Help needed in medication self-management for people with visual impairment: case-control study

Assistive products in pharmacy practice to optimize medications use for visually impaired patients: Focus groups to explore community pharmacists' opinions and expectations

Background

Visual impairment can significantly affect a person's ability to take medications safely. Therefore, pharmacists need to ensure safe and effective access to medication information, particularly through the use of assistive products, which are devices that compensate for partial or total vision loss. Although assistive products are used by visually impaired patients for activities of daily living, their use in medication management needs to be more widespread.

Objective

The study aimed to investigate community pharmacists' opinions and excpectations on the use of assistive products in pharmacy practice to optimize and secure medications use for visually impaired patients. The goal is to transfer these assistive products to pharmacy practice.

Methods

Focus groups were conducted with 6 French-speaking community pharmacists via videoconference in Belgium, following the principle of participatory action-research. The participants were recruited voluntarily, and moderator's guides were developed to lead the discussion. The focus groups were recorded, transcribed verbatim, and analyzed in a double-blind fashion using thematic analysis. The data were organized by NVivo software.

Results

Four themes were identified: easy-to-use assistive products according to pharmacists, usefulness of assistive products in pharmacy practice, barriers to the use of assistive products, and potential solutions. According to community pharmacists, certain assistive products were deemed easy-to-use and transferable to pharmacy practice.

Conclusions

This qualitative study demonstrates the transferability of assistive products to pharmacy practice for visually impaired patients in medications use. The study taken into account the patient's profile and the multidisciplinary approach, which community pharmacists consider essential.

Sustained release of 3D printed bupropion hydrochloride tablets bearing Braille imprints for the visually impaired

3D printing has been introduced as a novel approach for the design of personalized dosage forms and support patient groups with special needs that require additional assistance for enhanced medication adherence. In this study liquid crystal display (LCD) is introduced for the development of sustained release bupropion.HCl printed tablets. The optimization of printing hydrogel inks was combined with the display of Braille patterns on the tablet surface for blind or visually impaired patients. Due to the high printing accuracy, the Braille patterns could be verified by blind patients and provide the required information. Further characterization revealed the presence of BUP in amorphous state within the photopolymerized resins. The selection of poly(ethylene glycol) (PEG)-diacrylate (PEGDA) of different molecular weights and the presence of surfactants or solubilizers disrupted the resin photopolymerization, thus controlling the BUP dissolution rates. A small batch scale-up study demonstrated the capacity of LCD to print rapidly a notable number of tablets within 24 min.

Patient activation in adults with visual impairment: a study of related factors

This study aims to analyze variables related to patient activation in 78 individuals with visual impairment. The Patient Activation Measure (PAM) scores of participants showed no differences between males and females. It was found that the individuals living in urban areas, and participants with higher income and education levels had higher PAM scores. Still, the difference between the groups was statistically insignificant (p > 0.05). The PAM scores of the visually impaired individuals reflect taking action level of activation (66.51 ± 18.14-PAM level 3). There was a moderately significant relationship between PAM scores and visually impaired individuals' self-management, self-efficacy, healthy life awareness, social relations, and environment (p < 0.001). We found that the variables included in the regression model (marital status, self-management, self-efficacy, healthy life awareness, social relations, and environment) explained 72.2% of the PAM score. Individuals with visual impairment can be given training on self-management, self-efficacy, healthy life awareness, and quality of life associated with social relations and environment to develop positive health behaviors.

Pharmaceutical care for visually impaired patients: a qualitative study of community pharmacists' needs and professional experience

BACKGROUND

Visual impairment is a disability that can have a significant impact on the ability to take medication safely. As a result, pharmacists must adjust their practice to provide targeted and adapted support for this type of patient.

AIM

The aims of the present study were (1) to illustrate the usual clinical practice of community pharmacists to support the optimisation of medication use in visually impaired patients, and (2) to identify solutions to improve pharmaceutical care for visually impaired patients.

METHOD

Semi-structured interviews with 18 French-speaking community pharmacists were conducted via videoconference in Belgium. Participants were recruited on a voluntary basis and through a snowball method. An interview guide was developed based on literature review. Interviews were carried out until theoretical saturation of the data, recorded, transcribed verbatim and analysed using thematic analysis. Data were organised by NVivo Software.

RESULTS

Four themes were identified: community pharmacists' training, identification of visually impaired patients by the pharmacist, communication with visually impaired patients and their proxies, and provision of appropriate pharmaceutical care. Participants stated that they had not received any training regarding visual impairment. They described that they did not always know how to recognise visually impaired patients and that communication was often difficult.

CONCLUSION

This qualitative study has highlighted a lack of knowledge and skills among community pharmacists regarding visual impairment. One possible solution could be to develop recommendations and tools to improve the care of these patients.

Tools to measure barriers to medication management capacity in older adults: a scoping review

BACKGROUND

Medication management capacity is a crucial component of medication adherence, particularly among older adults. Various factors, including physical abilities, cognitive functions, sensory capabilities, motivational, and environmental factors, influence older adults' ability to manage medications. It is, therefore, crucial to identify appropriate tools that allow clinicians to determine which factors may impact medication management capacity and, consequently, nonadherence to medications.

PURPOSE

1)To identify tools that measure physical, cognitive, sensory (vision, hearing, touch), motivational, and environmental barriers to medication self-management in older adults, and 2) to understand the extent to which these tools assess various barriers.

METHODS

The scoping review was conducted using Arksey and O'Malley's scoping review framework and the PRISMA Extension for Scoping Reviews checklist. In June 2022, the relevant literature was identified by searching PubMed (MEDLINE), Ovid Embase, Ovid IPA, EBSCOhost CINAHL, APA PsycINFO, and Scopus.

RESULTS AND DISCUSSION

In total, 7235 studies were identified. Following the removal of duplicates, 4607 articles were screened by title and abstract, of which 4253 did not meet the inclusion criteria. Three reviewers reviewed the full texts of the remaining 354 articles; among them, 41 articles, 4 theses and 1 conference abstract met the inclusion criteria. From the included studies, 44 tools were identified that measured a combination of physical, cognitive, sensory, motivational, and environmental barriers (n=19) or only cognition (n=13), vision (n=5), environmental factors (n=3), auditory (n=1), and motivational factors (n=1). The review also examined the psychometric properties of the identified tools and found that most of them had reported validity and reliability data. Several tools have demonstrated promise in assessing a combination of barriers with validity and reliability. These tools include the Self-Medication Assessment Tool (SMAT), ManageMed Screening (MMS), Self-Medication Risk Assessment Tool (RAT), HOME-Rx revised, and Medication Management Ability Assessment (MMAA).

CONCLUSION

This scoping review identified 44 validated tools to measure various challenges that older adults encounter with medication management. However, no tool measures all five barriers (physical, cognitive, sensory, motivational, and environmental) to medication-taking at home. Therefore, utilizing a combination of tools would be most appropriate to measure these different aspects comprehensively. Further research is needed to develop a new comprehensive tool that simultaneously measures various barriers to medication self-management.

Novel tactile bottle neck adaptor facilitates eye drop adherence in visually impaired patients

PURPOSE

To test the use of Ring-IT, a novel 3D tactile bottle neck adaptor in topical eye drop adherence in visually impaired patients.

METHODS

Bottle neck ring adaptors with either one, two or three protrusions with cube or sphere endings were designed. In phase 1, low vision was simulated in healthy subjects (n=20) with a 20/200 vision simulator; while in phase 2, visually impaired patients (n=26; 20/70 or worse) were recruited. Subjects were randomised to six combinations of varying protrusions and shapes on medication bottles and asked to identify these traits at different presentations. Responses and time to identify were recorded.

RESULTS

Phase 1: 98.3% of subjects correctly identified the number of protrusions. Mean time to identify was 4.5±6.1 s. Identification success for cube and sphere end pieces were 91.7% and 73.3%, with average time for identification of 9.9±7.6 and 10.9±9.0 s. In phase 2, 92.3% of subjects correctly identified the number of protrusions. Mean time to identify was 6.0±3.0 s. Identification success for cube and sphere end pieces were 78.2% and 74.4%; with average time for identification of 7.5±4.8 and 8.5±5.6 s, respectively.

CONCLUSIONS

Ring-IT was identified with accuracy and speed by both low vision simulated subjects, and by patients with true limited visual capabilities. These tactile bottle neck ring adaptors can be used as an assistive low vision aid device and may increase eye drop regimen adherence in visually impaired patients.

Assistive technologies and strategies to support the medication management of individuals with hearing and/or visual impairment: A scoping review

BACKGROUND

Individuals with sensory impairment (visual and/or hearing) experience health inequalities and increased the risk of medication-related iatrogenic disease compared with the general population. Assistive technologies and tailored strategies could support medication management for individuals with sensory impairment to reduce harm and increase the likelihood of therapeutic benefit.

OBJECTIVE

This scoping review identified assistive technologies and strategies to support medication management of/for people with hearing and/or visual impairment.

METHODS

Standard scoping review methodology was used to identify studies that evaluated technologies or strategies designed to support people with sensory impairment with independent medicine management. Electronic databases were searched (MEDLINE, Embase, CINAHL, ACM, Cochrane) from inception to 18/07/22. Independent duplicate screening, selection, and data extraction were undertaken.

RESULTS

Of 1231 publications identified, 18 were included, reporting 17 studies, 16 of which evaluated technologies to assist people with visual impairment and one study to assist people with hearing impairment. The range of technologies and devices included: applications for android phones (n = 6); eyedrop-assistance devices (n = 5); audio-prescription labelling/reading systems (n = 2); touch-to-speech devices (n = 2); continuous glucose monitoring system (n = 1); magnifying technology (n = 1). Ten studies tested early-stage prototypes. Most participants could operate the technologies effectively and deemed them to be useful.

CONCLUSIONS

Despite the increasing number of medicine-related assistive technologies, there has been limited empirical evaluation of their effectiveness for supporting individuals with sensory impairment. Prototypes appear to be useful for people with visual or hearing impairment, however wider 'real-life' testing is needed to confirm the benefits of these technologies.

An Exploratory Mixed Methods Study of Diabetes self-management in Blind Americans

This study used mixed methods to investigate the experiences of 33 participants who are blind (PWB) and have diabetes in managing their diabetes, support (or lack thereof) from their health care providers, and diabetes distress as PWB. Participants most frequently reported barriers to check blood glucose (55%), maintaining a healthy diet (45%), and distress due to their intersectional status of having blindness and diabetes. Those who mentioned intersectional distress of managing diabetes as a PWB tended to be Braille illiterate and less likely to use mobility tools that are symbolic of blindness (e.g., white cane, guide dog). These results illuminate heterogenous characteristics of PWB with diabetes, an understudied population of public health significance, to be considered when setting priorities for diabetes self-management support and health care coverage policy.

Accuracy and User Satisfaction for an Audible Prescription Reader Among Adults With Low Vision and Blindness

Introduction: Research is needed to support accuracy and safe self-management of prescriptions among individuals living with low vision or blindness. This study evaluated user accuracy & satisfaction with the ScripTalk® device, an audible prescription reader, among participants with low vision and blindness. Methods: This mixed methods study utilized snowball and convenience sampling through low vision support groups in Indiana. Researchers trained 23 participants (69.6% female, 30.4% male, M age = 64.04, SD = 14.7 years) to use the ScripTalk® device for reading three empty prescription bottles, equipped with radio-frequency ID labels. Accuracy represented correct responses to 12 questions about the labels’ content. The QUEST 2.0's Device Subscale (intraclass correlation coefficient = 0.82) evaluated user satisfaction with the device. Participants answered six qualitative questions about their perceptions of the device. Results: Statistical analysis indicated highest frequencies of satisfaction occurred for Ease in Adjusting (100%), Comfort (100%), Ease of Use (95.6%), and the Weight (95.6%) of the device. Spearman rank order correlation coefficient tests revealed inverse relationships between participants’ accuracy rates and their satisfaction with the device's durability (rho = −0.690, p < .001) and safety & security (rho = −0.834, p < .001). Participants perceived the device as easy to use, adjustable, comfortable, and lightweight for reading prescription labels. However, the auditory quality posed challenges to identify unfamiliar prescription names. Health care professionals may need to provide additional training and practice opportunities with audible prescription readers to support consumers with low vision or blindness, particularly when new medications are prescribed.

Designing Hospital and Pharmacy Services for Visually Impaired Persons in Bangkok, Thailand

This cross-sectional study aimed to develop a hospital and pharmacy services model from the patient's perspective, identifying the gap and domain for services improvement. The study was conducted on 140 persons aged ≥ 18 years with visual impairment or low vision in Bangkok, Thailand. The results demonstrated that patients' perceived services were not inclusively designed for visually impaired persons. The domains with the highest gap analysis score were navigation systems, followed by a detailed explanation, such as dose mismanagement, observed medication expiration dates, and pharmacy self-identification. The patient-centered service model empowered visually impaired persons to achieve medication outcomes and safety.

Patient-Reported Measures of the Effects of Vision Impairments and Low Vision Rehabilitation on Functioning in Daily Life

The quantification of vision impairments dates to the mid-nineteenth century with standardization of visual acuity and visual field measures in the eye clinic. Attempts to quantify the impact of vision impairments on patients' lives did not receive clinical attention until the close of the twentieth century. Although formal psychometric theories and measurement instruments were well developed and commonplace in educational testing, as well as in various areas in psychology and rehabilitation medicine, the late start applying them to clinical vision research created a vacuum that invited poorly developed and poorly functioning instruments and analytic methods. Although this research is still burdened with legacy instruments, mandates by regulatory agencies to include the patients' perspectives and preferences in the evaluation of clinical outcomes have stimulated the development and validation of self-report instruments grounded in modern psychometric theory and methods. Here I review the progress and accomplishments of applying modern psychometrics to clinical vision research. Expected final online publication date for the Annual Review of Vision Science, Volume 8 is September 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Visual Impairment and Self-Efficacy in Diabetes Management

PURPOSE

The purpose of this study is to examine the relationship between visual impairment and diabetes management self-efficacy.

METHODS

The present study utilized pooled cross-sectional data (2008-2018) from the Medical Expenditure Panel Survey Household Component and Diabetes Care Survey. Binary and generalized ordinal logit regression models were used to compare diabetes management self-efficacy between patients with and without visual impairments.

RESULTS

Compared to their non-visually impaired counterparts, visually impaired persons had a lower odds of reporting high diabetes management self-efficacy. Similarly, visually impaired adults with diabetes have a significantly lower odds of being very confident in their ability to manage their conditions compared with adults who reported being not confident, somewhat confident, or confident. Several control factors, including self-behaviors and receipt of diabetes self-management education (DSME), were also associated with diabetes management self-efficacy.

CONCLUSIONS

Visually impaired persons experience significant disparities in diabetes management self-efficacy. Given the relationship between self-efficacy and diabetes-related outcomes, it is crucial that DSME be tailored to effectively meet the individual needs of this population. Future research should explore the relationship between DSME and self-care behaviors, self-efficacy, and diabetes-related outcomes in visually impaired persons.

Empowering the visually impaired by customized Braille prescription and thus reducing medication errors

Purpose:

To assess the use of routine Braille prescription in reducing medication errors in visually impaired patients.

Methods:

This observational, questionnaire-based study was conducted in 100 blind or visually impaired patients who were Braille literate (aged ≥18 years). We initiated our Braille prescription from January 2017 to March 2018. The questionnaire consisted of 8 items that captured patient details on the medication management process in addition to a face-to-face interview with them. It was administered twice to each patient at baseline and at the end. Braille prescription included details regarding all medicines, their dosages, instructions, expiry dates, and major side effects. The prescription was developed easily and quickly with an average turnaround time of 1 hour.

Results:

It was seen that most of the study patients aged between 30-40 years (n = 80) and majority were men (78%). At baseline, 73% of our respondents faced challenges when self-administering medications as compared to 17.5% at endline. After using Braille prescription, only 5% reported of taking a wrong dosage compared to 46.2% at baseline. Patients missing a dosage significantly reduced after using routine Braille prescription (43.7% vs. 7.5% respectively, P < 0.05).

Conclusion:

Our study successfully has rolled out Braille prescription as an efficacious method in addressing the key issues to medication safety with the visually impaired.

<p>Decreasing Avoidable Vision Loss: Identifying Antecedents of Adherence</p>

Adherence to medication treatment protocols and active participation by individuals in their medical care are important for all patients, but especially for those with chronic conditions such as vision loss. Adherence is crucial for decreasing avoidable vision loss. Failure to take medications as prescribed and keep scheduled appointments reduces treatment effectiveness, increases complications and results in poorer outcomes. Reasons for nonadherence vary by diagnosis and include not understanding the importance of adherence, low health literacy, lack of adequate self-efficacy, low level of activation and behavioral issues including depression. Patients may lack information about their condition and its prognosis, available treatment alternatives, and other essential information such as how to monitor their eye condition, what to do if vision deteriorates and how to get needed community-based help. Each of these factors impedes patients’ ability to engage with their physician and participate in their own care. The ability of individuals with vision loss to actively and effectively manage their health care, ie, activation, has been understudied. When patients are involved with their own care, their care experience, and most importantly, their outcomes, are improved. Identifying antecedents of adherence may help provide disease- and patient-specific pathways to reduce avoidable vision loss.

Patient-Centric Medicine Design: Key Characteristics of Oral Solid Dosage Forms that Improve Adherence and Acceptance in Older People

Older people represent a very heterogeneous patient population and are the major user group of medication. Age-related changes mean that this population can encounter barriers towards taking medicines orally. The aim of this study was to investigate the characteristics of oral solid dosage forms that contribute to an age appropriate dosage design, with an aim to improve overall medication adherence and acceptance in older people. Fifty-two semistructured interviews were conducted with older people, informal (family) carers, and health and social care professionals. Formulation characteristics impacted three stages of the medication taking process: (1) medication identification and memorability, (2) medication handling and (3) swallowability. Small round tablets (≤7 mm) are least accepted amongst older people and their carers and had a negative impact on all stages. The use of bright, two-coloured preparations and interesting shapes improves identification and further aids memorability of indications and the timing of tablets. Palatability, while useful to enhance swallowability, also has an impact on the visual appeal and memorability of medication. Environmental, patient, medication and disease characteristics also determine preferences for formulation. Developing an age appropriate dosage design for older people, therefore, requires a holistic, patient-centric approach to improve adherence and acceptance.

Kidney transplant outcomes in recipients with visual, hearing, physical and walking impairments: a prospective cohort study

BACKGROUND

Disability in general has been associated with poor outcomes in kidney transplant (KT) recipients. However, disability can be derived from various components, specifically visual, hearing, physical and walking impairments. Different impairments may compromise the patient through different mechanisms and might impact different aspects of KT outcomes.

METHODS

In our prospective cohort study (June 2013-June 2017), 465 recipients reported hearing, visual, physical and walking impairments before KT. We used hybrid registry-augmented Cox regression, adjusting for confounders using the US KT population (Scientific Registry of Transplant Recipients, N = 66 891), to assess the independent association between impairments and post-KT outcomes [death-censored graft failure (DCGF) and mortality].

RESULTS

In our cohort of 465 recipients, 31.6% reported one or more impairments (hearing 9.3%, visual 16.6%, physical 9.1%, walking 12.1%). Visual impairment was associated with a 3.36-fold [95% confidence interval (CI) 1.17-9.65] higher DCGF risk, however, hearing [2.77 (95% CI 0.78-9.82)], physical [0.67 (95% CI 0.08-3.35)] and walking [0.50 (95% CI 0.06-3.89)] impairments were not. Walking impairment was associated with a 3.13-fold (95% CI 1.32-7.48) higher mortality risk, however, visual [1.20 (95% CI 0.48-2.98)], hearing [1.01 (95% CI 0.29-3.47)] and physical [1.16 (95% CI 0.34-3.94)] impairments were not.

CONCLUSIONS

Impairments are common among KT recipients, yet only visual impairment and walking impairment are associated with adverse post-KT outcomes. Referring nephrologists and KT centers should identify recipients with visual and walking impairments who might benefit from targeted interventions pre-KT, additional supportive care and close post-KT monitoring.

Activation in individuals with vision loss

Vision loss and blindness are significant causes of disability. Patient activation has been previously unstudied in individuals with vision loss. Among our 146 participants, visual acuities for 38.3 percent were better than 20/70, 43.2 percent had acuities between 20/70 and 20/400, and 12.3 percent had acuities of <20/400. Participants with lower Patient Activation Measure scores missed more clinic visits (p = 0.017); those participants with caregivers also had lower PAM scores (p = 0.002). Targeting interventions to address patient activation in patients with vision loss may increase patient involvement in their care, increase treatment protocol adherence, and improve outcomes.

The effect of age and vision on functional measures of medication management, across different prescription drug container shapes in persons with visual impairment

The relative effect of age and vision on medication management tasks (time and accuracy of entering the pharmacy phone number and interpreting dose) across four different prescription drug container shapes is examined. A mixed measures three-factor design was employed, with within-subject control. The repeated-measure independent variable of interest was container shape (four conditions), and the two between-subject independent variables were vision and age. Older age and decreased vision were found to be generally negatively associated with time and accuracy of entering the phone number and correct interpretation of dose. Container shape modified the effect of vision and age on the medication management tasks. Interactions between independent variables of age, vision, and container shape make it difficult to recommend one container shape for all participants. The results presented give credence for further examination of packing for label readability and other aspects of medication management, given the ease at which packaging can be modified.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

3D Printed Tablets (Printlets) with Braille and Moon Patterns for Visually Impaired Patients

Visual impairment and blindness affects 285 million people worldwide, resulting in a high public health burden. This study reports, for the first time, the use of three-dimensional (3D) printing to create orally disintegrating printlets (ODPs) suited for patients with visual impairment. Printlets were designed with Braille and Moon patterns on their surface, enabling patients to identify medications when taken out of their original packaging. Printlets with different shapes were fabricated to offer additional information, such as the medication indication or its dosing regimen. Despite the presence of the patterns, the printlets retained their original mechanical properties and dissolution characteristics, wherein all the printlets disintegrated within ~5 s, avoiding the need for water and facilitating self-administration of medications. Moreover, the readability of the printlets was verified by a blind person. Overall, this novel and practical approach should reduce medication errors and improve medication adherence in patients with visual impairment.

A qualitative exploration of the experiences of community dwelling older adults with sensory impairment/s receiving polypharmacy on their pharmaceutical care journey

BACKGROUND

Most developed countries have increasing numbers of community dwelling older people with both multi-morbidity and sensory impairment that includes visual, hearing or dual impairment. Older people with sensory impairment are more likely to have chronic health conditions and to be in receipt of polypharmacy (>4 medicines). It is important to understand their experience of pharmaceutical care provision to facilitate a safe, appropriate and person centred approach.

AIM

this study explored the pharmaceutical care experiences and perspectives of older people with sensory impairment receiving polypharmacy.

DESIGN AND SETTING

exploratory qualitative study with semi-structured telephone or face-to-face interviews with community dwelling older adults with sensory impairment receiving polypharmacy in Scotland in 2016.

METHODS

in total, 23 interviews were conducted with older people from seven of the 14 Scottish Health Board areas.

SUBJECTS

over half the participants (n = 12) had dual sensory impairment, six had visual impairment and five had hearing impairment.

RESULTS

three overarching themes were identified reflecting different stages of participants' pharmaceutical care journey: ordering and collection of prescriptions; medicine storage; and administration. At each stage of their journey, participants identified barriers and facilitators associated with their pharmaceutical care.

CONCLUSIONS

this is the first comprehensive, in-depth exploration of the pharmaceutical care journey needs of older people with sensory impairment. As the number of community dwelling older people with sensory impairment and polypharmacy increases there is a requirement to identify challenges experienced by this population and offer solutions for safe and effective pharmaceutical care provision.

A systematic review of pharmacists' interventions to support medicines optimisation in patients with visual impairment

Background People with visual impairment often report poorer health and encounter many challenges when using medicines. Pharmacists can play a significant role in optimising medicines use for these patients. However, little is known about pharmacists' current practices when providing services to this population nor the impact of such services, if any, on medicines optimisation-related outcomes. Aim of the review This systematic review aims to identify the types, and assess the effectiveness of, interventions provided by pharmacists on medicines optimisation-related outcomes. Method Systematic searches of the following electronic databases were carried out from date of inception to March 2018: Cochrane Library; MEDLINE; EMBASE; International Pharmaceutical Abstracts; Scopus; and Cumulative Index to Nursing and Allied Health Literature. Several trial registries and grey literature resources were also searched. Any randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies, or interrupted time series analyses reporting on interventions provided by pharmacists to adult visually impaired patients and/or their caregivers in order to improve medicines optimisation-related outcomes of medicine safety, adherence, patient satisfaction, shared decision making, or quality of life were included. Results A total of 1877 titles/abstracts were screened, and 27 full text articles were assessed for eligibility. On examination of full texts, no studies met the inclusion criteria for this review. Conclusion This review highlights the need for future research that would be vital for promoting the safe and effective use of medicines and the delivery of pharmaceutical care services to people with visual impairment.

Beliefs and Adherence Associated With Oral and Infusion Chelation Therapies in Jordanian Children and Adolescents With Thalassemia Major: A Comparative Study

The researcher assessed the beliefs and adherence associated with both oral deferasirox and deferoxamine infusion chelation therapies among Jordanian children with thalassemia major, and compared the adherence levels between the recipients of each. In this descriptive cross-sectional study, 120 participants were recruited from 3 major thalassemia treatment clinics in Jordan using convenience sampling. Data were collected through questionnaires on demographic- and disease-related information, the beliefs about medicines, and a medication adherence report scale. Most participants showed a high adherence to deferoxamine infusion and oral deferasirox (87.20% and 89.08%, respectively), and believed in the necessity of deferoxamine for maintaining health (89.34%). However, 41.32% of the participants had strong concerns about deferoxamine use. While most participants believed in the need for oral deferasirox (89.84%), about 40.7% had strong concerns about its use. An independent samples t test showed no statistically significant difference in the adherence between the oral deferasirox and infusion deferoxamine recipients (t=1.048, DF=118, P=0.075). Jordanian children with thalassemia have positive beliefs and adherence to both oral and infusion chelation therapies. Health care providers should pay attention to patients' beliefs and discuss the major concerns pertaining to iron chelation therapy with them to enhance the continuity of adherence therapy.

Visual acuity, literacy, and unintentional misuse of nonprescription medications

PURPOSE

Results of a study of associations between visual acuity and the risk of misuse of nonprescription acetaminophen products in a sample of community-dwelling adults are reported.

METHODS

In a study involving English-speaking adults at 4 primary care clinics, the potential for misuse of nonprescription acetaminophen products was measured via a functional assessment of product self-dosing and by testing patients' understanding of the risks of concomitant use (i.e., taking 2 products at the same time when contraindicated). Vision was assessed using the Rosenbaum vision chart and dichotomized as normal (visual acuity of 20/20-20/25) or low (acuity of 20/30-20/100). Bivariable and multivariable analyses were performed to determine the impact of visual acuity on medication misuse outcomes.

RESULTS

Among the study participants (n = 500), 39% had limited literacy, and 54% were categorized as having low vision. After controlling for age, race, and prior acetaminophen use, low vision was independently associated with an increased risk of self-dosing errors (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.25-2.21; p < 0.001) and misunderstanding of concomitant-use risks (OR, 1.41; 95% CI, 1.00-2.00; p = 0.05). Limited literacy was an independent risk factor for incorrect dosing (OR, 1.71; 95% CI, 1.25-2.35; p = 0.001) and unawareness of concomitant use instructions (OR, 4.14; 95% CI, 2.80-6.12; p < 0.001).

CONCLUSION

Misunderstanding of nonprescription acetaminophen product information was common among study participants and independently associated with both impaired visual acuity and low literacy skills.

Healthcare use among persons with visual impairment: Difference-in-difference estimations

BACKGROUND

Studies on healthcare service use among persons with visual impairments in countries with different healthcare systems are needed for drawing global inferences.

OBJECTIVE

The goal was to assess the impact of visual impairment on healthcare service use.

METHODS

A retrospective cohort study on health insurance claims data from the National Health Insurance System (NHIS) was conducted. All data from 2002 to 2013 for 2206 and 8824 persons with and without visual impairments, respectively, were extracted and aggregated monthly, generating a total of 162,876 and 568,459 person-month observations, respectively. The dependent variable was total expenditures. Difference-in-difference estimations based on a multivariate log-normal random-effect regression were employed.

RESULTS

Persons with visual impairments spent 5.7% and 6.8% more on total healthcare expenditures per month and outpatient healthcare expenditures, respectively, than those without visual impairments, after adjusting for pre-impairment differences. Further results revealed an upward trend in expenditures, particularly among those with visual impairments; this increase was the highest during the year prior impairment (approximately 32% and 21% more for total and outpatient services, respectively, compared with baseline). Inpatient healthcare expenditures showed a similar increase (by approximately 26%) during the year prior impairment compared with baseline; however, the magnitude dropped to approximately 14% and 6% during the 1st and 2nd years of impairment, respectively. Conversely, the annual pattern of expenditure increase was parallel over time for persons without visual impairments, regardless of service.

CONCLUSION

Our findings suggest a need for health management and effective care use, particularly the year prior to visual impairment onset.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

'Has she seen me?': a multiple methods study of the pharmaceutical care needs of older people with sensory impairment in Scotland

OBJECTIVES

To explore the pharmaceutical care needs of, and service provision to, older people with sensory impairment (visual, hearing and dual impairment) on prescribed polypharmacy (≥4 medicines) in Scotland.

DESIGN

Interviews were conducted with older people with sensory impairment and community pharmacy personnel, which informed the content of a subsequent national cross-sectional survey of community pharmacists.

SETTING

Scotland, 2015-2016.

PARTICIPANTS

Older people with sensory impairment and community pharmacy personnel.

RESULTS

Interviews were completed with 23 older people with sensory impairment (dual impairment n=13, visual or hearing impairment n=5 of each) and 30 community pharmacy personnel from eight of 14 Scottish Health Boards. A total of 171 survey responses were received.Older people reported that they did not always disclose their sensory impairment to pharmacy personnel. They also reported that medicines were difficult to identify particularly when their name, shape or colour changed. Pharmacy personnel relied on visible cues such as white canes or guide dogs to identify visual impairment and suggested that hearing loss was less visible and more difficult to identify. Many assistive aids in support of medicine management, such as dosette boxes, seemed inadequate for complex medication regimens. Few community pharmacy personnel reported receiving training in the care of people with sensory impairment.

CONCLUSIONS

This is the first comprehensive, multistakeholder, in-depth exploration of the pharmaceutical care needs of older people with sensory impairment. Strategies are needed to enable people with sensory impairment to disclose their impairment to pharmacy personnel (and other healthcare providers). Community pharmacy personnel require training to deliver person-centred pharmaceutical care for older people with sensory impairment particularly regarding communication with individuals in this vulnerable population.

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

OBJECTIVES

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

METHODS

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

KEY FINDINGS

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

CONCLUSIONS

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

Mild Visual Impairment and Its Impact on Self-Care Among Older Adults

OBJECTIVE

To determine the prevalence of mild visual impairment (MVI) among urban older adults in primary care settings, and ascertain whether MVI was a risk factor for inadequate performance on self-care health tasks.

METHOD

We used data from a cohort of 900 older adults recruited from primary care clinics. Self-management skills were assessed using the Comprehensive Health Activities Scale, and vision with corrective lenses was assessed with the Snellen. We modeled visual acuity predicting health task performance with linear regression.

RESULTS

Normal vision was associated with better overall health task performance ( p = .004). Individuals with normal vision were more likely to recall health information conveyed via multimedia ( p = .02) and during a spoken encounter ( p = .04), and were more accurate in dosing multi-drug regimens ( p = .05).

DISCUSSION

MVI may challenge the performance of self-care behaviors. Health care systems and clinicians should consider even subtle detriments in visual acuity when designing health information, materials, and devices.

Low Vision Rehabilitation, Age-Related Vision Loss, and Risk: A Critical Interpretive Synthesis

PURPOSE

Given the centrality of risk in geriatric rehabilitation, it is critically important to attend to how conceptualizations of risk shape research, policies, and rehabilitation practices. This paper presents a critical interpretive synthesis (CIS) of literature addressing risk and low vision rehabilitation for older adults with age-related vision loss (ARVL) to identify key guiding assumptions regarding risk and discuss implications for what gets attended to, and not attended to, within research and rehabilitation.

DESIGN AND METHODS

This CIS combined guidelines proposed by Dixon-Woods and colleagues (2006-Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Medical Research Methodology, 6, 35) and Alvesson and Sandberg (2011-Generating research questions through problematization. Academy of Management Review, 36, 247-271; 2013-Constructing research questions: Doing interesting research. London: Sage). The iterative review process involved 3 steps: literature search and selection, data extraction, and syntheses to identify boundary assumptions. The dataset included 83 research and practice description articles.

RESULTS

Older adults with ARVL were constructed as "at risk" for various adverse outcomes, particularly dependency and self-harm, and as posing risks to others. An epidemiological approach to risk based in assumptions aligned with a technico-scientific perspective was dominant, with risk conceptualized as an embodied, individual-level phenomenon that is to be determined and managed through objective screening and expert monitoring.

IMPLICATIONS

Key concerns include a lack of: attention to the tensions created when rehabilitation research and practice attempt to promote independence while simultaneously reducing risk, incorporation of aging adults' perspectives on risk, and analysis of environmental factors that shape risks. Research that starts by valuing older adults' experiences and attends to context can inform rehabilitation practices that support health-promoting, risk-taking, and facilitate collaborative approaches to risk management.

Identifying solutions to medication adherence in the visually impaired elderly

Adults older than 65 years of age with vision impairment are more likely to have difficulty managing medications compared with people having normal vision. This patient population has difficulty reading medication information and may take the wrong medication or incorrect doses of medication, resulting in serious consequences, including overdose or inadequate treatment of health problems. Visually impaired patients report increased anxiety related to medication management and must rely on others to obtain necessary drug information. Pharmacists have a unique opportunity to pursue accurate medication adherence in this special population. This article reviews literature illustrating how severe medication mismanagement can occur in the visually impaired elderly and presents resources and solutions for pharmacists to take a larger role in adherence management in this population.

ClereMed: Lessons Learned From a Pilot Study of a Mobile Screening Tool to Identify and Support Adults Who Have Difficulty With Medication Labels

BACKGROUND

In order to take medications safely and effectively, individuals need to be able to see, read, and understand the medication labels. However, one-half of medication labels are currently misunderstood, often because of low literacy, low vision, and cognitive impairment. We sought to design a mobile tool termed ClereMed that could rapidly screen for adults who have difficulty reading or understanding their medication labels.

OBJECTIVE

The aim of this study was to build the ClereMed prototype; to determine the usability of the prototype with adults 55 and over; to assess its accuracy for identifying adults with low-functional reading ability, poor ability on a real-life pill-sorting task, and low cognition; and to assess the acceptability of a touchscreen device with older adults with age-related changes to vision and cognition.

METHODS

This pilot study enrolled adults (≥55 years) who were recruited through pharmacies, retirement residences, and a low-vision optometry clinic. ClereMed is a hypertext markup language (HTML)-5 prototype app that simulates medication taking using an iPad, and also provides information on how to improve the accessibility of prescription labels. A paper-based questionnaire included questions on participant demographics, computer literacy, and the Systems Usability Scale (SUS). Cognition was assessed using the Montreal Cognitive Assessment tool, and functional reading ability was measured using the MNRead Acuity Chart. Simulation results were compared with a real-life, medication-taking exercise using prescription vials, tablets, and pillboxes.

RESULTS

The 47 participants had a mean age of 76 (SD 11) years and 60% (28/47) were female. Of the participants, 32% (15/47) did not own a computer or touchscreen device. The mean SUS score was 76/100. ClereMed correctly identified 72% (5/7) of participants with functional reading difficulty, and 63% (5/8) who failed a real-life pill-sorting task, but only 21% (6/28) of participants with cognitive impairment. Participants who owned a computer or touchscreen completed ClereMed in a mean time of 26 (SD 16) seconds, compared with 52 (SD 34) seconds for those who do not own a device (P<.001). Those who had difficulty, struggled with screen glare, button activation, and the "drag and drop" function.

CONCLUSIONS

ClereMed was well accepted by older participants, but it was only moderately accurate for reading ability and not for mild cognitive impairment. Future versions may be most useful as part of a larger medication assessment or as a tool to help family members and caregivers identify individuals with impaired functional reading ability. Future research is needed to improve the sensitivity for measuring cognitive impairment and on the feasibility of implementing a mobile app into pharmacy workflow.

Lived experiences and challenges of older surgical patients during hospitalization for cancer: an ethnographic fieldwork

This paper explores the lived experiences of older surgical patients’ (aged 74 years and older) experienced challenges during a brief admission to hospital. Age, gender, polypharmacy, and the severity of illness are also factors known to affect the hospitalization process. For an ethnographic study using participant observation and interviews, surgical cancer patients (n = 9, aged 74 years and older) were recruited during admission to a Danish teaching hospital. Using ethnographic strategies of participant observation and interviews, each patient was followed through the course of 1 day during their stay at the hospital. Interviews were carried out with all patients during this time. Three areas of concern were identified as prominent in the patients’ experiences and challenges during their short hospital stay: teeth and oral cavity, eating in a hospital setting, and medication during hospitalization. Short-term hospitalization requires focused collaboration between staff and patient concerning individual challenges from their teeth and oral cavity as support of nutritional needs during surgical treatment for cancer.

Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework

BACKGROUND

Patients' beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it.

OBJECTIVE

To assess the utility of the NCF in explaining nonadherence to prescribed medicines.

DATA SOURCES

We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles.

STUDY ELIGIBILITY CRITERIA

Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication.

PARTICIPANTS

Patients with long-term conditions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models.

RESULTS

We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used.

LIMITATIONS

Few prospective longitudinal studies using objective adherence measures were identified.

CONCLUSIONS

The Necessity-Concerns Framework is a useful conceptual model for understanding patients' perspectives on prescribed medicines. Taking account of patients' necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

More than meets the eye: relationship between low health literacy and poor vision in hospitalized patients

Patient-centered care includes involving patients and their families in self-management of chronic diseases. Identifying and addressing barriers to self-management, including those related to health literacy and vision limitations, may enhance one's ability to self-manage. A set of brief verbal screening questions (BVSQ) that does not rely on sufficient vision to assess health literacy was developed by Chew and colleagues in the outpatient setting. The authors aimed to evaluate the usefulness of this tool for hospitalized patients and to determine the prevalence of poor vision among inpatients. In a prospective study, the BVSQ and the Rapid Estimate of Adult Learning in Medicine-Revised (REALM-R; among participants with sufficient vision, ≥ 20/50 Snellen) were administered to general medicine inpatients. Of 893 participants, 79% were African American, and 57% were female; the mean age was 53 years. Among 668 participants who completed both tools, the proportion with low health literacy was 38% with the BVSQ versus 47% with the REALM-R (p = .0001). Almost one fourth of participants had insufficient vision; participants with insufficient vision were more likely to be identified as having low health literacy by the BVSQ, compared with those with sufficient vision (59% vs. 38%, p < .001).