Medication regimen complexity and adherence among older adults

Reliability and validity of the Turkish version of the Family Caregiver Medication Administration Hassles Scale

BACKGROUND

The Family Caregiver Medication Administration Hassles Scale (FCMAHS) was developed to evaluate the hassles and concerns experienced by family caregivers in medication administration.

OBJECTIVE

This study aimed to evaluate the reliability and validity of the Turkish version of the Family Caregiver Medication Administration Hassles Scale (FCMAHS-TR).

METHODS

The FCMAHS-TR was developed after translation, cultural adaptation, and a pilot study. The cross-sectional study was conducted among family caregivers (≥18 years) in community pharmacies. Test-retest reliability analysis, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA) were performed. Hypothesis testing was used for the assessment of construct validity.

RESULTS

The majority (68.7%) of the family caregivers were female (n = 470). In the test-retest reliability analysis (n = 30), the ICC value was 0.917 (P < 0.001). In EFA analysis (n = 251), the Kaiser‒Meyer‒Olkin (KMO) measure was 0.799, 62.6% of the total variance was explained by five factors including eighteen items, and Cronbach's alpha was 0.836. According to CFA (n = 219), the root mean square error of approximation (RMSEA) was 0.0654, and the comparative fit index (CFI) was 0.918. In construct validity, family caregivers with low reading ability of health-related materials and with high care burden had significantly higher median scores for all the factors of the FCMAHS-TR (P < 0.05 for all).

CONCLUSIONS

The FCMAHS-TR can be used to evaluate the hassle and concerns experienced by family caregivers in medication administration. This scale can be used by healthcare professionals to identify family caregivers who need individualized interventions for medication administration hassles.

Medication Regimen Complexity Index Score at Admission as a Predictor of Inpatient Outcomes: A Machine Learning Approach

BACKGROUND

In the intensive care unit, traditional scoring systems use illness severity and/or organ failure to determine prognosis, and this usually rests on the patient's condition at admission. In spite of the importance of medication reconciliation, the usefulness of home medication histories as predictors of clinical outcomes remains unexplored.

METHODS

A retrospective cohort study was conducted using the medical records of 322 intensive care unit (ICU) patients. The predictors of interest included the medication regimen complexity index (MRCI) at admission, the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Sequential Organ Failure Assessment (SOFA) score, or a combination thereof. Outcomes included mortality, length of stay, and the need for mechanical ventilation. Machine learning algorithms were used for outcome classification after correcting for class imbalances in the general population and across the racial continuum.

RESULTS

The home medication model could predict all clinical outcomes accurately 70% of the time. Among Whites, it improved to 80%, whereas among non-Whites it remained at 70%. The addition of SOFA and APACHE II yielded the best models among non-Whites and Whites, respectively. SHapley Additive exPlanations (SHAP) values showed that low MRCI scores were associated with reduced mortality and LOS, yet an increased need for mechanical ventilation.

CONCLUSION

Home medication histories represent a viable addition to traditional predictors of health outcomes.

Medication Complexity Among Older Adults with HF: How Can We Assess Better?

Medical management of heart failure (HF) has evolved and has achieved significant survival benefits, resulting in highly complex medication regimens. Complex medication regimens create challenges for older adults, including nonadherence and increased adverse drug events, especially associated with cognitive impairment, physical limitations, or lack of social support. However, the association between medication complexity and patients' health outcomes among older adults with HF is unclear. The purpose of this review is to address how the complexity of HF medications has been assessed in the literature and what clinical outcomes are associated with medication regimen complexity in HF. Further, we aimed to explore how older adults were represented in those studies. The Medication Regimen Complexity Index was the most commonly used tool for assessment of medication regimen complexity. Rehospitalization was most frequently assessed as the clinical outcome, and other studies used medication adherence, quality of life, healthcare utilization, healthcare cost, or side effect. However, the studies showed inconsistent results in the association between the medication regimen complexity and clinical outcomes. We also identified an extremely small number of studies that focused on older adults. Notably, current medication regimen complexity tools did not consider a complicated clinical condition of an older adult with multimorbidity, therapeutic competition, drug interactions, or altered tolerance to the usual dose strength of the medications. Furthermore, the outcomes that studies assessed were rarely comprehensive or patient centered. More studies are required to fill the knowledge gap identifying more comprehensive and accurate medication regimen complexity tools and more patient-centered outcome assessment.

Pharmacists' Role in Older Adults' Medication Regimen Complexity: A Systematic Review

Medication regimen complexity (MRC) may influence health outcomes, such as hospitalisation, hospital readmission and medication adherence. Pharmacists have been referred to as health professionals with the opportunity to act on MRC reduction. This study aimed to investigate pharmacists' role in studies about older adults' medication regimen complexity. A literature search was performed in PubMed, Web of Science and the Cochrane Library-CENTRAL-up to October 2019. Out of 653 potentially relevant studies, 17 articles met the inclusion criteria for this review. Most studies used the 65-item medication regimen complexity index (MRCI) to assess medication complexity. Pharmacists' role was mainly confined to data collection. It seems that pharmacists' active role in older adults' medication complexity has not been studied in depth so far. However, the few existing interventional ones suggest that, after previous training, regimen simplification is feasible.

Development of measurable criteria to identify and prioritize patients for inclusion in comprehensive medication management programs within primary care settings

BACKGROUND: Pharmacists optimize medication use and ensure the safe and effective delivery of pharmacotherapy to patients using comprehensive medication management (CMM). Identifying and prioritizing individual patients who will most likely benefit from CMM can be challenging. Health systems have far more candidates for CMM than there are clinical pharmacists to provide this service. Furthermore, current evidence lacks widely accepted standards or automated mechanisms for identifying patients who would likely benefit from a pharmacist consultation. Existing tools to prioritize patients for pharmacist review often require manual chart review by a pharmacist or other clinicians or data collection by patient survey. OBJECTIVES: To (1) create new medication risk markers for identifying and prioritizing patients within a population and (2) identify patients who met these new markers, assess their clinical characteristics, and compare them with criteria that are widely used for medication therapy management (MTM). METHODS: Along with published literature, a panel of subject matter experts informed the development of 3 medication risk markers. To assess the prevalence of markers developed, we used Multum, a medication database, for medication-level characteristics, and for patient-level characteristics, we used QuintilesIMS, an administrative claims database derived from health plans across the United States, with data for 1,541,873 eligible individuals from 2014-2015. We compared the health care costs, utilization, and medication gap among patients identified through MTM criteria (both broad and narrow, as these are provided as ranges) and our new medication management score markers. RESULTS: We developed 3 claims-derivable markers: (1) instances when a patient filled a medication with high complexity that could affect adherence, (2) instances where a patient filled a medication defined as costly within a therapeutic category that could affect access, and (3) instances when a patient filled a medication defined as risky that could increase incidence of adverse drug events. In the QuintilesIMS database, individuals with 2 new medication risk markers plus at least 3 conditions and more than $3,017 in medication costs when compared with individuals meeting narrow MTM eligibility criteria (≥ 8 medications, ≥ 3 conditions, and > $3,017 medication costs) had increased costs ($36,000 vs $26,100 total; $24,800 vs 21,400 medical; $11,300 vs $4,800 pharmacy); acute care utilization (0.328 vs 0.256 inpatient admissions and 0.627 vs 0.579 emergency department visits); and 1 or more gaps in medication adherence(41.5% vs 34.7%). CONCLUSIONS: We identified novel markers of medication use risk that can be determined using insurance claims and can be useful to identify patients for CMM programs and prioritize patients who would benefit from clinical pharmacist intervention. These markers were associated with higher costs, acute care utilization, and gaps in medication use compared with the overall population and within certain subgroups. Providing CMM to these patients may improve health system performance in relevant quality measures. Evaluation of CMM services delivered by a pharmacist using these markers requires further investigation. DISCLOSURES: No outside funding supported this study. All authors are Johns Hopkins employees. The Johns Hopkins University receives royalties for nonacademic use of software based on the Johns Hopkins Adjusted Clinical Group (ACG) methodology. Chang, Kitchen, Weiner, and Kharrazi receive a portion of their salary support from this revenue. The authors have no conflicts of interests relevant to this study.

Comparison of drug-related problem risk assessment tools for older adults: a systematic review

PURPOSE

This study aims to systematically review studies describing screening tools that assess the risk for drug-related problems (DRPs) in older adults (≥ 60 years). The focus of the review is to compare DRP risks listed in different tools and describe their development methods and validation.

METHODS

The systematic search was conducted using evidence-based medicine, Medline Ovid, Scopus, and Web of Science databases from January 1, 1985, to April 7, 2016. Publications describing general DRP risk assessment tools for older adults written in English were included. Disease, therapy, and drug-specific tools were excluded. Outcome measures included an assessment tool's content, development methods, and validation assessment.

RESULTS

The search produced 15 publications describing 11 DRP risk assessment tools. Three major categories of risks for DRPs included (1) patient or caregiver related risks; (2) pharmacotherapy-related risks; and (3) medication use process-related risks. Of all the risks included in the tools only 8 criteria appeared in at least 4 of the tools, problems remembering to take the medication being the most common (n=7). Validation assessments varied and content validation was the most commonly conducted (n = 9). Reliability assessment was conducted for 6 tools, most commonly by calculating internal consistency (n = 3) and inter-rater reliability (n = 2).

CONCLUSIONS

The considerable variety between the contents of the tools indicates that there is no consensus on the risk factors for DRPs that should be screened in older adults taking multiple medicines. Further research is needed to improve the accuracy and timeliness of the DRP risk assessment tools.

Predicting medication adherence in older Hispanic patients with type 2 diabetes

PURPOSE

Potential cognitive and demographic correlates of medication nonadherence in older Hispanic adults with type 2 diabetes were investigated.

METHODS

Forty community-dwelling participants 65 years of age or older were recruited. Executive control function (ECF) was assessed using the executive clock drawing task (CLOX 1) test and the 25-item Executive Interview. Self-reported medication adherence was measured on a visual analog scale (VAS); measures of glycemic control included glycosylated hemoglobin (HbA_1c) concentration. The primary objective was to determine if ECF performance correlated with medication adherence or glycemic control.

RESULTS

Participants' mean ± S.D. age was 74.95 ± 7.07 years, and 73% (n = 29) were female. Lower VAS scores correlated with worse CLOX 1 performance (r = 0.38, p = 0.02) and worse HbA_1c status (r = -0.42, p = 0.007). Linear regression modeling indicated significant associations between VAS scores and both CLOX 1 results (beta coefficient [β] = 0.41, p = 0.01) and educational level (β = 0.345, p = 0.03). Receiver operating characteristic analysis of CLOX 1 scores (scoring range, 0-15; lower scores indicate greater impairment) showed that a highly sensitive cutoff score for predicting adherence of <90% would be 7, but a cutoff of 10 would provide more specificity.

CONCLUSION

Results of an evaluation of a small sample of Hispanic older adults with type 2 diabetes demonstrated a relationship between ECF, as measured by the CLOX 1 instrument, and self-reported medication adherence.

Many caregivers of persons with memory loss or Alzheimer's disease are unaware of the abilities of their persons with AD to recall their drugs and medical histories

BACKGROUND

Caregiver awareness of the abilities of those they care for has much practical importance, especially from the safety standpoint.

OBJECTIVES

To determine whether the caregivers of persons with memory impairment or Alzheimer's disease know if their persons are able to recall their own drugs and medical histories.

METHOD

Persons with prodromal or probable AD (persons with AD) and their caregivers who were visiting our medical school's neurology and internal medicine clinics for routine follow-up care were recruited on the days of their appointments. Sixty-four caregiver-person with AD dyads were recruited. We first asked the caregivers to predict the ability of their persons with AD to answer questions about their drugs and medical histories. We then asked the persons with AD the questions to determine the accuracy of their caregivers' predictions.

RESULTS

Considering the caregivers of those with Mini-Mental State Exam scores ≥24, 41% incorrectly predicted whether their persons with AD could recall the number of drugs they were taking, 24% incorrectly predicted whether they could recall the names of the drugs, and 34% incorrectly predicted whether they could recall why they were taking the drugs. Most of the caregivers' errors were overestimations. As expected, the persons with AD themselves had much difficulty in answering the questions; only 30% could recall the number of drugs they were taking, only 14% could recall the names of the drugs, and only 16% could recall why they were taking the drugs.

CONCLUSIONS

Many caregivers of persons with memory impairment or AD are unaware of their persons' inability to recall their drugs and medical histories. Particularly concerning is the relatively high frequency of caregiver overestimations of the abilities of their persons with AD, which highlights a safety concern and presents an opportunity for caregiver education.

Association between medication regimen complexity and pharmacotherapy adherence: a systematic review

PURPOSE

The purpose of this study was to systematically review evidence regarding the association between regimen complexity and adherence.

METHODS

Articles were searched in MEDLINE, LILACS, Cochrane, CINAHL, PsycINFO and references of included studies. Search terms included medication regimen complexity, medication adherence and their synonyms. Randomized clinical trials, cross-sectional, cohort or case-control studies published until March 2016 in English, Portuguese or Spanish were eligible if quantitatively examined the association between complexity and adherence in patients of any age and sex, under any type of medication therapy. Complexity was defined according to the strategy used to assess it in the individual studies. All types of instruments used to assess complexity and adherence were considered. Data extraction was performed using an electronic spreadsheet. Quality assessment was conducted independently using standard scales. The data were qualitatively synthesized.

RESULTS

Fifty-four studies were included: 37 cross-sectional and 17 cohorts. Most were conducted in outpatient setting. Most frequently, studies were carried out with HIV-infected individuals or patients with chronic conditions. The most frequent methods used to assess complexity and adherence were complexity index (19) and self-report (27), respectively. Complexity was associated with adherence in 35 studies. Most of them (28) identified that participants with more complex regimens were less likely to adhere to pharmacotherapy; seven studies found a direct correlation. The others found inconclusive results or no association between complexity and adherence. The studies had low to moderate-methodological quality.

CONCLUSION

Although there was variability regarding the association between complexity and adherence, most studies showed that an increased regimen complexity reduces medication adherence.

Profiling Patient Characteristics Associated With the Intensity of Nurse Care Coordination

The purpose of this study was to identify characteristics of chronically ill community-dwelling older adults that differentiate the intensity of care provided by nurse care coordinators. We performed data mining on electronic health records, nurses' activity logs, and health status measures from 784 care episodes provided to 196 older adults. An inductively created decision tree identified nine groups from a combination of the six participant characteristics including medication regimen complexity, cognition, physical and mental health, hospital admission, and physical functioning. Overall there was a 5-hr difference in the intensity (or contact hours) per quarter of nurse care coordinators between individuals in the highest versus lowest intensity groups. The highest intensity group presented higher medication complexity and lower mental/physical health status. With caseloads of 30 to 35 participants, nurse care coordinators were able to provide care based on participant needs that were not influenced by regulatory payment requirements.

Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review

OBJECTIVES

To systematically review clinical outcomes associated with medication regimen complexity in older people.

DESIGN

Systematic review of EMBASE, MEDLINE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane library.

SETTING

Hospitals, home, and long-term care.

PARTICIPANTS

English-language peer-reviewed original research published before June 2016 was eligible if regimen complexity was quantified using a metric that considered number of medications and at least one other parameter, regimen complexity was calculated for participants' overall regimen, at least 80% of participants were aged 60 and older, and the study investigated a clinical outcome associated with regimen complexity.

MEASUREMENTS

Quality assessment was conducted using an adapted version of the Joanna Briggs Institute critical appraisal tool.

RESULTS

Sixteen observational studies met the inclusion criteria. Regimen complexity was associated with medication nonadherence (2/6 studies) and higher rates of hospitalization (2/4 studies). One study found that participants with less-complex medication administration were more likely to stop medications when feeling worse. One study each identified an association between regimen complexity and higher ability to administer medications as directed, medication self-administration errors, caregiver medication administration hassles, hospital discharge to non-home settings, postdischarge potential adverse drug events, all-cause mortality, and lower patient knowledge of their medication. Regimen complexity had no association with postdischarge medication modification, change in medication- and health-related problems, emergency department visits, or quality of life as rated by nursing staff.

CONCLUSION

Research into whether medication regimen complexity is associated with nonadherence and hospitalization has produced inconsistent results. Moderate-quality evidence from four studies (two each for nonadherence and hospitalization) suggests that medication regimen complexity is associated with nonadherence and higher rates of hospitalization.

Prescription Medications: Beliefs, Experiences, Behavior, and Adherence of Sheltered Housing Residents

Background:

Data on medication utilization among residents of sheltered housing complexes (SHCs) are limited.

Objective:

To evaluate the extent of nonadherence to prescribed medications among residents of SHCs and identify factors associated with nonadherence.

Methods:

A 58 item, pre-piloted questionnaire with validated items for patient self-assessment of medication risk; adherence; disability; health beliefs, experiences, and behavior; and general items on demographics, health, and medication use was mailed to 1137 SHC residents in Aberdeen, Scotland. Predictors of nonadherence (Morisky score >0) were identified using logistic regression.

Results:

Of the 695 (61.1%) respondents, 645 (mean ± SD age, 78.2 ± 7.8 y) reported using prescribed drugs. Nonadherence was reported by 176 of 627 (28.1%) residents. The predictors of nonadherence were: disagreeing with the statement, “I ensure I have enough medicines so that I don't run out” (OR 0.48; 95% CI 0.30 to 0.77), agreeing with the statements, “I make changes in the recommended management to suit my lifestyle” (OR 1.32; 95% CI 1.09 to 1.60) and “I get confused about my medicines” (OR 1.39; 95% CI 1.10 to 1.77), younger age (OR 0.96; 95% CI 0.94 to 0.99), not getting help from someone to use the medications correctly (OR 2.20; 95% CI 1.21 to 3.99), and agreeing with the statement, “I am concerned about the side effects from my medicines” (OR 1.31; 95% CI 1.05 to 1.63).

Conclusions:

Over one-quarter of SHC residents were found to be nonadherent to prescribed drugs. Risk factors for nonadherence include younger age, confusion about drugs, lack of support for drug supply and administration, interference of treatment recommendations with lifestyle, and a perceived view of risks outweighing benefits in using recommended drug therapy.

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.

Identifying Care Coordination Interventions Provided to Community-Dwelling Older Adults Using Electronic Health Records

Although care coordination is a popular intervention, there is no standard method of delivery. Also little is known about who benefits most, or characteristics that predict the amount of care coordination needed, especially with chronically ill older adults. The purpose of this study was to identify types and amount of nurse care coordination interventions provided to 231 chronically ill older adults who participated in a 12-month home care medication management program in the Midwest. For each participant, the nurse care coordinator spent an average of 134 min/mo providing in-person home care, 48 min/mo of travel, and 18 min/mo of indirect care occurring outside the home visit. This accounted for 67.2%, 23.8%, and 9.0% of nursing time, respectively, for home visits, travel, and indirect care. Four of 11 nursing interventions focused on medication management were provided to all participants. Seven of the 11 main interventions were individualized according to each person's special needs. Wide variations were observed in time provided with in-person home care and communications with multiple stakeholders. Study findings indicate the importance of individualizing interventions and the variability in the amount of nursing time needed to provide care coordination to chronically ill older adults.

The inability of older adults to recall their drugs and medical conditions

BACKGROUND/OBJECTIVES

Previous research has shown that many older adults without known cognitive impairment are unable to recall basic knowledge about their medical history. We sought to determine whether older adult patients in our own clinic population were able to recall their drug regimens and medical conditions from memory.

METHODS

Patients aged 65 years or older with no known cognitive impairment, dementia, or memory loss who were presenting for routine outpatient follow-up in our medical school neurology and general medicine clinics were recruited. Each patient was asked to recall the number and names of their presently prescribed drugs and their associated medical conditions. Each patient was also administered a Mini-Mental State Examination (MMSE) cognitive screening test (range 0-30).

RESULTS

Most patients were unable to recall their drug regimens or their medical conditions. Of 99 patients taking drugs, only 22% correctly named their drugs from memory, and only 34% correctly named their medical conditions associated with the drugs. Fewer than half (49%) correctly recalled the number of drugs they were taking. Poor recall performance was evident even in high-cognitive (MMSE>27) patients.

CONCLUSION

The accuracy of recall memory in older adults regarding their drugs and medical conditions may be poor, which has important implications towards medication reconciliation within meaningful-use doctrine. Clinicians treating older adults should be very cautious before relying on their patients' memories for accurate recall of their medical conditions, their drug regimens, and even the number of drugs they are taking.

Systematic review of the barriers affecting medication adherence in older adults

Medication adherence is a crucial part in the management of chronic diseases. As older adults form a greater proportion of the population with chronic diseases and multiple morbidities, understanding medication adherence in older adults becomes important. In the present article, we aimed to systematically review the literature for the factors associated with medication adherence in the geriatric population. We carried out a literature search using electronic databases and related keywords. 17 391 articles were reviewed in total. 65 articles were found to be relevant to our objective. A total of 80 factors of five different categories were found to be associated with medication adherence in older adults. The factors, the types of studies and the number of studies that agreed or disagreed were presented. A flower model for medication adherence was also presented to allow clinicians to better understand the complex nature of medication adherence in this population. The 80 factors reviewed were categorized into five main categories; namely, patient factors, medication factors, physician factors, system-based factors and other factors as factors affecting poor medication adherence in older adults. Clinicians need to be mindful of the complex nature of factors affecting medication adherence in this population to optimize therapeutic outcomes. Clinicians have to be more skillful to discover and to optimize the medication adherence factors in geriatric patients. The flower model is presented as a framework for clinicians to better understand the various factors affecting medication adherence in older adults. Geriatr Gerontol Int 2016; 16: 1093-1101.

Comparative adherence to oral hormonal agents in older women with breast cancer

We aim to (1) compare compliance of anastrozole, letrozole, exemestane, and tamoxifen in women and (2) identify clinical factors associated with medication non-adherence and non-persistence. Female Medicare beneficiaries who were new users of anastrozole, letrozole, exemestane, or tamoxifen between 2007 and 2010 were analyzed. Multivariate-modified Poisson and Cox regression models were constructed to compare non-adherence and non-persistence, respectively, across the different oral agents. A total of 5,150 women were included: mean age was 76.4 years, 2352 initiated anastrozole, 1401 letrozole, 248 exemestane, and 1149 tamoxifen. Non-adherence and non-persistence were 41 and 49% respectively, with exemestane being associated with the worst non-adherence and non-persistence (RR 1.57, 95% CI 1.37-1.80, p < 0.001; HR 1.93, 95% CI 1.63-2.30, respectively, p < 0.001), followed by letrozole (RR 1.39, 95% CI 1.26-1.53, p < 0.001; HR 1.47, 95% CI 1.32-1.64, respectively, p < 0.001), and anastrozole (RR 1.16, 95% CI 1.05-1.27, p = 0.003; HR 1.14, 95%CI 1.03-1.27, respectively, p = 0.011), whereas tamoxifen was associated with the best compliance. Use of statins and osteoporosis medications was correlated with improved adherence (RR 0.89, 95 % CI 0.82-0.96, p = 0.002 and RR 0.84, 95 % CI 0.76-0.92, p < 0.001, respectively, for non-adherence) and persistence (HR 0.86, 95 % CI 0.79-0.94, p < 0.001 and HR 0.86, 95 % CI 0.78-0.96, p = 0.005, respectively, for non-persistence), but chronic kidney disease was correlated with worse non-persistence (HR 1.15, 95 % CI 1.04-1.33, p = 0.04). Age ≥ 70 years was also associated with worse compliance. Compliance to oral hormonal therapy varied depending on the type of agent, age, and concurrent medications, highlighting specific opportunities to improve adherence and persistence in older women with breast cancer.

Patient-level medication regimen complexity in older adults with depression

PURPOSE

Polypharmacy and medication adherence are well known challenges facing older adults. Medication regimen complexity increases the demands of self-care in the home. Some medication regimens may be more complex than others, especially when dosage form, frequency of dosing, and additional usage directions are included in complexity along with the number of medications In older adults with depression, it is unknown what features of their medications most influence their medication regimen complexity.

METHODS

A sample cohort of 100 adults ≥65 years old with a diagnosis of depression was randomly selected from electronic medical records (EMR) in ambulatory clinics at the University of Colorado (CU) and University of San Diego (SD). Demographic, medical history, and medication-related information was extracted from the EMR. Complexity was determined using the Medication Regimen Complexity Index (MRCI). IRB approval was obtained.

FINDINGS

The cohort mean age was 74.3 years (SD) and 79.7 years (CU). The mean unweighted Charlson comorbidity index for 1.0 (SD) and 1.8 (CU). The mean number of medications was 7.1 and 8.0, with 1.1 and 1.2 depression meds, 5.4 and 4.3 non-depression prescription meds, and 0.6 and 2.4 OTC meds for the SD and CU cohorts, respectively. 66% of SD adults and 70% of CU adults took six or more meds. Individual MRCI scores were on average 17.62 (SD) and 19.36 (CU). Dosing frequency contributed to 57-58% of the MRCI score, with patients facing an average of 7-8 unique dosing frequencies in their regimen. In both cohorts, there was an average of 3 additional directions added to the regimens to clarify dosing.

IMPLICATIONS

As expected, in our older adult cohorts with depression the majority of patients took multiple medications. Using a standardized instrument, we characterized the regimen complexity and found that it was increasingly complex due to numerous dosing forms, frequencies and additional directions for use. Patient-level medication regimen complexity should go beyond depression medication to encompass the patient's entire regimen for opportunities to reduce complexity and improve ease of self-care.

Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication: randomized clinical trial to test efficacy

BACKGROUND

Self-management of complex medication regimens for chronic illness is challenging for many older adults.

OBJECTIVES

The purpose of this study was to evaluate health status outcomes of frail older adults receiving a home-based support program that emphasized self-management of medications using both care coordination and technology.

DESIGN

This study used a randomized controlled trial with three arms and longitudinal outcome measurement.

SETTING

Older adults having difficulty in self-managing medications (n = 414) were recruited at discharge from three Medicare-certified home healthcare agencies in a Midwestern urban area.

METHODS

All participants received baseline pharmacy screens. The control group received no further intervention. A team of advanced practice nurses and registered nurses coordinated care for 12 months to two intervention groups who also received either an MD.2 medication-dispensing machine or a medplanner. Health status outcomes (the Geriatric Depression Scale, Mini Mental Status Examination, Physical Performance Test, and SF-36 Physical Component Summary and Mental Component Summary) were measured at baseline and at 3, 6, 9, and 12 months.

RESULTS

After covariate and baseline health status adjustment, time × group interactions for the MD.2 and medplanner groups on health status outcomes were not significant. Time × group interactions were significant for the medplanner and control group comparisons.

DISCUSSION

Participants with care coordination had significantly better health status outcomes over time than those in the control group, but addition of the MD.2 machine to nurse care coordination did not result in better health status outcomes.

Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity

INTRODUCTION

Complex medication regimens are error prone and challenging for patients, which may impact medication adherence and safety. No universal method to assess the complexity of medication regimens (CMRx) exists. The authors aim to review literature for CMRx measurements to establish consistencies and, secondarily, describe CMRx impact on healthcare outcomes.

AREAS COVERED

A search of EMBASE and PubMed for studies analyzing at least two medications and complexity components, among those self-managing medications, was conducted. Out of 1204 abstracts, 38 studies were included in the final sample. The majority (74%) of studies used one of five validated CMRx scales; their components and scoring were compared.

EXPERT OPINION

Universal CMRx assessment is needed to identify and reduce complex regimens, and, thus, improve safety. The authors highlight commonalities among five scales to help build consensus. Common components (i.e., regimen factors) included dosing frequency, units per dose, and non-oral routes. Elements (e.g., twice daily) of these components (e.g., dosing frequency) and scoring varied. Patient-specific factors (e.g., dexterity, cognition) were not addressed, which is a shortcoming of current scales and a challenge for future scales. As CMRx has important outcomes, notably adherence and healthcare utilization, a standardized tool has potential for far-reaching clinical, research, and patient-safety impact.

Automating the medication regimen complexity index

Objective

To adapt and automate the medication regimen complexity index (MRCI) within the structure of a commercial medication database in the post-acute home care setting.

Materials and Methods

In phase 1, medication data from 89 645 electronic health records were abstracted to line up with the components of the MRCI: dosage form, dosing frequency, and additional administrative directions. A committee reviewed output to assign index weights and determine necessary adaptations. In phase 2 we examined the face validity of the modified MRCI through analysis of automatic tabulations and descriptive statistics.

Results

The mean number of medications per patient record was 7.6 (SD 3.8); mean MRCI score was 16.1 (SD 9.0). The number of medications and MRCI were highly associated, but there was a wide range of MRCI scores for each number of medications. Most patients (55%) were taking only oral medications in tablet/capsule form, although 16% had regimens with three or more medications with different routes/forms. The biggest contributor to the MRCI score was dosing frequency (mean 11.9). Over 36% of patients needed to remember two or more special instructions (eg, take on alternate days, dissolve).

Discussion

Medication complexity can be tabulated through an automated process with some adaptation for local organizational systems. The MRCI provides a more nuanced way of measuring and assessing complexity than a simple medication count.

Conclusions

An automated MRCI may help to identify patients who are at higher risk of adverse events, and could potentially be used in research and clinical decision support to improve medication management and patient outcomes.

Adherence and medication management by the elderly

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

Descriptive qualitative design.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Cognitive Impairment and Medication Complexity in Community-Living Older Adults: The Health, Aging and Body Composition Study

BACKGROUND

Medication complexity is a large determinant of adherence. Few studies have explored the relationship between cognitive impairment and medication complexity.

OBJECTIVE

To evaluate whether cognitive impairment is associated with medication complexity for prescription and over-the-counter (OTC) medications.

METHODS

In this cross-sectional analysis, we studied the association between cognitive impairment and the complexity of prescription and OTC drug regimens. Baseline participants were from the Health, Aging and Body Composition study, consisting of 3075 well-functioning 70- to 79-year-old black and white men and women. Cognitive impairment was defined by having a Modified Mini-Mental State Examination score <80. The complexity of prescription and OTC (including supplements/herbals) medications was assessed using a modified version of the Medication Regimen Complexity Index (mMRCI). The mMRCI score increases with complexity of dosage forms, number of medications, pill burden, and nondaily dosing.

RESULTS

The mean (SD) age was 74 (2.9) years (n = 3055; 52% female, 41% black). The median prescription mMRCI score was 6 (range 0-66). The median OTC mMRCI score was 4 (range 0-71). Adjusting for health status, demographics, and access to care, medication complexity was lower in participants with cognitive impairment for prescription (adjusted RR 0.89; 95% CI 0.80 to 0.99) and OTC medications (adjusted RR 0.76; 95% CI 0.64 to 0.93) compared to those without cognitive impairment. The number of prescription medications was not different, but the number of OTC drugs was lower for those with cognitive impairment.

CONCLUSIONS

In this cohort of well-functioning older adults, those with cognitive impairment had lower prescription complexity due to less-complex dosage forms, pill burden, or daily dosing. OTC complexity was also lower, primarily due to a lower number of OTC drugs. The results of this study show that further research on medication complexity and adherence and health outcomes in cognitively impaired individuals is warranted.

Looking beyond polypharmacy: quantification of medication regimen complexity in the elderly

BACKGROUND

Polypharmacy has been shown to influence outcomes in elderly patients. However, the impact of medication regimen complexity, quantified by the Medication Regimen Complexity Index (MRCI), on health outcomes after discharge of elderly patients has not been studied.

OBJECTIVE

Our aim was to test the convergent, discriminant, and predictive validity of the MRCI in older hospitalized patients with varying functional and cognitive levels.

METHODS

We retrospectively applied the MRCI to the medication regimen of 212 hospitalized patients and assessed its validity.

RESULTS

The mean (SD) MRCI scores for medication regimens and number of medications at discharge were 30.27 (13.95) and 5.95 (2.40), respectively. The MRCI scores were strongly correlated with the number of medications (r=0.94, P<0.001) and the number of daily doses (r=0.87, P<0.001) and increased as the number of medications taken ≥3 times daily increased (27.35, 34.45, and 43.00 for none, 1, and 2 drugs, respectively; P<0.001). Positive correlations were observed between the Cumulative Illness Rating Scale-Geriatrics score and both the number of medications and the MRCI score (r=0.40, r=0.46, P<0.001, respectively). No relationship was found between MRCI scores and the number of medications and age, sex, and postdischarge medication modifications. Patients nonadherent to at least 1 drug were discharged with a higher MRCI score and higher number of medications compared with medication-compliant patients (33.3 and 7.0 vs 27 and 5.8, respectively; P<0.01). An inverse correlation was found between overall adherence 1 month after discharge and the MRCI score (r=-0.188, P= 0.028); however, no such correlation was found regarding the number of medications at discharge.

CONCLUSIONS

The MRCI showed satisfactory validity and good evidence of classifying regimen complexity over a simple medication count. The MRCI demonstrated application in clinical research and practice in the elderly. However, more studies are needed to investigate its advantage over the number of medications for identifying patients with complex medication regimens and directing interventions to simplify their medication regimen complexity.

Development and psychometric evaluation of the German version of the Medication Regimen Complexity Index (MRCI-D)

BACKGROUND

Several factors contribute to the complexity of pharmacotherapeutic regimens, like the total number of medications to be taken, the number of dosage units to take at a time, dosage frequency, as well as specific directions concerning the administration. The Medication Regimen Complexity Index (MRCI) is a validated instrument developed in English for the measurement of the complexity of a given pharmacotherapeutic regimen.

OBJECTIVES

Translation of the MRCI into German and evaluation of the translated instrument (MRCI-D) in order to make it more easily accessible for use in German practice and research.

METHODS

The process of validation included the translation of the English version to German, back-translation into English, comparison of the back-translated and the original versions, pre-tests, and pilot-testing of the German version by three raters using 20 medication regimens for inpatients. The subsequent psychometric evaluation included the calculation of inter-rater and test-retest reliability, as well as the assessment of convergent validity.

RESULTS

The number of medications correlated highly and statistically significantly with the MRCI-D score (0.91, P < 0.001), indicating sufficient convergent validity of the instrument. Both inter-rater and test-retest reliability were very high (intraclass correlation coefficients above 0.80 in all cases).

CONCLUSION

Our results demonstrate that the German version of the MRCI reflects the complexity of therapeutic regimens with similar validity and reliability as the established English version. Thus, it may be a valuable tool to analyse therapeutic regimens in both clinical practice and science.

Predictors of adherence to medication in older Korean patients with hypertension

BACKGROUND AND RESEARCH OBJECTIVES

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

SUBJECTS AND METHOD

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

RESULTS AND CONCLUSIONS

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

Differences in Complexity of Discharge Medication Regimens between Men and Women Discharged from Acute Care to Home following Total Joint Arthroplasty

Purpose

This study determined whether discharge medication regimens that patients managed at home following hip or knee total joint arthroplasty differed between men and women. Comparisons were made among overall complexity of the regimen and the separate components contributing to complexity: number of medications, dosage forms, dosing frequencies, and additional administration directions.

Methods

Patient demographics and discharge medication regimens for serially discharged patients were retrospectively collected for a 3-month period from medical records at a large urban acute care hospital. Complexity of discharge medication regimens was quantified with the Medication Regimen Complexity Index (MRCI), which accounts for each separate component of complexity.

Results

The serial sample comprised 105 men and 93 women discharged to home following total joint arthroplasty. Men and women did not differ by hospital length of stay or by proportions with the most common secondary diagnoses (hypertension, hyperlipidemia, diabetes). Women were discharged with significantly more complex medication regimens to manage at home than men ( P = .047). Among the individual components contributing to complexity, women were discharged with significantly more medications on their lists than men ( P = .006) and had significantly larger dosing frequency scores than men ( P = .01).

Conclusions

Women discharged to home following lower extremity total joint arthroplasty may be at greater risk for an adverse drug event than men due to increased medication regimen complexity. These findings suggest that attempts should be made to mitigate this risk through reduced regimen complexity, specifically targeting dosing frequency, increased education for patients with complex regimens, or increased monitoring.

Adherence to medication in patients with dementia: predictors and strategies for improvement

Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of older patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise adherence behaviour. Therefore, a literature review was performed to identify factors associated with adherence to medication in patients with cognitive impairment or dementia, and to discuss strategies for improvement of non-adherence. Evidence-based information on how to deal with adherence to medication in patients with dementia is scarce because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behaviour in older age, and emerging insight into the relationships between adherence behaviour and cognitive capacity, memory and executive function, in particular. Nevertheless, understanding elderly persons' strategies for maintaining regular use of even complex drug regimens is still limited. Progress of research in this field is needed. It is notable that measures to improve adherence consist of combinations of educational interventions and cognitive support but assessment of study participants' cognitive function is rare. In clinical practice, awareness of non-adherence as a result of cognitive impairment is relatively low. The most important step is early detection of cognitive impairment when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment. Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs) and proxy information. However, no feasible screening methods have as yet found their way into clinical practice. Patients with impaired executive function, lack of awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence. The question is when to switch patient medication self-management to another person's responsibility if cognitive decline progresses. Further research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use and medication management. Also, studies evaluating the influence of personal support, health status and depression on the memory strategies used are needed. It is important to assess patients' attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible. When providing medication organizers, it is important to observe the patient's ability to use devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects. This holds true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient's cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy. No evidence-based recommendations can be given as yet. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.

Medication nonadherence and subsequent risk of hospitalisation and mortality among older adults

BACKGROUND

Despite a higher risk for medication nonadherence among older adults residing in the community, few prospective studies have investigated the health outcomes associated with nonadherence in this population or the possible variations in risk in urban versus rural residents.

OBJECTIVES

The primary objective of this study was to examine, in a prospective manner, the risk for hospitalisation (including an emergency department visit) and/or mortality associated with medication nonadherence in older, at-risk adults residing in the community. A secondary objective was to examine differences in the prevalence, determinants and consequences of medication nonadherence between rural and urban home care clients.

METHODS

Data were derived from a 1-year prospective study of home care clients aged > or =65 years (n = 319) randomly selected from urban and rural settings in southern Alberta, Canada. Trained nurses conducted in-home assessments including a comprehensive medication review, self-report measures of adherence and the Minimum Data Set for Home Care (MDS-HC) tool. Hospitalisation and mortality data during 12-month follow-up were obtained via linkages with regional administrative and vital statistics databases.

RESULTS

Nonadherent clients showed an increased but nonsignificant risk for an adverse health outcome (hospitalisation, emergency department visit or death) during follow-up (hazard ratio [adjusted for relevant covariates] = 1.24, 95% CI 0.93, 1.65). Subgroup analyses suggested this risk may be higher for unintentional nonadherence (unadjusted hazard ratio = 1.55, 95% CI 0.97, 2.48). The prevalence of nonadherence was similar among rural (38.2%) and urban (38.9%) clients and was associated with the presence of vision problems, a history of smoking, depressive symptoms, a high drug regimen complexity score, residence in a private home (vs assisted-living setting) and absence of assistance with medication administration. In both settings, approximately 20% of clients received one or more inappropriate medications.

CONCLUSIONS

Although not associated with rural/urban residence, medication nonadherence was common in our study population, particularly among those with depressive symptoms and complex medication regimens. The absence of a significant association between overall medication nonadherence and health outcomes may reflect study limitations and/or the need to differentiate among types of nonadherent behaviours.

The complexity of treatments for persons with epilepsy

The purpose of this study was to describe the types of antiepileptic medication regimens and the types of actions required to take medications for a group of patients with epilepsy. The Epilepsy Medication and Treatment Complexity Index (EMTCI) was used to gather information about medications and treatments. The sample of 314 reported on 585 epilepsy medications. The majority (56%) were on more than one treatment. On average, an individual took 1.86 medications per day (range, 1-6) and 7.98 pills per day (range, 1-36 pills). Most medications (54%) were taken twice a day. The most common special instruction was taking different doses on the same day. Taking more than one tablet per dose was the most common administrative action. Data presented here raise interesting areas for further research as well as important clinical implications.

Development and validation of the medication regimen complexity index

BACKGROUND

Medication regimen attributes, such as the number of drugs, dosage frequency, administration instructions, and the prescribed dosage forms, have been shown to influence patient outcomes. No single tool for quantifying the complexity of general medication regimens has been published in the medical literature.

OBJECTIVE

To develop and validate a tool to quantify the complexity of prescribed medication regimens.

METHODS

Literature findings and the expertise of the authors were used for developing the tool. Eight pharmacy researchers helped in establishing the tool's face and content validity. The new tool was tested on 134 medication regimens from patients with moderate to severe chronic obstructive pulmonary disease. Six regimens with a spread of scores on the tool were presented to a 5-member expert panel that subjectively ranked these regimens to confirm the tool's criterion-related validity. The relationships between scores on the tool and various independent variables were tested to judge the tool's construct validity. Two raters scored 25 regimens using the tool to test its inter-rater and test-retest reliabilities.

RESULTS

A 65-item Medication Regimen Complexity Index (MRCI) was developed. The expert panel had strong agreement (Kendall's W = 0.8; p = 0.001) on their individual rankings of the 6 regimens. The panel's consensus ranking had perfect correlation with the MRCI ranking. The total MRCI score had significant correlation with the number of drugs in the regimen (Spearman's Rho = 0.9; p < 0.0001), but not with the age and gender of the patients. Inter-rater and test-retest reliabilities for the total score and scores for individual sections on the MRCI were > or = 0.9.

CONCLUSIONS

The MRCI is a reliable and valid tool for quantifying drug regimen complexity with potential applications in both practice and research.

Measurement, Correlates, and Health Outcomes of Medication Adherence Among Seniors

OBJECTIVE

To provide a comprehensive review of the literature on the measurement, correlates, and health outcomes of medication adherence among community-dwelling older adults.

DATA SOURCES

Searches of MEDLINE, PubMed, and International Pharmaceutical Abstracts databases for English-language literature (1966–December 2002) were conducted using one or more of the following terms: elderly, adherence/nonadherence, compliance/noncompliance, medication/drug, methodology/measurement, and hospitalization.

STUDY SELECTION AND DATA EXTRACTION

From the above search, studies of medication adherence in community-dwelling seniors were selected for review along with relevant publications from the reference lists of articles identified in the initial database search.

DATA SYNTHESIS

Although several methods are available for the assessment of adherence, accurate measurement continues to be difficult. The available evidence suggests that polypharmacy and poor patient–healthcare provider relationships (including the use of multiple providers) may be major determinants of nonadherence among older persons, with the impact of most sociodemographic factors being negligible. There is little consensus regarding other determinants of nonadherence. Relatively few high-quality investigations have examined the associations between nonadherence and subsequent health outcomes. Available data provide some support for increased health risks with nonadherence. However, interventions to improve adherence have seldom demonstrated positive effects on health outcomes.

CONCLUSIONS

There are few empirical data to support a simple systematic descriptor of the nonadherent patient. The inconsistencies across studies may be attributable, in part, to the inherent difficulties involved in the measurement of a behavioral risk factor such as nonadherence. Future research in this area would be strengthened by incorporation of detailed assessments of patient-reported reasons for nonadherence, the appropriateness of drug regimens, and the effect of nonadherence on health outcomes.

Predictors of older adults' capacity for medication management in a self-medication program: a retrospective chart review

The aim of this project was to identify variables that predicted older adults' ability to manage medications.

METHODS

The study used a retrospective cohort design and was set in a self-medication program within a rehabilitation hospital. A random sample of charts from 301 participants in the self-medication program was reviewed.

RESULTS

Logistic regression models accounted for 26.7% and 55.8% of the variance in the probability of making one or more self-medication errors during the initial and final weeks of the program, respectively. The importance of cognition in predicting medication management capacity was seen in bivariate and multivariate analyses and through a number of interactions with other predictors. Statistically significant predictors in one or both analyses included medication regimen complexity, Mini-Mental State Exam (MMSE) score, duration of institutionalization, depression, and interactions between (a) medication regimen complexity and MMSE score and (b) ability to cook and MMSE score.

DISCUSSION

The direct effects of cognition and medication regimen complexity were important predictors of medication management capacity.

Drug therapy in the elderly: what doctors believe and patients actually do

AIMS

To examine the medication adherence among old persons living in their own homes, to assess their knowledge of their medication, and to indicate target areas for intervention.

METHODS

A cross-sectional study of data collected from randomly selected samples of 348 persons, aged 75 years recruited from a population-based register in the municipality of Aarhus, Denmark. Information on all drugs was collected from the subjects during a home visit, and their drug storage was examined. Information was collected from the general practitioners (GP). The measures of adherence were scores of agreements between the GPs' lists and the subjects' actual drug consumption.

RESULTS

We found disagreement between the drug information collected from the study population and from the GPs: concerning drugs in 22% of the study-population, concerning doses in 71%, and concerning regimens prescribed by the GP in 66%. Twenty-four percent stated that they did not always follow prescriptions. Most of the deviations from prescriptions were toward lower doses and less frequent drug intake. The drugs most often involved in deviations were hypnotics, analgesics, bronchodilators and diuretics. Sixty percent of the participants knew the purpose of medication, and 21% knew the consequences of omission of the drugs. Less than 6% of the subjects knew about the toxic risks, side-effects, or potential drug interactions. The participants' knowledge of the drugs was positively associated with their adherence. We found a correlation between an increased number of prescribed frequency of drug intake per day and deviation from the regimen (r = 0.25, P = 0.01). There was a positive association between nonadherence and the use of three or more drugs (odds ratio (OR) 2.5; 95% confidence interval (CI) 1.5,4.1), prescriptions from more than one doctor (OR 2.5; 95% CI 1.3,4.8), and probability of dementia (OR 9.0; 95% CI 1.1,72.5). Moreover compliance aids facilitated adherence (OR 4.4; 95% CI 1.6,12.3). Persons living alone were more prone to medication errors (OR 2.0; 95% CI 1.1,3.5).

CONCLUSIONS

A differentiated evaluation of adherence by considering the drug, the dose, and the regimen separately produced quantifiable data concerning the subjects' medication habits. Non-adherence ranged from 20 to 70% depending on the measuring method. The participants' knowledge of the treatment was poor. Our results suggest that better information on medication and the use of compliance aids may prevent nonadherence. Special attention should be paid to persons receiving three or more drugs, living alone, receiving drugs from other doctors, and to persons with predementia symptoms, as they are at higher risk of nonadherence.

Motivation and compliance in wound management

A review of health psychology research identifying factors that may influence outcomes in wound management.

High risk for ineffective management of therapeutic regimen: a protocol study

In this article, the authors present a protocol study developed to evaluate the usefulness of the nursing diagnosis "high risk for ineffective management of therapeutic regimen" among patients with congestive heart failure (CHF). Nursing interventions for increasing the CHF patient's abilities to perform therapeutic self-care for the promotion and maintenance of a prescribed medication regimen were evaluated based on predicted outcomes. Orem's self-care deficit theory of nursing provided the theoretical framework used in the protocol. Orem's supportive-educative nursing system was the approach used. Knowledge deficit was noted to be a major obstacle to maintaining the prescribed medication regimen among CHF patients. Comprehensive teaching of the patient, supported by a therapeutic nurse-patient relationship, was found to be the most important factor in the promotion and maintenance of a prescribed medication regimen among patients with CHF.