Experience of self-management of medications among older people with multimorbidity

The Experiences and Perceptions of Older Adults with Multimorbidity Toward E-Health Care: A Qualitative Evidence Synthesis

Background: Given the growing population of older adults globally, e-Health plays an indispensable role in the chronic disease management of multimorbidity. However, qualitative evidence that synthesizes the experiences of older adults with multimorbidity using e-Health service is currently lacking. The objective was to explore the experiences and perceptions of e-Health care in community-based settings among the older adults with multimorbidity. Methods: Seven electronic databases including PubMed, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Embase, Web of Science, China National Knowledge Infrastructure, and Chinese BioMedical Literature were searched, and the search was limited to studies from inception to September 1, 2023. Screening, data extraction, and quality appraisal were conducted independently by two reviewers. Thomas and Harden's thematic synthesis methodology was applied to synthesize the original themes. The methodological quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research, and the confidence of synthesized themes was evaluated by the Confidence in the Evidence from Reviews of Qualitative Research approaches. Results: Ten studies with moderate methodological quality met eligibility criteria and were included finally. Studies were conducted in four countries with 235 participants who were living with multiple chronic conditions. Among the 10 included studies, 37 credible findings were extracted and interpreted into 3 synthesized themes and 12 subthemes: (1) advantages and benefits perceived during e-Health service, (2) multidimensional challenges and negative experience posed by e-Health service, and (3) preferences, suggestions, and expectations for future e-Health improvement. The confidence in the majority of the three final synthesized themes was rated between "low" and "moderate" scales. Conclusions: The findings of this study provide new insights into implementing tailored e-Health care for older adults with multimorbidity. Further research should emphasize on realizing the potential value of e-Health service based on users' needs and perspectives to promote age-friendliness in geriatric practice.

The efficacy of self-monitoring of blood glucose (SMBG) intervention package through a subscription model among type-2 diabetes mellitus in Malaysia: a preliminary trial

BACKGROUND

The aim of this study was to determine the effect of a Self-Monitoring Blood Glucose (SMBG) intervention package through a subscription model in improving HbA1c and health parameters among type-2 diabetes mellitus (T2DM) individuals in Malaysia.

METHODS

This is a quasi-experimental study involving a total number of 111 individuals with T2DM (mean age 57.0 ± 11.7 years, 61% men) who were assigned to intervention (n = 51) and control (n = 60) groups. The intervention group participants were the subscribers of SugO365 program which provided a personalized care service based on self-recorded blood glucose values. Subscribers received a Contour® Plus One glucometer which can connect to Health2Sync mobile app to capture all blood glucose readings as well as physical and virtual follow up with dietitians, nutritionists, and pharmacists for 6 months. Outcome measures were body weight, body mass index (BMI), random blood glucose (RBG), glycated haemoglobin (HbA1c) and health-related quality of life (HRQoL, assessed by SF-36 questionnaire). Data were measured at baseline, third and sixth months.

RESULTS

Repeated-measure analysis of covariance showed significant improvement in HbA1c level (ƞp2 = 0.045, p = 0.008) in the intervention (baseline mean 7.7% ± 1.1%; end mean 7.3% ± 1.3%) as compared to control (baseline mean 7.7% ± 0.9%; end mean 8.1% ± 1.6%) group. Similar trend was observed for Role Emotional domain of the quality of life (ƞp2 = 0.047, p = 0.023) in the intervention (baseline mean 62.8 ± 35.1, end mean 86.3 ± 21.3) compared to control (baseline mean group 70.5 ± 33.8; end mean 78.4 ± 27.3) group. Negative association was found in HbA1c changes using Z-score and Physical Function domain (r = - 0.217, p = 0.022).

CONCLUSION

A 6 months SMBG intervention package through a subscription model improved blood glucose control as measured by HbA1c and health-related quality of life, particularly the Role Emotional domain. Elevated HbA1c levels are correlated with decreased physical function.There is a need to further examine the efficacy of SMBG intervention package using a larger sample and a longer period of intervention and to determine its cost efficacy.

Uncertainty in serious illness: A national interdisciplinary consensus exercise to identify clinical research priorities

BACKGROUND

Serious illness is characterised by uncertainty, particularly in older age groups. Uncertainty may be experienced by patients, family carers, and health professionals about a broad variety of issues. There are many evidence gaps regarding the experience and management of uncertainty.

AIM

We aimed to identify priority research areas concerning uncertainty in serious illness, to ensure that future research better meets the needs of those affected by uncertainty and reduce research inefficiencies.

METHODS

Rapid prioritisation workshop comprising five focus groups to identify research areas, followed by a ranking exercise to prioritise them. Participants were healthcare professionals caring for those with serious illnesses including geriatrics, palliative care, intensive care; researchers; patient/carer representatives, and policymakers. Descriptive analysis of ranking data and qualitative framework analysis of focus group transcripts was undertaken.

RESULTS

Thirty-four participants took part; 67% female, mean age 47 (range 33-67). The highest priority was communication of uncertainty, ranked first by 15 participants (overall ranking score 1.59/3). Subsequent priorities were: 2) How to cope with uncertainty; 3) healthcare professional education/training; 4) Optimising clinical approaches to uncertainty; and 5) exploring in-depth experiences of uncertainty. Research questions regarding optimal management of uncertainty were given higher priority than questions about experiences of uncertainty and its impact.

CONCLUSIONS

These co-produced, clinically-focused research priorities map out key evidence gaps concerning uncertainty in serious illness. Managing uncertainty is the most pressing issue, and researchers should prioritise how to optimally manage uncertainty in order to reduce distress, unlock decision paralysis and improve illness and care experience.

Uncertainty in multimorbidity: a shared experience we should recognise, acknowledge and communicate

Multimorbidity is increasingly common and inevitably results in uncertainties about health, care and the future. Such uncertainties may be experienced by patients, carers and health professionals. Given the ubiquitous presence of uncertainty, all professionals should be prepared to approach and address it in clinical practice. Uncertainty in multimorbidity can rarely be eliminated, and so, must be carefully addressed and communicated; however, there is little evidence on how to approach it. Key areas are: recognising the existence of uncertainty, acknowledging it, and communicating to achieve a shared understanding. Evaluation of what has been discussed, and preparedness to repeat such conversations are also important. Future research should explore optimal communication of uncertainty in multimorbidity.

Domiciliary medication review (ReMeDo): development, reliability and acceptability of a tool for community pharmacists

OBJECTIVES

Polymedication and medication hoarding in patients' homes may increase the risk of drug-related problems (DRPs). Community pharmacists can prevent DRPs through medication reconciliation and review. This study aims to (1) develop a tool for community pharmacists to perform domiciliary medication review (ReMeDo) and (2) assess the interrater and test-retest reliability and acceptability of the tool.

METHODS

The ReMeDo tool was first developed 6 years before this study to perform medication review during pharmacist home visits. A literature review was performed to update the content of the existing tool. Ten pharmacy students participated in the assessment of the interrater and test-retest reliability using three vignettes based on former ReMeDo patients. Test-retest reliability coefficients were calculated for the entire tool and each segment. Global and individual interrater reliability coefficients were also computed. Acceptability was assessed through a satisfaction survey.

KEY FINDINGS

The ReMeDo tool was structured to guide the collection of information before, during and after the pharmacist home visit. The global kappa coefficients for interrater and test-retest reliability were 0.70 (95% confidence interval (CI), 0.67 to 0.73) and 0.71 (95% CI, 0.68 to 0.74), respectively. The test-retest reliability coefficients for each segment and the interrater reliability coefficients for participants were higher than 0.60 (except for one participant), demonstrating a moderate to substantial level of agreement. The tool was deemed acceptable by participants.

CONCLUSIONS

The ReMeDo tool proved to be reliable and acceptable for use by community pharmacists to perform medication review in patients' homes.

Existential uncertainty in health care: A concept analysis

RATIONALE, AIMS AND OBJECTIVES

According to an influential taxonomy of varieties of uncertainty in health care, existential uncertainty is a key aspect of uncertainty for patients. Although the term "existential uncertainty" appears across a number of disciplines in the research literature, its use is diffuse and inconsistent. To date there has not been a systematic attempt to define it. The aim of this study is to generate a theoretically-informed conceptualisation of existential uncertainty within the context of an established taxonomy.

METHOD

Existential uncertainty was subjected to a concept analysis, which drew on existing uses of the term across multiple disciplines as well as insights from uncertainty theory more broadly and from the existential therapy literature to generate a tentative definition of the concept. Antecedents, consequences, and empirical referents of existential uncertainty were also identified. A model case was described as well as a borderline case and a related case in order to illustrate and delineate the concept.

RESULTS

Existential uncertainty is conceptualised as an awareness of the undetermined but finite nature of one's own being-in-the-world, concerned primarily with identity, meaning, and choice. This awareness is fundamental and ineradicable, and manifests at different levels of consciousness.

CONCLUSION

Humans rely on identity, worldview, and a sense of meaning in life as ways of managing the ineradicable uncertainty of our being-in-the-world, and these can be challenged by a serious diagnosis. It is important that medical professionals acknowledge issues around existential uncertainty as well as issues around scientific uncertainty, and recognise when patients might be struggling with these. Further research is required to identify ways of measuring existential uncertainty and to develop appropriate interventions, but it is hoped that this conceptualisation provides a useful first step towards that goal.

Medication-related experiences of patients with polypharmacy: a systematic review of qualitative studies

BACKGROUND

We aimed to synthesise qualitative studies exploring medication-related experiences of polypharmacy among patients with multimorbidity.

METHODS

We systematically searched PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature in February 2020 for primary, peer-reviewed qualitative studies about multimorbid patients' medication-related experiences with polypharmacy, defined as the use of four or more medications. Identified studies were appraised for methodological quality by applying the Critical Appraisal Skills Programme checklist for qualitative research, and data were extracted and synthesised by the meta-aggregation approach.

RESULTS

We included 13 qualitative studies, representing 499 patients with polypharmacy and a wide range of chronic conditions. Overall, most Critical Appraisal Skills Programme items were reported in the studies. We extracted 140 findings, synthesised these into 17 categories, and developed five interrelated syntheses: (1) patients with polypharmacy are a heterogeneous group in terms of needing and appraising medication information; (2) patients are aware of the importance of medication adherence, but it is difficult to achieve; (3) decision-making about medications is complex; (4) multiple relational factors affect communication between patients and physicians, and these factors can prevent patients from disclosing important information; and (5) polypharmacy affects patients' lives and self-perception, and challenges with polypharmacy are not limited to practical issues of medication-taking.

DISCUSSION

Polypharmacy poses many challenges to patients, which have a negative impact on quality of life and adherence. Thus, when dealing with polypharmacy patients, it is crucial that healthcare professionals actively solicit individual patients' perspectives on challenges related to polypharmacy. Based on the reported experiences, we recommend that healthcare professionals upscale communicative efforts and involve patients' social network on an individualised basis to facilitate shared decision-making and treatment adherence in multimorbidpatients with polypharmacy.

An exploration of attitudes and preferences towards medications among healthcare providers and persons with spinal cord injury/dysfunction: a qualitative comparison

PURPOSE

To compare the attitudes and preferences of persons with spinal cord injury/dysfunction (SCI/D) and healthcare providers regarding prescription medications, over-the-counter medications, and natural health products (NHPs).

MATERIALS AND METHODS

A qualitative study involving semi-structured interviews with healthcare providers (n = 32) and persons with SCI/D (n = 19) in Canada. Inductive descriptive and interpretive analyses were conducted using data display matrices and a constant comparative approach.

RESULTS

Participants described differing perceptions of therapeutic benefits based on medication type, with shared attitudes about the therapeutic benefits of prescription medications and differing views about the effectiveness of NHPs. Despite the perceived effectiveness of prescription medications, persons with SCI/D preferred to avoid them due to concerns about side effects, safety, and stigma. Persons with SCI/D were often concerned about the long-term safety of prescription medications, whereas providers focused more on medication-related addictions. Participants discussed stigma relating to prescription medications, NHPs, and medicinal marijuana.

CONCLUSION

Healthcare providers and persons with SCI/D described different attitudes about and preferences for pharmacotherapeutic products, contributing to challenges in optimizing medication management. Strategies to improve medication management include shared decision-making to incorporate patient preferences into care plans and explicit discussions about long-term medication safety. Further, steps are needed to combat the stigma associated with medication use.Implications for rehabilitationFollowing a person-centered approach to shared decision-making, prescribers should initiate explicit conversations about patient medication preferences, short and long-term prescription medication side effects, and alternative treatment options.Regarding prescription medication safety, persons with spinal cord injury/dysfunction focused on the long term impact of medications, while providers focused on medication-related addictions, highlighting a disconnect that should be discussed during initiation, continuation, or discontinuation of a medication.Providers should be mindful of the stigma associated with taking multiple prescription medications, including medicinal marijuana, as well as the stigma associated with over-the-counter medications and natural health products.Providers could benefit from education about spinal cord injury/dysfunction-specific prescription medications and could benefit from increased education about natural health products.

Symptom management strategies used by older community-dwelling people with multimorbidity and a high symptom burden - a qualitative study

BACKGROUND

Older community-dwelling people with multimorbidity are often not only vulnerable, but also suffer from several conditions that could produce a multiplicity of symptoms. This results in a high symptom burden and a reduced health-related quality of life. Even though these individuals often have frequent contact with healthcare providers they are expected to manage both appropriate disease control and symptoms by themselves or with the support of caregivers. The aim of this study was therefore to describe the symptom management strategies used by older community-dwelling people with multimorbidity and a high symptom burden.

METHOD

A qualitative descriptive design using face-to-face interviews with 20 community-dwelling older people with multimorbidity, a high healthcare consumption and a high symptom burden. People ≥75 years, who had been hospitalized ≥3 times during the previous year, ≥ 3 diagnoses in their medical records and lived at home were included. The participants were between 79 and 89 years old. Data were analysed using content analyses.

RESULT

Two main strategy categories were found: active symptom management and passive symptom management. The active strategies include the subcategories; to plan, to distract, to get assistance and to use facilitating techniques. An active strategy meant that participants took matters in their own hands, they could often describe the source of the symptoms and they felt that they had the power to do something to ease their symptoms. A passive symptom management strategy includes the subcategories to give in and to endure. These subcategories often reflected an inability to describe the source of the symptoms as well as the experience of having no alternative other than passively waiting it out.

CONCLUSIONS

These findings show that older people with multimorbidity and a high symptom burden employ various symptom management strategies on daily basis. They had adopted appropriate strategies based on their own experience and knowledge. Healthcare professionals might facilitate daily life for older people with multimorbidity by providing guidance on active management strategies with focus on patient's own experience and preferences.

Spinal cord injury/dysfunction and medication management: a qualitative study exploring the experiences of community-dwelling adults in Ontario, Canada

Purpose: To explore the attitudes, beliefs and experiences pertaining to the management of prescribed and unprescribed medications among community-dwelling adults with spinal cord injury/dysfunction (SCI/D) in Ontario, Canada.Materials and Methods: In-depth semi-structured interviews were conducted by telephone. Each interview was audio-recorded, transcribed verbatim and analyzed using inductive thematic analysis.Results: Of the 19 participants, 11 were male and 8 were female, with an age range from 36 to 76 years; 14 participants had traumatic SCI and 5 had non-traumatic spinal cord dysfunction. All but three participants were taking five or more medications, including prescription medications, over-the-counter medications and natural health products. The three main themes identified were: disruptive nature of medications, fear of negative outcomes and self-management: playing a critical role.Conclusions: Medication management is a complex, multifaceted and non-linear process. Persons with SCI/D described experiences with medication-taking that are not well understood by current medication management frameworks. Thus, it is essential to broaden our lens and situate persons with SCI/D medication-taking experiences within self-management frameworks to allow for a more comprehensive and reflective understanding of their experiences. Based on the findings from this study, recommendations for future research, practice and policy have been suggested.IMPLICATIONS FOR REHABILITATIONPersons with spinal cord injury/dysfunction identified numerous challenges and concerns with medication use post-injury.Educational medication management programs should be implemented post-discharge to improve the state of knowledge around medications (indication, side effects, strategies for taking medications) and how to optimize medication management.In order to optimize experiences and outcomes, there is a need for explicit and ongoing discussions around medication management between persons with spinal cord injury/dysfunction and their healthcare providers.

Older persons' experiences regarding evaluation of their medication treatment-An interview study in Sweden

BACKGROUND

Older persons with polypharmacy are at increased risk of harm from medications, and this issue is a global patient safety challenge. Harm may arise at all stages of medication use and may cause hospital admission, additional resource utilization and lower patient satisfaction. Older persons' participation in their own care may increase patient safety. Their views on the evaluation of their medication treatment, and their own involvement in it, are crucial yet poorly understood.

OBJECTIVES

To identify opportunities to make the medication use process safer, we explored and described older persons' experiences of evaluation of their medication treatment.

DESIGN

Semi-structured interviews were performed with 20 community-dwelling older persons (age 75-91 years) in Sweden. Data were analysed using inductive qualitative content analysis.

RESULTS

These older persons reported having a responsibility to engage in their medication evaluations, although some felt unable to do so or considered themselves unconcerned. Evaluation, in their experience, was facilitated by continuity of care and an invitation to participate. However, some older persons experienced not receiving a comprehensive medication evaluation.

DISCUSSION AND CONCLUSION

Older persons want to be actively involved in their medication evaluations, and this may represent an underutilized resource in the pursuit of patient safety. Their trust in physicians to undertake evaluations on a regular basis, although that does not necessarily occur, may cause harm. Patient safety could benefit from a co-production approach to medication evaluations, with health-care professionals explicitly sharing information with older persons and agreeing on responsibilities related to on-going medication treatment.

A Smart Home System for Information Sharing, Health Assessments, and Medication Self-Management for Older People: Protocol for a Mixed-Methods Study

Background

Older adults often want to stay in a familiar place, such as their home, as they get older. This so-called aging in place, which may involve support from relatives or care professionals, can promote older people’s independence and well-being. The combination of aging and disease, however, can lead to complex medication regimes and difficulties for care providers in correctly assessing the older person's health. In addition, the organization of health care is fragmented, which makes it difficult for health professionals to encourage older people to participate in their own care. It is also a challenge to perform adequate health assessments and to engage in appropriate communication between health care professionals.

Objective

The purpose of this paper is to describe the design for an integrated home-based system that can acquire and compile health-related evidence for guidance and information-sharing among care providers and care receivers in order to support and promote medication self-management among older people.

Methods

The authors used a participatory design approach for this mixed-methods project, which was divided into four phases. Phase I, Conceptualization, consists of the conceptualization of a system to support medication self-management, objective health assessments, and communication between health care professionals. Phase II, Development of a System, consists of building and bringing together the conceptualized systems from Phase I. Phase III, Pilot Study, and Phase IV, Full-Scale Intervention, are described briefly.

Results

Participants in Phase I were people who were involved in some way in the care of older adults and included older adults themselves, relatives of older adults, care professionals, and industrial partners. With input from Phase I participants, we identified two relevant concepts for promoting medication self-management, both of which related to systems that participants believed could provide guidance for the older adults themselves, relatives of older adults, and care professionals. The systems will also encourage information-sharing between care providers and care receivers. The first is the concept of the Intelligent Age-Friendly Home (IAFH), defined as an integrated residential system that evolves to sense, reason, and act in response to individuals’ needs, preferences, and behaviors as these change over time. The second concept is the Medication safety, Objective assessments of health-related behaviors, and Personalized medication reminders (MedOP) system, a system that would be supported by the IAFH, and which consists of three related components: one that assesses health behaviors, another that communicates health data, and a third that promotes medication self-management.

Conclusions

The participants in this project were older adults, relatives of older adults, care professionals, and our industrial partners. With input from the participants, we identified two main concepts that could comprise a system for health assessment, communication, and medication self-management: the IAFH and the MedOP system. These concepts will be tested in this study to determine whether they can facilitate and promote medication self-management among older people.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12447

Inappropriate Use of Medication by Elderly, Polymedicated, or Multipathological Patients with Chronic Diseases

The growth of the aging population leads to the increase of chronic diseases, of the burden of multimorbility, and of the complexity polypharmacy. The prevalence of medication errors rises in patients with polypharmacy in primary care, and this is a major concern to healthcare systems. This study reviews the published literature on the inappropriate use of medicines in order to articulate recommendations on how to reduce it in chronic patients, particularly in those who are elderly, polymedicated, or multipathological. A systematic review of articles published from January 2000 to October 2015 was performed using MEDLINE, EMBASE, PsychInfo, Scopus, The Cochrane Library, and Index Medicus databases. We selected 80 studies in order to analyse the content that addressed the question under consideration. Our literature review found that half of patients know what their prescribed treatment is; that most of elderly people take five or more medications a day; that in elderly, polymedicated people, the probability of a medication error occurring is higher; that new tools have been recently developed to reduce errors; that elderly patients can understand written information but the presentation and format is an important factor; and that a high percentage of patients have remaining doubts after their visit. Thus, strategies based on the evidence should be applied in order to reduce medication errors.

Self-Management of Multiple Chronic Conditions by Community-Dwelling Older Adults: A Concept Analysis

The proportion of the aging population living with multiple chronic conditions (MCC) is increasing. Self-management is valuable in helping individuals manage MCC. The purpose of this study was to conduct a concept analysis of self-management in community-dwelling older adults with MCC using Walker and Avant's method. The review included 30 articles published between 2000 and 2017. The following attributes were identified: (a) using financial resources for chronic disease management, (b) acquiring health- and disease-related education, (c) making use of ongoing social supports, (d) responding positively to health changes, (e) ongoing engagement with the health system, and (f) actively participating in sustained disease management. Self-management is a complex process; the presence of these attributes increases the likelihood that an older adult will be successful in managing the symptoms of MCC.

Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review

BACKGROUND

In order to provide adequate care for the growing group of persons with multi-morbidity, innovative integrated care programmes are appearing. The aims of the current scoping review were to i) identify relevant models and elements of integrated care for multi-morbidity and ii) to subsequently identify which of these models and elements are applied in integrated care programmes for multi-morbidity.

METHODS

A scoping review was conducted in the following scientific databases: Cochrane, Embase, PubMed, PsycInfo, Scopus, Sociological Abstracts, Social Services Abstracts, and Web of Science. A search strategy encompassing a) models, elements and programmes, b) integrated care, and c) multi-morbidity was used to identify both models and elements (aim 1) and implemented programmes of integrated care for multi-morbidity (aim 2). Data extraction was done by two independent reviewers. Besides general information on publications (e.g. publication year, geographical region, study design, and target group), data was extracted on models and elements that publications refer to, as well as which models and elements are applied in recently implemented programmes in the EU and US.

RESULTS

In the review 11,641 articles were identified. After title and abstract screening, 272 articles remained. Full text screening resulted in the inclusion of 92 articles on models and elements, and 50 articles on programmes, of which 16 were unique programmes in the EU (n=11) and US (n=5). Wagner's Chronic Care Model (CCM) and the Guided Care Model (GCM) were most often referred to (CCM n=31; GCM n=6); the majority of the other models found were only referred to once (aim 1). Both the CCM and GCM focus on integrated care in general and do not explicitly focus on multi-morbidity. Identified elements of integrated care were clustered according to the WHO health system building blocks. Most elements pertained to 'service delivery'. Across all components, the five elements referred to most often are person-centred care, holistic or needs assessment, integration and coordination of care services and/or professionals, collaboration, and self-management (aim 1). Most (n=10) of the 16 identified implemented programmes for multi-morbidity referred to the CCM (aim 2). Of all identified programmes, the elements most often included were self-management, comprehensive assessment, interdisciplinary care or collaboration, person-centred care and electronic information system (aim 2).

CONCLUSION

Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.