Methods to Assess Patient Preferences in Old Age Pharmacotherapy - A Systematic Review

Person-centred medicine in the care home setting: development of a complex intervention

BACKGROUND

Person-centred medicine is recommended in the care of older patients. Yet, involvement of care home residents and relatives in medication processes remains limited in routine care. Therefore, we aimed to develop a complex intervention focusing on resident and relative involvement and interprofessional communication to support person-centred medicine in the care home setting.

METHODS

The development took place from October 2021 to March 2022 in the Municipality of Aarhus, Denmark. The study followed the Medical Research Council guidance on complex intervention development using a combination of theoretical, evidence-based, and partnership approaches. The patient involvement tool, the PREparation of Patients for Active Involvement in medication Review (PREPAIR), was included in a preliminary intervention model. Study activities included developing programme theory, engaging stakeholders, and exploring key uncertainties through interviews, co-producing workshops, and testing with end-users to develop the intervention and an implementation strategy. The Consolidated Framework for Implementation Research and the Interprofessional Shared Decision Making Model were used. Data were analysed using a rapid analysis approach.

RESULTS

Before the workshops, six residents and four relatives were interviewed. Based on their feedback, PREPAIR was modified to the PREPAIR care home to fit the care home population. In total, ten persons participated in the co-producing workshops, including health care professionals and municipal managerial and quality improvement staff. The developed intervention prototype was tested for three residents and subsequently refined to the final intervention, including two fixed components (PREPAIR care home and an interprofessional medication communication template) delivered in a flexible three-stage workflow. Additionally, a multi-component implementation strategy was formed. In line with the developed programme theory, the intervention supported health care professionals´ awareness about resident and relative involvement. It provided a structure for involvement, empowered the residents to speak, and brought new insights through dialogue, thereby supporting involvement in medication-related decisions. The final intervention was perceived to be relevant, acceptable, and feasible in the care home setting.

CONCLUSION

Our results indicate that the final intervention may be a viable approach to facilitate person-centred medicine through resident and relative involvement. This will be further explored in a planned feasibility study.

Preferences for deprescribing antihypertensive medications amongst clinicians, carers and people living with dementia: a discrete choice experiment

BACKGROUND

Optimal management of hypertension in people with dementia may involve deprescribing antihypertensives. Understanding differing treatment priorities is important to enable patient-centred care. This study explored preferences for antihypertensive deprescribing amongst people living with dementia, carers and clinicians.

METHODS

Discrete choice experiments (DCEs) are a stated preference survey method, underpinned by economic theory. A DCE was conducted, and respondents completed 12 labelled choice-questions, each presenting a status quo (continuing antihypertensives) and antihypertensive deprescribing option. The questions included six attributes, including pill burden, and event risks for stroke, myocardial infarction, increased blood pressure, cognitive decline, falls.

RESULTS

Overall, 112 respondents (33 carers, 19 people living with dementia, and 60 clinicians) completed the survey. For people with dementia, lower pill burden increased preferences for deprescribing (odds ratio (OR) 1.95, 95% confidence interval (95% CI) 1.08-3.52). Increased stroke risk (for each additional person out of 100 having a stroke) decreased the likelihood of deprescribing for geriatricians (OR 0.71, 95% CI 0.55-0.92) and non-geriatrician clinicians (OR 0.62, 95% CI 0.45-0.86), and carers (OR 0.71, 95% CI 0.58-0.88). Increased myocardial infarction risk decreased preferences for deprescribing for non-geriatricians (OR 0.81, 95% CI 0.69-0.95) and carers (OR 0.84, 95% CI 0.73-0.98). Avoiding cognitive decline increased preferences for deprescribing for geriatricians (OR 1.17, 95% CI 1.03-1.33) and carers (OR 1.27, 95% CI 1.09-1.48). Avoiding falls increased preferences for deprescribing for clinicians (geriatricians (OR 1.20, 95% CI 1.11-1.29); non-geriatricians (OR 1.16, 95% CI 1.07-1.25)). Other attributes did not significantly influence respondent preferences.

CONCLUSIONS

Antihypertensive deprescribing preferences differ amongst people with dementia, carers and clinicians. The study emphasises the importance of shared decision-making within the deprescribing process.

Methods to elicit and evaluate the attainment of patient goals in older adults: A scoping review

OBJECTIVE

This scoping review aimed to identify patient goal elicitation and evaluation methods for older adults, and to investigate which methods can be used in medication optimization interventions for nursing home residents (NHRs).

METHODS

The Arksey and O'Malley framework guided the review. A search was launched in PubMed, Embase, CINAHL, and Web of Science. Reference selection and data extraction were performed by three independent reviewers, followed by team discussions to solve discrepancies. Inductive thematic analysis was applied to synthesize the data. Included papers were reconsidered to identify methods for medication optimization interventions for NHRs.

RESULTS

Ninety-six references, encompassing 38 elicitation and 12 evaluation methods, were included. Elicitation methods differed in structure, content, and patient involvement levels. Qualitative and quantitative methods were found to assess goal attainment. Five elicitation and three evaluation methods were developed for NHRs, but none of these contained a medication-related assessment.

CONCLUSION

A variety of goal elicitation and evaluation methods for older adults was found, but none for medication optimization interventions in NHRs.

PRACTICE IMPLICATIONS

A holistic approach seems important to integrate patient goals into medication optimization interventions, not limiting goal elicitation to a medication-related assessment. Also, the choice of assessor seems important to obtain patient goals.

Development of an Electronic Tool to Assess Patient Preferences in Geriatric Polypharmacy (PolyPref)

PURPOSE

Medical decision-making in older adults with multiple chronic conditions and polypharmacy should include the individual patient's treatment preferences. We developed and pilot-tested an electronic instrument (PolyPref) to elicit patient preferences in geriatric polypharmacy.

PATIENTS AND METHODS

PolyPref follows a two-stage direct approach to preference assessment. Stage 1 generates an individual preselection of relevant health outcomes and medication regimen characteristics, followed by stage 2, in which their importance is assessed using the Q-sort methodology. The feasibility of the instrument was tested in adults aged ≥70 years with ≥2 chronic conditions and regular intake of ≥5 medicines. After the assessment with PolyPref, the patients rated the tool with regard to its comprehensibility and usability and assessed the accuracy of the personal result. Evaluators rated the patients' understanding of the task.

RESULTS

Eighteen short-term health outcomes, 3 long-term health outcomes, and 8 medication regimen characteristics were included in the instrument. The final population for the pilot study comprised 15 inpatients at a clinic for geriatric rehabilitation with a mean age of 80.6 (± 6.0) years, a median score of 28 (range 25-30) points on the Mini-Mental State Examination, and a mean of 11.6 (± 3.6) regularly taken medicines. Feedback by the patients and the evaluators revealed ratings in favor of understanding and comprehensibility of 86.7% to 100%. The majority of the patients stated that their final result summarized the most important aspects of their pharmacotherapy (93.3%) and that its ranking order reflected their personal opinion (100%). Preference assessment took an average of 35 (± 8.5) min, with the instrument being handled by the evaluator in 14 of the 15 participants.

CONCLUSION

Preference assessment with PolyPref was feasible in older adults with multiple chronic conditions and polypharmacy, offering a new strategy for the standardized evaluation of patient priorities in geriatric pharmacotherapy.

Patient values and preferences on polypharmacy and deprescribing: a scoping review

Background Understanding how patient values and preferences towards polypharmacy and deprescribing have been studied is important to gain insight on current knowledge in this area and to identify knowledge gaps. Aim To describe methods and outcomes for studying patient values and preferences towards polypharmacy and deprescribing, and to identify gaps in the existing literature. Method A scoping review was conducted on English-language studies that examined patient preferences and values related to polypharmacy and/or deprescribing among community-dwelling adults. MEDLINE, Embase, PubMed, PsycINFO, EconLit, Social Science Citation Index, Science Citation Index Expanded, International Pharmaceutical Abstracts, and CINAHL/AgeLine were searched. Results Thirty articles were included. Surveys (n = 17, 56.7%), interviews/focus groups (n = 9, 30.0%), and mixed methods (n = 3, 10.0%), were commonly used methods. Patients Attitudes Towards Deprescribing (PATD) was the most common tool used (n = 9, 30.0%). Twelve themes related to attitudes, social pressure, and control of polypharmacy/deprescribing were identified. The most frequently-encountered themes included desire or willingness to reduce medication load and influence of healthcare provider on medication use. Conclusion PATD was commonly used to assess preferences and values towards polypharmacy and limited knowledge on patient-important outcomes were addressed. Future research should focus on shared decision-making and communicating risk versus benefit of medications.

Beliefs about Polypharmacy among Home-Dwelling Older Adults Living with Multiple Chronic Conditions, Informal Caregivers and Healthcare Professionals: A Qualitative Study

Although home-dwelling older adults are frequently assisted with polypharmacy management by their informal caregivers, they can still face medication-related problems. Identifying older adults’ and their informal caregivers’ beliefs about medication is a gateway to understanding and improving medication adherence. This study aimed to analyse beliefs about polypharmacy among home-dwelling older adults with multiple chronic conditions and their informal caregivers, focusing on their daily medication practices. Semi-structured interviews were conducted with 28 older adults, 17 informal caregivers, but also 13 healthcare professionals. Based on an inductive methodological approach, data were analysed using thematic content analysis. Interviews revealed the different attitudes adopted by older adults and their informal caregivers in relation to the treatment information provided by healthcare professionals. A variety of beliefs were identified and linked to medication adherence by examining daily medication practices. Polypharmacy was experienced as a habit but also an obligation, highlighting some of the strategies and negotiations underlying medication use at home. Collecting viewpoints from multiple stakeholders is an innovative way of accessing and analysing beliefs about polypharmacy. Daily medication practices provided information about medication beliefs and may contribute to developing targeted professional interventions that improve medication adherence.

Using Theories of Behavior Change to Develop Interventions for Healthy Aging

Healthy aging requires people to adopt and maintain beneficial behaviors in all stages of the life span. Supporting behavior change, including via the motivation to make and maintain those changes, is therefore important for the promotion of healthy aging. The aim of this overview is to introduce theoretical frameworks from the psychology of motivation that lend themselves to the development of effective interventions promoting behavior change conducive to healthy aging. We discuss theoretical frameworks referring to the determinants, properties, and functionality of goals aimed at behavior change, and consider the implications of the various theories for designing interventions to support healthy aging. We first consider theories that focus on beliefs and attitudes as determinants of goals, then we address theories that focus on the structure and content as important properties of goals, and, finally, we examine theories drawing on conscious and nonconscious processes underlying the functionality of these goals. We will present if-then planning and mental contrasting, as well as nudging and boosting, that is, novel strategies of behavior change that support the creation of scalable interventions for healthy aging across the life span. Against this background, new perspectives emerge for modern, state-of-the-art, and individually tailored interventions with the aim of enhancing older people's healthy living.

Assessing the perspective of well-being of older patients with multiple morbidities by using the LAVA tool - a person-centered approach

Background

Older patients with multiple morbidities are a particularly vulnerable population that is likely to face complex medical decisions at some time in their lives. A patient-centered medical care fosters the inclusion of the patients’ perspectives, priorities, and complaints into clinical decision making.

Methods

This article presents a short and non-normative assessment tool to capture the priorities and problems of older patients. The so-called LAVA (“Life and Vitality Assessment”) tool was developed for practical use in seniors in the general population and for residents in nursing homes in order to gain more knowledge about the patients themselves as well as to facilitate access to the patients. The LAVA tool conceptualizes well-being from the perspectives of older individuals themselves rather than from the perspectives of outside individuals.

Results

The LAVA tool is graphically presented and the assessment is explained in detail. Exemplarily, the outcomes of the assessments with the LAVA of three multimorbid older patients are presented and discussed. In each case, the assessment pointed out resources as well as at least one problem area, rated as very important by the patients themselves.

Conclusions

The LAVA tool is a short, non-normative, and useful approach that encapsulates the perspectives of well-being of multimorbid patients and gives insights into their resources and problem areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02342-3.

Moving the Dial on Heart Failure Patient Adherence Rates

INTRODUCTION

Heart failure remains a substantive contributor to patient morbidity and mortality rates worldwide and represents a significant burden on the healthcare ecosystem. Faced with persistent physical symptoms and debilitating social consequences, patients follow complex treatment regimens and often have difficulty adhering to them.

PURPOSE

In this manuscript, we review factors which contribute to low adherence rates and advance potential single- and multi-factor-based interventions. It is hoped that these observations can lead to improvements in managed care of this vulnerable population of patients.

METHODS

A narrative review of the primary literature was performed on contributing factors with primary focus on the period 2015-2020 using available databases and search engines. Adherence pain points identified were mapped against a series of potential solutions which are presented.

RESULTS

Enhancement of treatment adherence relies on two approaches viz. single-factor and multi-factor solutions. Single factors identified include electronic reminders, enhanced health education, financial incentives, gamification strategies, community drivers, persona-based modeling, and burden relief of poly pharmacy. Multi-factor solutions combine two or more of the seven approaches offering the potential for flexible interventions tailored to the individual.

DISCUSSION AND CONCLUSION

Heart failure patients with poor adherence have increased mortality, hospitalization needs, and healthcare costs. This review highlights current single-factor and multi-factor adherence methods. Against a backdrop of diversity of approaches, multi-factor solutions cast the widest net for positively influencing adherent behaviors. A key enabler lies in the development and leveraging of patient personas in the synthesis of successful intervention methods. Deployable solutions can also be envisioned in clinical trials where adherence tracking represents an essential component.