarely able to anticipate in advance what approach would work best for them.

CONCLUSIONS

Future behaviour change interventions that rely on routine behaviours might fruitfully include the provision of educational information regarding what approaches are suboptimal (single factors, vaguely defined plans) and what is most likely to work (combining multiple clearly defined cues). They should also assess people's existing beliefs about how to best remember specific behaviours as such beliefs can either enhance or inhibit the cues they select. Finally, interventions should account for the fact that early failures to remember are part of the process of developing a reliable remembering strategy and to be expected.

Adherence to abiraterone or enzalutamide in elderly metastatic castration-resistant prostate cancer

PURPOSE

To evaluate adherence to abiraterone or enzalutamide for the treatment of metastatic castration-resistant prostate cancer (mCRPC).

METHODS

In an observational prospective cohort study, we monitored patients with mCRPC for their adherence to abiraterone or enzalutamide in the pre- or post-chemotherapy setting.

RESULTS

Fifty-eight patients with median age of 76 years (range 56-94), age-adjusted Charlson comorbidity score of 10 (range, 4-15), and geriatric G8 score of 14 (range, 6-17) were enrolled. Twenty-two (38%) patients were treated with abiraterone and 36 (62%) with enzalutamide, while forty-two (72%) were in the pre-chemotherapy setting. Forty-seven patients (81%) had a caregiver. Based on the pill counting, a non-adherence rate of 4.8% and 6.2% was observed for the whole period and the first 3 months, respectively, without a statistically significant difference between abiraterone and enzalutamide cohorts. A lower non-adherence rate (1.3%) was reported by patients during the whole period, mainly due to a misperception (77%) and forgetfulness (19%). Non-adherence rate to the fulfilling of the clinical diary was 38% for the whole period. Non-adherence in the whole period was related to the radiological response (p = 0.03) and geriatric G8 score (p = 0.005). By the receiver operating characteristic (ROC) curve based on the radiological response, non-adherence cut-off was 1.87% (p = 0.04). By this non-adherence cut-off, the G8 cut-off was 14.75 (p = 0.0003).

CONCLUSION

Non-adherence to abiraterone or enzalutamide for mCRPC may have an impact on disease response and be related to patients' frailty, suggesting their geriatric assessment and clinical interventions to monitor and increase their adherence.

Effectiveness of pharmacist home visits for individuals at risk of medication-related problems: a systematic review and meta-analysis of randomised controlled trials

Background

Medication mismanagement is a major cause of both hospital admission and nursing home placement of frail older adults. Medication reviews by community pharmacists aim to maximise therapeutic benefit but also minimise harm. Pharmacist-led medication reviews have been the focus of several systematic reviews, but none have focussed on the home setting.

Review methods

To determine the effectiveness of pharmacist home visits for individuals at risk of medication-related problems we undertook a systematic review and meta-analysis of randomised controlled trials (RCTs). Thirteen databases were searched from inception to December 2018. Forward and backward citation of included studies was also performed. Articles were screened for inclusion independently by two reviewers. Randomised controlled studies of home visits by pharmacists for individuals at risk of medication-related problems were eligible for inclusion. Data extraction and quality appraisal were performed by one reviewer and checked by a second. Random-effects meta-analyses were performed where sufficient data allowed and narrative synthesis summarised all remaining data.

Results

Twelve RCTs (reported in 15 articles), involving 3410 participants, were included in the review. The frequency, content and purpose of the home visit varied considerably. The data from eight trials were suitable for meta-analysis of the effects on hospital admissions and mortality, and from three trials for the effects on quality of life. Overall there was no evidence of reduction in hospital admissions (risk ratio (RR) of 1.01 (95%CI 0.86 to 1.20, I² = 69.0%, p = 0.89; 8 studies, 2314 participants)), or mortality (RR of 1.01 (95%CI 0.81 to 1.26, I² = 0%, p = 0.94; 8 studies, 2314 participants)). There was no consistent evidence of an effect on quality of life, medication adherence or knowledge.

Conclusion

A systematic review of twelve RCTs assessing the impact of pharmacist home visits for individuals at risk of medication related problems found no evidence of effect on hospital admission or mortality rates, and limited evidence of effect on quality of life. Future studies should focus on using more robust methods to assess relevant outcomes.

Thai family caregivers' experiences helping dependent elders during medical emergencies: a qualitative study

AIM

To describe the experience of family caregivers of dependent elders during medical emergencies in rural settings in Thailand.

METHODS

This was a descriptive qualitative research using in-depth interviews of 15 participants. Content analysis was applied to transcribed interviews, including data reduction as well as identification of key words, phrases, and themes.

RESULTS

The findings described the experience of caregivers of dependent older persons who faced emergency illness. Most of the family caregivers described their roles in unusual situations as practising assessment first and doing something that may relieve the symptoms experienced by the older persons before initiating and calling for help from relatives, neighbors, and, finally, the emergency medical services. The caregivers four main barriers to them feeling competent: (1) lack of home monitoring devices, (2) inexperienced caregivers in assessing warning signs to report during emergency care, (3) lack of information and understanding of patient rights in emergency health services, and (4) delayed arrival of emergency medical services.

CONCLUSIONS

There are barriers to the development of competency in caregiving skills, especially in assessing and recognizing warning signs and initiating first aid accurately before the arrival of the emergency health care team.

Polypharmacy Among Home-Dwelling Older Adults: The Urgent Need for an Evidence-Based Medication Management Model

Ageing populations with multiple chronic conditions challenge low-, middle-, and high-income countries. Older adults frequently depend on complex medication regimens and polypharmacy, both of which can lead to potentially devastating and debilitating medication-related problems and to subsequent far-reaching public health, social, and economic effects. This perspectives article provides an overview of the current state of medication management, reflects on its relevance among polymedicated home-dwelling older adults living with multiple chronic conditions, and proposes patient-centered approaches for optimizing medication management and preventing medication-related problems.

Optimising medication management for polymedicated home-dwelling older adults with multiple chronic conditions: a mixed-methods study protocol

INTRODUCTION

Optimal medication management is one of the basic conditions necessary for home-dwelling older adults living with multiple chronic conditions (OAMCC) to be able to remain at home and preserve their quality of life. Currently, the reasons for such high numbers of emergency department visits and the very significant rate of hospitalisations for OAMCC, due to medication-related problems (MRPs), is poorly explored. This study aims to reveal the current state of the medication management practices of polymedicated, home-dwelling OAMCC and to make proposals for improving clinical and medication pathways through an innovative and integrated model for supporting medication management and preventing adverse health outcomes.

METHODS AND ANALYSIS

A mixed-methods study will address the medication management of polymedicated, home-dwelling OAMCC. Its explanatory sequential design will involve two major phases conducted sequentially over time. The quantitative phase will consist of retrospectively exploiting the last 5 years of electronic patient records from a local hospital (N ≈ 50 000) in order to identify the different profiles-made up of patient-related, medication-related and environment-related factors-of the polymedicated, home-dwelling OAMCC at risk of hospitalisation, emergency department visits, hospital readmission (notably for MRPs), institutionalisation or early death. The qualitative study will involve: (a) obtaining and understanding the medication management practices and experiences of the identified profiles extracted from the hospital data of OAMCC who will be interviewed at home (N ≈ 30); (b) collecting and analysing the perspectives of the formal and informal caregivers involved in medication management at home in order to cross-reference perspectives about this important dimension of care at home. Finally, the mixed-methods findings will enable the development of an innovative, integrated model of medication management based on the Agency for Clinical Innovation framework and Bodenheimer and Sinsky's quadruple aim.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human Research Ethics Committee of the Canton Vaud (2018-02196). Findings will be disseminated in peer-reviewed journals, professional conferences and other knowledge transfer activities with primary healthcare providers, hospital care units, informal caregivers' and patients' associations.

The spatial dimensions of medication management by home-dwelling older adults after hospital discharge

Ageing in place raises pressing questions about medication practices at home. Understanding how medication practices are integrated into older adults' domestic settings requires an interest in where activities linked to medication take place and why. This study aimed to describe the medication practices and spatial dimensions of medication management for home-dwelling older adults after hospital discharge, using a qualitative research design. Semi-structured interviews were carried out with ten older adults aged 65 years old or more and discharged home from hospital, together with nine informal caregivers. Thematic content analysis identified two main themes dealing with the spatial dimensions of medication management in this specific context: the process of integrating medication changes into routines and familiar spaces, and the individual and collective management of medication changes linked to a renegotiation of the boundaries between public and private spaces.

Evaluation of a one-dose package medication support system for community-based elderly patients and eldercare facilities

PURPOSE

Results of an evaluation of a one-dose package medication support system (ODP-MSS) for medication support and telecare home monitoring of elderly persons are reported.

METHODS

ODP-MSS units were provided to 10 elderly patients living at home, with adherence assistance provided by family members or other medication supporters in response to telephone alerts. In addition, ODP-MSS units were installed in 2 group homes. At the end of the designated study periods, device data logs were analyzed, and study participants were interviewed or surveyed regarding the impact of ODP-MSS use.

RESULTS

Overall, 2 patients were reported to have missed medication doses due to forgetfulness; in both cases, alerted medication supporters called the patients and reminded them to take their medicine. Five home-dwelling patients and 5 supporters reported that the ODP-MSS provided useful reminders; 4 patients and 7 supporters indicated that calls to supporters were useful as a telecare home monitoring system. Eleven group home staff members reported that the ODP-MSS was useful in reducing medication errors and the need for medication assistance.

CONCLUSION

An ODP device plus follow-up calls from a medication supporter helped prevent missed doses resulting from patients' forgetfulness and may serve as a useful component of telecare home monitoring for elderly people living independently at home. The ODP device was also useful for reducing the burdens associated with medication support and medication errors on staff members of group homes for elderly patients with dementia.

"We're really not ready for this": A qualitative exploration of community pharmacy personnel's perspectives on the pharmaceutical care of older people with sensory impairment

Background

In most developed countries there is an increasing ageing population living in the community with long-term conditions and sensory impairment (sight; hearing; dual impairment). Community pharmacy personnel are key providers of pharmaceutical care to this patient population.

Objective

This study explored community pharmacy personnel's experiences with providing pharmaceutical care for older people with sensory impairment.

Methods

Semi-structured telephone interviews were conducted with community pharmacy personnel across Scotland between 2015 and 2016.

Results

Thirty interviews were completed with community pharmacists (n = 17) and other pharmacy personnel (n = 13). Two overarching themes emerged: safety and communication. Interviewees reported patients' reluctance to disclose their impairment “patients are very good at hiding it” and had considerable safety concerns “it's a fear that they're going to take too much … accidentally taking the same medicine twice”. Difficulties in communication were cited “no matter what you do or how you label things, leaflets and telling people, things can go wrong”. Additionally, interviewees identified training needs to increase their disability awareness and to identify strategies to provide safe and reliable pharmaceutical care to this vulnerable group “We don't specifically have anything in place to deal with anyone with impairments of that kind”.

Conclusions

This is the first in-depth exploration of providing pharmaceutical care to older people with sensory impairment from the perspective of community pharmacy personnel. Strategies are needed to encourage older people to disclose their sensory impairment. Education and training are also needed to optimise the provision of pharmaceutical care to this vulnerable population.

Access and adherence to medications for the primary and secondary prevention of atherosclerotic cardiovascular disease in Singapore: a qualitative study

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is a growing public health threat globally, and many individuals remain undiagnosed, untreated, and their condition remains uncontrolled. The key to effective ASCVD management is adherence to pharmacotherapy, and non-adherence has been associated with an increased risk of cardiovascular events and complications such as stroke, further impacting a patient's ability to be adherent. Our qualitative study aimed to explore factors influencing medication adherence in the primary and secondary prevention of ASCVD in Singapore. We propose a synthesized framework, which expands on current understandings of the factors of medication adherence, as a frame of analysis in this study.

METHODS

We conducted in-depth, semi-structured interviews with 20 patients over the age of 40 with ASCVD and/or its risk factors in Singapore. QSR Nvivo 11 was used to conduct thematic analysis using an inductive approach.

RESULTS

Using a synthesized framework, we reported that complex medication regimens, the lack of support received during regimen changes, and the perceived seriousness of a condition could impact a patient's medication adherence. Key findings suggest that the relationship between health care professionals and patients impacted patient acceptability of the medication regimen and consequently medication adherence. Different patient beliefs regarding diagnosis, medication, and adherence had some bearing on the ability to perceive the need to adhere to their medication. Patients also reported that they could afford medication, sometimes with the help of family members. Patients also largely reported not needing help managing their medication, considering it an individual responsibility.

CONCLUSION

We identified key factors which future interventions looking to improve medication adherence ought to consider. These include changing patient perceptions of health systems, diagnosis, medication, and adherence; patient-centeredness in developing interventions that facilitate adherence through building self-efficacy and stronger support networks via patient empowerment and engagement; decreasing patient co-payments on medication; and cultivating a trusting patient-provider relationship.

"This Is What Family Does": The Family Experience of Caring for Serious Illness

Background:

As the demographics of caregiving in United States evolve toward multigenerational, distributed family structures, the ways in which individuals and their families experience serious illness are changing. As part of a project to create an innovative model of supportive care for serious illness, a series of user interviews were conducted, forming the basis for this article.

Objective:

To understand the experience of caregiving for individuals with serious illness from an intergenerational family perspective.

Methods:

Twelve semistructured group interviews were conducted with patients, families, and professionals. Transcript data were analyzed with descriptive coding, looking for major themes and subthemes related to family experiences.

Results:

Seventy-three individuals participated in group interview sessions. While both families and individuals encountered caregiving challenges, the family unit experienced care in several unique ways. It accommodated differences in temperament and readiness, managed internal conflict, and strived to emerge as a cohesive unit. Individual struggles were often magnified or, more often, ameliorated by family context. Caregiving itself formed a legacy for future generations. Finally, care was seen as bidirectional, being tendered both by the family caregivers and in turn by the patient.

Conclusions:

When talking about care for serious illness, individuals report both rewards and challenges, often in a family context. The family enterprise manages a loved one’s care, negotiates the health-care system, and adjusts its own internal dynamics. Integrating the family narrative provides a more balanced view of the family system that provides the day-to-day care for individuals with serious illness.

Medication management activities performed by informal caregivers of older adults

BACKGROUND

Medication management is commonly performed by informal caregivers, yet they are often unprepared and ill-equipped to manage complex medication regimens for their older adult care recipients. In order to develop interventions that will enhance the caregiver's ability to safely and confidently manage medications, it is critical to first understand caregiver challenges and unmet needs related to medication management.

OBJECTIVES

To explore how informal caregivers manage medications for their older adult care recipients by identifying the activities involved in medication management and the tools or strategies used to facilitate these activities.

METHODS

Four focus groups with caregivers of older adults were conducted with 5-9 caregivers per group. Participants were asked to describe the medication management activities performed and the tools or strategies used to facilitate these activities. Focus groups were recorded, transcribed verbatim, and analyzed for themes using an inductive approach.

RESULTS

Caregivers were commonly involved in 2 types of activities: direct activities requiring physical handling of medications such as obtaining medications, preparing pill boxes, and assisting with medication administration; and indirect activities that were more complex and required more of a cognitive effort by the caregiver, such as organizing and tracking medications, gathering information, and making treatment decisions. They utilized a variety of tools and strategies to support these medication management activities; however, these approaches often needed to be modified or personalized to meet the specific needs of their caregiving situation.

CONCLUSIONS

Informal caregivers play a vital role in ensuring safe and appropriate medication use by older adults. Medication management is complex and involves many activities that are supported through the use of a variety of tools and strategies that have been adapted and individualized to each specific caregiving scenario. Caregivers should be an important component of interventions that aim to improve medication use among older adults.

Understanding the use of contextual cues: design implications for medication adherence technologies that support remembering

Objective

Forgetfulness is one of the main reasons of unintentional medication non-adherence. Adherence technologies that help people remember to take their medications on time often do not take into account the context of people’s everyday lives. Existing evidence that highlights the effectiveness of remembering strategies that rely on contextual cues is largely based on research with older adults, and thus it is not clear whether it can be generalized to other populations or used to inform the design of wider adherence technologies that support medication self-management. Understanding how younger populations currently remember medications can inform the design of future adherence technologies that take advantage of existing contextual cues to support remembering.

Methods

We conducted three surveys with a total of over a thousand participants to investigate remembering strategies used by different populations: women who take oral contraception, parents and carers who give antibiotics to their children, and older adults who take medications for chronic conditions.

Results

Regardless of the population or the type of regimen, relying on contextual cues—routine events, locations, and meaningful objects—is a common and often effective strategy; combinations of two or more types of cues are more effective than relying on a single cue.

Conclusions

To effectively support remembering, adherence technologies should help users recognize contextual cues they already have at their disposal and reinforce relevant cues available in their environment. We show that, given the latest developments in technology, such support is already feasible.