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.

Medication self-management capacity among older adults living in low-income housing communities

BACKGROUND

Medication self-management capacity (MMC) is essential to safe and independent living. There is a need to understand the challenges low-income older adults face during the routine use of medications to promote safe medication use and healthy aging in place.

OBJECTIVE

To assess the cognitive and physical deficiencies in MMC and the impact of using pharmaceutical aids/services on MMC among low-income older adults.

METHODS

This was a cross-sectional study of 107 older residents of 5 low-income housing buildings in Richmond, VA. The Medication Management Instrument for Deficiencies in the Elderly was used to measure MMC during individual in-person interviews. Participants were asked whether they used any medication aids, including medication lists, organizers, or reminders, or pharmacy services such as specialized medication packaging, medication synchronization, prescription home delivery, or mail order services. Multiple regression modeling was used to assess the relationship between MMC and the use of pharmaceutical aids/services.

RESULTS

Eighty-nine percent of participants were African American with a mean (standard deviation [±SD]) age of 68.5 (7.2) years. The mean deficit in MMC was 3 (±2.0). The most challenging skill was naming all the medications (69.2%), followed by stating their indications (46.7%) and knowing how or when all of the medications should be taken (38.3%). Seventy-nine percent used at least 1 pharmaceutical aid/service; using 1 pharmaceutical aid/service was significantly associated with better MMC (P = .0285). Low educational level and health literacy were associated with deficits in MMC (P < .05).

CONCLUSION

Many older adults residing in low-income housing had impaired capacity to manage their medications independently. Inadequate medication knowledge affected their cognitive ability to manage medications. Using a pharmaceutical aid/service was associated with better MMC. Greater attention to developing medication self-management skills for older adults with low health literacy and adverse social determinants of health is needed.

Probabilistic Prediction of Nonadherence to Psychiatric Disorder Medication from Mental Health Forum Data: Developing and Validating Bayesian Machine Learning Classifiers

Background

Medication nonadherence represents a major burden on national health systems. According to the World Health Organization, increasing medication adherence may have a greater impact on public health than any improvement in specific medical treatments. More research is needed to better predict populations at risk of medication nonadherence.

Objective

To develop clinically informative, easy-to-interpret machine learning classifiers to predict people with psychiatric disorders at risk of medication nonadherence based on the syntactic and structural features of written posts on health forums.

Methods

All data were collected from posts between 2016 and 2021 on mental health forum, administered by Together 4 Change, a long-running not-for-profit organisation based in Oxford, UK. The original social media data were annotated using the Tool for the Automatic Analysis of Syntactic Sophistication and Complexity (TAASSC) system. Through applying multiple feature optimisation techniques, we developed a best-performing model using relevance vector machine (RVM) for the probabilistic prediction of medication nonadherence among online mental health forum discussants.

Results

The best-performing RVM model reached a mean AUC of 0.762, accuracy of 0.763, sensitivity of 0.779, and specificity of 0.742 on the testing dataset. It outperformed competing classifiers with more complex feature sets with statistically significant improvement in sensitivity and specificity, after adjusting the alpha levels with Benjamini-Hochberg correction procedure. Discussion. We used the forest plot of multiple logistic regression to explore the association between written post features in the best-performing RVM model and the binary outcome of medication adherence among online post contributors with psychiatric disorders. We found that increased quantities of 3 syntactic complexity features were negatively associated with psychiatric medication adherence: "dobj_stdev" (standard deviation of dependents per direct object of nonpronouns) (OR, 1.486, 95% CI, 1.202-1.838, P < 0.001), "cl_av_deps" (dependents per clause) (OR, 1.597, 95% CI, 1.202-2.122, P, 0.001), and "VP_T" (verb phrases per T-unit) (OR, 2.23, 95% CI, 1.211-4.104, P, 0.010). Finally, we illustrated the clinical use of the classifier with Bayes' monograph which gives the posterior odds and their 95% CI of positive (nonadherence) versus negative (adherence) cases as predicted by the best-performing classifier. The odds ratio of the posterior probability of positive cases was 3.9, which means that around 10 in every 13 psychiatric patients with a positive result as predicted by our model were following their medication regime. The odds ratio of the posterior probability of true negative cases was 0.4, meaning that around 10 in every 14 psychiatric patients with a negative test result after screening by our classifier were not adhering to their medications.

Conclusion

Psychiatric medication nonadherence is a large and increasing burden on national health systems. Using Bayesian machine learning techniques and publicly accessible online health forum data, our study illustrates the viability of developing cost-effective, informative decision aids to support the monitoring and prediction of patients at risk of medication nonadherence.

Patient preferences for medication adherence financial incentive structures: A discrete choice experiment

BACKGROUND

Medication adherence for chronic conditions continues to be a challenge for patients. Patient incentives for medication adherence may help. Financial incentives delivered at the point of care may act as cues for medication-taking behavior.

OBJECTIVES

The purpose of this study was to investigate patient preferences for specific structures of financial medication adherence incentives that could feasibly be delivered at the point of care.

METHODS

A discrete choice experiment (DCE) was performed using a national online survey. Study participants were adults who self-reported taking at least one prescription medication for one or more chronic conditions. Following an orthogonal design generated in SAS, the DCE included 32 paired-choice tasks. Data were analyzed using mixed logit models and stratified on participants' income level.

RESULTS

In the full cohort (n = 933), form of financial reward (such as gift-card or cash) was 1.02 times as important to participants as the probability of incentive receipt, 1.58 times as important as monetary value, and 1.93 times as important as timing of receipt. Participants were willing to give up $31.04 of an incentive's monetary value (95% CI = $27.11-$34.98) to receive the incentive 5 months sooner (1-month vs. 6-month time-lag); $60.79 (95% CI = $53.19-$68.39) for probability of receipt to increase from a 1 out of 100 chance to a 1 out of 20 chance; and $10.52 (95% CI = $6.46-$14.58) to receive an incentive in the form of a Visa® gift-card instead of grocery store voucher. These patterns of trade-offs between attributes were generally consistent among participants with lower and higher income.

CONCLUSIONS

Regardless of socioeconomic status, patient preferences for financial medication adherence incentives delivered at the point of care may be most heavily influenced by incentive form and probability of receipt. This has implications for designing medication adherence programs in terms of incentive sustainability, patient engagement, plan star ratings, and patient outcomes.

Community Medication Education, Data, & Safety (C-MEDS): Findings from a Pilot Project

OBJECTIVES

Medication-related problems remain one of the largest health risks for older adults, yet there are few resources available to effectively reduce medication-related problems for community dwelling older adults. The aim of this pilot program was to determine the effectiveness of a multifaceted medication intervention on medication adherence and self-efficacy in medication use.

DESIGN

A single sample, pre-post-test design.

SETTING

This pilot study was conducted at Independence at Home, a Senior Care Action Network (SCAN) community service in Southern California.

PARTICIPANTS

One hundred and eighty community-dwelling, diverse older adults with potential medication-related problems and their caregivers.

INTERVENTION

The Community Medication Education, Data, & Safety (C-MEDS) Program identified community-dwelling older adults with potential medication-related problems and provided in-depth personalized medication safety, management and support, based on an in-home assessment and interventions delivered by trained geriatrics experts including pharmacists, nurses, a community health worker, and a pharmacy technician.

MEASUREMENTS

The primary outcomes included medication use self-efficacy, measured by the MUSE, and select medication adherence measures. Adherence was measured via pill count and via the MedAdhIR tool, a scale that measures risk for medication non-adherence.

RESULTS

Following participation in the C-MEDS program, community-dwelling older adult C-MEDS graduates (n = 105) had higher self-efficacy in managing medications (P < .001). Additionally, C-MEDS graduates also exhibited increased adherence to three types of medications (statins, diabetes-related, and certain hypertension drugs; P < .001). Moreover, risk of non-adherence declined significantly following C-MEDS graduation (P < .001).

CONCLUSION

C-MEDS holds promise as an effective intervention among community-dwelling older adults in improving medication self-efficacy, medication adherence among select medications, and reducing risk for non-adherence. Additional studies are needed to assess replicability and impact on clinical outcomes.

Measuring Medication Self-Management Capacity: A Scoping Review of Available Instruments

BACKGROUND

Managing a medication regimen is a complex self-care activity that requires a high level of integration and coordination between cognitive and physical skills. This scoping review aims to identify available instruments designed to assess an adult individual's ability to manage a medication regimen independently and to identify reliable and valid tools to be used in clinical practice and research.

METHODS

Five databases (PubMed/MEDLINE, CINAHL Complete, PsycINFO, Embase, and International Pharmaceutical Abstracts) were searched to identify articles reporting the development of an instrument to assess medication self-management capacity in adults. The process included a broad initial search of the databases, followed by screening of titles and abstracts, and full review of relevant articles. For each instrument identified, characteristics, including validity and reliability assessments, were summarized.

RESULTS

Sixteen papers were identified that reviewed or described the development and/or validation of 26 instruments designed to assess medication self-management capacity. Most instruments were designed to identify cognitive and physical barriers to successful medication management, but there was inconsistency across instruments in the specific skills assessed and the assessment method used. Most instruments were validated by testing at least one related construct, such as cognitive function, activities of daily living or instrumental activities of daily living performance, or medication adherence.

CONCLUSION

Development of standardized instruments to quantify medication self-management capacity is still growing. The choice of instrument for use in a specific clinical or research setting will depend on the purpose for making the assessment and the population that it will be applied to. Results of this review can assist in selecting an appropriate instrument or guiding the development of new instruments for assessment of medication self-management capacity for specific clinical or research purposes.

Overview of High Yield Geriatrics Assessment for Clinic and Hospital

Geriatric assessment is a comprehensive, multifaceted, and interdisciplinary evaluation of medical, socioeconomic, environmental, and functional concerns unique to older adults; it can be focused or broadened according to the needs of the patient and the concerns of clinical providers. Herein, the authors present a high-yield framework that can be used to assess older adult patients across a variety of settings.

Can Brief Cognitive or Medication Management Tasks Identify the Potential for Dependence in Instrumental Activities of Daily Living?

Background and Objectives: The identification of functional performance deficits is critical to the community independence of older adults. We examined whether a combined cognitive and performance-based medication management measure would be able to better classify an individual’s functional cognitive status and potential for instrumental activities of daily living (IADL) impairment than either measure alone.

Research Design and Methods: Community-dwelling adults age 55 and older (n = 185) were administered the Mini-Cog, the Medication Transfer Screen-Revised (MTS-R), a combination measure the Medi-Cog-Revised (Medi-Cog-R), the Performance Assessment of Self-Care Skills (PASS) Checkbook Balancing and Shopping tasks (PCST), additional cognitive screening measures, and a self-report daily living scale. Receiver operating characteristic (ROC) curve analyses were computed for the Mini-Cog, MTS-R and the Medi-Cog-R using the PCST performance as the criterion measure. The area under the curve (AUC), sensitivity, and specificity were computed for each measure.

Results: The Medi-Cog-R most accurately identified individuals as impaired on the PCST. An AUC statistic of 0.82 for the Medi-Cog-R was greater than either the Mini-Cog (0.75) or the MTS-R (0.73). The Medi-Cog-R demonstrated a sensitivity of 0.71 and a specificity of 0.78 in classifying individuals with impaired IADL as measured by the PCST.

Discussion and Implications: The Mini-Cog, the MTS-R, and the Medi-Cog-R all show discriminant validity, but the combined measure demonstrates greater sensitivity and specificity than either component measure alone in identifying IADL impairment. The Medi-Cog-R appears to be a useful screening measure for functional cognition and can be used to prompt further assessment and intervention to promote community independence.

The association of cognitive impairment as screened by the Mini-Cog with long term post-hospitalization outcomes

BACKGROUND

Prior studies have suggested that patients with cognitive impairment are at increased risk for adverse post-hospitalization outcomes. We aimed to determine if cognitive status assessed by the Mini-Cog, a quick bedside screening test, is associated with long-term outcomes.

METHODS

In this secondary analysis of data from a prospective cohort study, 668 patients >65 years of age admitted to a tertiary care academic hospital over a two-year period were screened for cognitive impairment with the Mini-Cog within 24 h of admission. We performed multivariable regression adjusting for demographics, comorbidities, principal diagnoses and functional status to determine association between cognitive impairment and discharge to post-acute care, 90-day readmission and one-year mortality.

RESULTS

Overall 35% screened positive for cognitive impairment. Those with impairment were older (median age 83 versus 78), less likely to be admitted from home and had lower functional independence and self-reported performance scores (p < 0.001 for all). Patients with cognitive impairment were more likely to be discharged to post-acute care facilities (54% versus 39%, p < 0.001). 90-day readmission rate of patients with and without cognitive impairment was 35% versus 27%; one-year survival 77% versus 84% and median length-of-stay was 4 days for both groups. Differences in readmission and mortality were not statistically significant after adjusting for covariates.

CONCLUSION

Cognitive impairment as screened for by the Mini-Cog was not associated with readmission, length-of-stay, or 1-year mortality but was associated with discharge to post-acute care. Other tools such as frailty assessment may be more useful in predicting these outcomes in hospitalized older adults.

Screening Positive for Cognitive Impairment: Impact on Healthcare Utilization and Provider Action in Primary and Specialty Care Practices

BACKGROUND

Alzheimer's disease, the most common cause of dementia, goes unrecognized in half of patients presenting to healthcare providers and is associated with increased acute care utilization. Routine cognitive screening of older adults in healthcare settings could improve rates of dementia diagnosis and patterns of healthcare utilization.

OBJECTIVE

To evaluate the impact of screening positive for cognitive impairment on provider action in primary and specialty care practices and patient healthcare utilization.

DESIGN

Individuals asymptomatic for cognitive impairment completed cognitive screening with the Mini-Cog (MC). Outcomes included MC screen-positive rates, provider follow-up actions, and healthcare utilization for all participants over a period of 36 months (18 months prior to and following MC screening). Data were extracted from the electronic medical record (EMR). Healthcare provider interventions and healthcare utilization for screen-positive and -negative groups, before and after screening, were compared.

PARTICIPANTS

Primary and specialty care patients (n = 787) aged ≥ 65 without history of cognitive impairment seen in HealthPartners, an integrated healthcare system in Minnesota and Western Wisconsin.

KEY RESULTS

In primary care and neurology practices combined, over the entire 36-month study window, individuals screening positive showed 32% higher rates of ED visits (p < 0.05) pre and post-screening compared to those screening negative. Screen positive also showed 39% higher rates of hospitalizations pre-screening (p < 0.05) and 58% higher rates post-screening (p < 0.01). While screen-detected cognitive impairment was associated with some relevant provider follow-up action in 32% of individuals, subsequent healthcare utilization did not change between the 18-month pre- and post-screening periods.

CONCLUSION

Despite being associated with higher rates of healthcare utilization, screening positive on the MC led to a change in provider action in a minority of cases and did not reduce post-screening healthcare utilization. Screening for cognitive impairment alone is not sufficient to alter patterns of provider practice or patient healthcare utilization.

Testing the validity and reliability of the Self-Administration of Medication (SAM) instrument in Chinese chronic disease patients: A cross-cultural adaptation

AIMS

To develop a culturally appropriate and functional standard Mandarin Chinese translation of the Self-Administration of Medication tool and to examine its validity and reliability.

METHODS

We used Brislin's guidelines for the translation and back-translation procedures. We recruited 130 patients from June 2015 to September 2016. Correlation analysis, Cronbach's alpha coefficient, split-half reliability, item analysis and the content validity index, and exploratory factor analysis were performed.

RESULTS

Strong and moderate correlations were seen between the total Self-Administration of Medication score and nurses' and patients' perceptions. Item analysis indicated that the correlation coefficient ranged from 0.744 to 0.975. Cronbach's alpha ranged from 0.933 to 0.976. The split-half reliability ranged from 0.911 to 0.936 for the instrument's subscales, and 0.953 for the total scale. The content validity index value ranged from 0.823 to 0.972 for individual items and was 0.968 for the total scale. The factor loading matrix of the SAM ranged from 0.514 to 0.837. A moderate correlation existed between the scores of the Self-Administration of Medication tool and the Barthel Index.

CONCLUSION

The Chinese version of the Self-Administration of Medication tool is statistically acceptable and can be used in the evaluation of self-medication ability based on self-report and nurses' assessment.

Medication self-management skills and cognitive impairment in older adults hospitalized for heart failure: A cross-sectional study

Background:

Cognitive impairment is highly prevalent among older adults (aged ≥65 years) hospitalized for heart failure and has been associated with poor outcomes. Poor medication self-management skills have been associated with poor outcomes in this population as well. The presence and extent of an association between cognitive impairment and poor medication self-management skills in this population has not been clearly defined.

Objective:

We assessed the cognition of consecutive older adults hospitalized for heart failure, in relation to their medication self-management skills.

Methods:

We conducted a cross-sectional study of older adults (aged ≥65 years) who were hospitalized for heart failure and were being discharged home. Prior to discharge, we assessed cognition using the Mini-Cog. We also tested patients’ ability to read a pill bottle label, open a pill bottle safety cap, and allocate mock pills to a pill box. Pill allocation performance was assessed quantitatively (counts of errors of omission and commission) and qualitatively (patterns suggestive of knowledge-based mistakes, rule-based mistakes, or skill-based slips).

Results:

Of 55 participants, 22% were found to have cognitive impairment. Patients with cognitive impairment tended to be older as compared to those without cognitive impairment (mean age = 81 vs 76 years, p = NS). Patients with cognitive impairment had a higher prevalence of inability to read pill bottle label (prevalence ratio = 5.8, 95% confidence interval = 3.2–10.5, p = 0.001) and inability to open pill bottle safety cap (prevalence ratio = 3.3, 95% confidence interval = 1.3–8.4, p = 0.03). While most patients (65%) had pill-allocation errors regardless of cognition, those patients with cognitive impairment tended to have more errors of omission (mean number of errors = 48 vs 23, p = 0.006), as well as more knowledge-based mistakes (75% vs 40%, p = 0.03).

Conclusion:

There is an association between cognitive impairment and poor medication self-management skills. Medication taking failures due to poor medication self-management skills may be part of the pathway linking cognitive impairment to poor post-discharge outcomes among patients with heart failure transitioning from hospital to home.

Ability of older people with dementia or cognitive impairment to manage medicine regimens: a narrative review

Impaired cognition has a significant impact on a person’s ability to manage their medicines. The aim of this paper is to provide a narrative review of contemporary literature on medicines management by people with dementia or cognitive impairment living in the community, methods for assessing their capacity to safely manage medicines, and strategies for supporting independent medicines management. Studies and reviews addressing medicines management by people with dementia or cognitive impairment published between 2003 and 2013 were identified via searches of Medline and other databases. The literature indicates that as cognitive impairment progresses, the ability to plan, organise, and execute medicine management tasks is impaired, leading to increased risk of unintentional non-adherence, medication errors, preventable medication-related hospital admissions and dependence on family carers or community nursing services to assist with medicines management. Impaired functional capacity may not be detected by health professionals in routine clinical encounters. Assessment of patients’ (or carers’) ability to safely manage medicines is not undertaken routinely, and when it is there is variability in the methods used. Self-report and informant report may be helpful, but can be unreliable or prone to bias. Measures of cognitive function are useful, but may lack sensitivity and specificity. Direct observation, using a structured, standardised performance-based tool, may help to determine whether a person is able to manage their medicines and identify barriers to adherence such as inability to open medicine packaging. A range of strategies have been used to support independent medicines management in people with cognitive impairment, but there is little high-quality research underpinning these strategies. Further studies are needed to develop and evaluate approaches to facilitate safe medicines management by older people with cognitive impairment and their carers.

Primary Care: A New Context for the Scholarship of Practice Model

Interest in the emerging role for occupational therapy in the primary care practice setting has increased due to implementation of the Patient Protection and Affordable Care Act (ACA), which intends to expand health care coverage to uninsured Americans while improving coordination of care, health outcomes, and cost savings. Expanding occupational therapy to encompass promotion of wellness and prevention in a primary care context provides an opportunity for occupational therapy. The purpose of this article is to describe the role of occupational therapy in primary care and how the Scholarship of Practice model can guide the development of occupation-based and evidence-based best practice in primary care.

Determinants of medication adherence among adults with type 2 diabetes mellitus in three Malaysian public health clinics: a cross-sectional study

Medication adherence (MA) in adults with type 2 diabetes mellitus (T2D) is associated with improved disease control (glycated hemoglobin, blood pressure, and lipid profile), lower rates of death and diabetes-related complications, increased quality of life, and decreased health care resource utilization. However, there is a paucity of data on the effect of diabetes-related distress, depression, and health-related quality of life on MA. This study examined factors associated with MA in adults with T2D at the primary care level. This was a cross-sectional study conducted in three Malaysian public health clinics, where adults with T2D were recruited consecutively in 2013. We used the 8-item Morisky Medication Adherence Scale (MMAS-8) to assess MA as the main dependent variable. In addition to sociodemographic data, we included diabetes-related distress, depressive symptoms, and health-related quality of life as independent variables. Independent association between the MMAS-8 score and its determinants was done using generalized linear models with a gamma distribution and log link function. The participant response rate was 93.1% (700/752). The majority were female (52.8%), Malay (52.9%), and married (79.1%). About 43% of patients were classified as showing low MA (MMAS-8 score <6). Higher income (adjusted odds ratio 0.90) and depressive symptoms (adjusted odds ratio 0.99) were significant independent determinants of medication non-adherence in young adults with T2D. Low MA in adults with T2D is a prevalent problem. Thus, primary health care providers in public health clinics should focus on MA counselling for adult T2D patients who are younger, have a higher income, and symptoms of depression.

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.

A Spanish pillbox app for elderly patients taking multiple medications: randomized controlled trial

Background

Nonadherence and medication errors are common among patients with complex drug regimens. Apps for smartphones and tablets are effective for improving adherence, but they have not been tested in elderly patients with complex chronic conditions and who typically have less experience with this type of technology.

Objective

The objective of this study was to design, implement, and evaluate a medication self-management app (called ALICE) for elderly patients taking multiple medications with the intention of improving adherence and safe medication use.

Methods

A single-blind randomized controlled trial was conducted with a control and an experimental group (N=99) in Spain in 2013. The characteristics of ALICE were specified based on the suggestions of 3 nominal groups with a total of 23 patients and a focus group with 7 professionals. ALICE was designed for Android and iOS to allow for the personalization of prescriptions and medical advice, showing images of each of the medications (the packaging and the medication itself) together with alerts and multiple reminders for each alert. The randomly assigned patients in the control group received oral and written information on the safe use of their medications and the patients in the experimental group used ALICE for 3 months. Pre and post measures included rate of missed doses and medication errors reported by patients, scores from the 4-item Morisky Medication Adherence Scale (MMAS-4), level of independence, self-perceived health status, and biochemical test results. In the experimental group, data were collected on their previous experience with information and communication technologies, their rating of ALICE, and their perception of the level of independence they had achieved. The intergroup intervention effects were calculated by univariate linear models and ANOVA, with the pre to post intervention differences as the dependent variables.

Results

Data were obtained from 99 patients (48 and 51 in the control and experimental groups, respectively). Patients in the experimental group obtained better MMAS-4 scores (P<.001) and reported fewer missed doses of medication (P=.02). ALICE only helped to significantly reduce medication errors in patients with an initially higher rate of errors (P<.001). Patients with no experience with information and communication technologies reported better adherence (P<.001), fewer missed doses (P<.001), and fewer medication errors (P=.02). The mean satisfaction score for ALICE was 8.5 out of 10. In all, 45 of 51 patients (88%) felt that ALICE improved their independence in managing their medications.

Conclusions

The ALICE app improves adherence, helps reduce rates of forgetting and of medication errors, and increases perceived independence in managing medication. Elderly patients with no previous experience with information and communication technologies are capable of effectively using an app designed to help them take their medicine more safely.

Trial Registration

Clinicaltrials.gov NCT02071498; http://clinicaltrials.gov/ct2/show/NCT02071498 (Archived by WebCite at http://www.webcitation.org/6OJjdHVhD).

Medication management capacity in relation to cognition and self-management skills in older people on polypharmacy

OBJECTIVE

To determine the medication management capacity of independently living older people (≥75 years) on polypharmacy (≥ 5 medications) in relation to their cognitive- and self-management skills.

DESIGN

Cross-sectional study.

SETTING

Two homecare organizations in the Netherlands.

PARTICIPANTS

Homecare clients aged 75 and older on polypharmacy (N=95).

MEASUREMENTS

The primary outcome measure was medication management capacity, quantified as the number of 'yes' answers (range = 0-17) on the Medication Management Capacity (MMC) questionnaire. Other measures included self-management ability (assessed with the SMAS30) and cognitive skills (assessed with the clock drawing test).

RESULTS

Overall, 48.4% (n= 46) of the participants were able to manage their medication by themselves at home. About 40% of the participants were unable to state the names of their medications, even with the aid of a medication list, and about 25% reported having problems with opening medication packages. Correlations were found between self-management ability (Rs = 0.473; p < 0.001), cognitive skills (Rs = 0.372; p < 0.001), and age (Rs = 0.216; p < 0.005) and Medication Management Capacity score. Self-management ability and medication management support were significantly associated with medication management capacity.

CONCLUSION

A considerable proportion of independently living older people who receive home care and regularly use five or more medications lack the knowledge and skills needed to independently manage their own medications. Cognition and self management ability were related to medication management capacity. Self-management ability and medication management support were predictors of medication management capacity.

Testing the validity, reliability and utility of the Self-Administration of Medication (SAM) tool in patients undergoing rehabilitation

BACKGROUND

Determination of patients' ability to self-administer medications in the hospital has largely been determined using the subjective judgment of health professionals.

OBJECTIVES

To examine the validity, reliability and utility of the Self-Administration of Medication (SAM) tool as an objective means to determine patients' ability to self-administer in a rehabilitation unit of a public teaching hospital in Melbourne, Australia.

METHODS

To assess validity of the SAM tool, associations were examined between the total SAM tool score and of the patients' competence to self-administer from the perceptions of the tool administrator, patients and nurses. Validity also was determined from a principal component analysis. Pearson correlations were calculated for how SAM scores related to scores obtained from the Functional Independence Measure (FIM) and Barthel Score Index (BSI). To assess the SAM tool's reliability, a Cronbach's alpha coefficient was calculated. Utility of the SAM tool was evidenced by documenting its administration time.

RESULTS

One hundred patients participated in this study. The SAM tool had a Cronbach's alpha coefficient of 0.75 and took a mean time of 5.36 min to complete. The capability to self-medicate section of the SAM tool had strong correlations with the FIM (r = 0.485) and BSI (r = 0.472) data, respectively, and the total SAM tool had moderate and strong correlations with the nurses' (r = 0.315) and tool administrator's (r = 0.632) perceptions of patients' ability to self-administer, respectively. Bland-Altman and ROC curve analyses showed poor agreement between the total SAM tool score and the nurses' perceptions.

CONCLUSIONS

The SAM tool demonstrated acceptable overall internal consistency. It only requires a short time to be completed and is more objective than seeking out health professionals' perceptions. Additional research is needed to further validate this approach to determining patients' ability to self-medicate.

Intelligence in early adulthood and subsequent risk of unintentional injury over two decades: cohort study of 1 109 475 Swedish men

BACKGROUND

There is growing evidence of an inverse association between intelligence (IQ) and unintentional injuries.

METHODS

Analyses are based on a cohort of 1 109 475 Swedish men with IQ measured in early adulthood. Men were followed up for an average 24 years, and hospital admissions for unintentional injury were recorded.

RESULTS

198 133 (17.9%) men had at least one hospital admission for any unintentional injury during follow-up. The most common cause of unintentional injury was falling, followed by road accidents, poisoning, fire and drowning. In addition, 14 637 (1.3%) men had at least one admission for complications of medical care. After adjusting for confounding variables, lower IQ scores were associated with an elevated risk of any unintentional injury (HR (95% CI) per SD decrease in IQ: 1.15 (1.14 to 1.15)) and of cause-specific injuries other than drowning (poisoning (1.53 (1.49 to 1.57)), fire (1.36 (1.31 to 1.41)), road traffic accidents (1.25 (1.23 to 1.26)), medical complications (1.20 (1.18 to 1.22)) and falling (1.17 (1.16 to 1.18))). These gradients were stepwise across the full IQ range.

CONCLUSIONS

Low IQ scores in early adulthood were associated with a subsequently increased risk of unintentional injury. A greater understanding of mechanisms underlying these associations may provide opportunities and strategies for prevention.

Drug treatment in an ageing population: practical implications

The population of the industrialised nations is ageing. By 2020 those of 65 years and older will constitute nearly 17% of the US population; it is predicted that the proportion of the population aged 80 years and over will then range from 3.5 to 6.5%, around the world. Those over 65, due to age-related chronic disease and more prophylactic prescribing, receive a disproportionate number of drugs; in the UK for example, 45% of the total prescriptions dispensed. Older patients may benefit from prophylactic treatments to a greater extent than younger people because of a higher absolute risk of disease and it is therefore important that they are not inappropriately denied these. However, it is also important that, as each additional drug prescribed brings an increased risk of an adverse drug effect, prescribers have enough knowledge of pharmacological issues in old age to enable them to weigh up these conflicting pressures to arrive at good prescribing decisions.

An active-learning course model to teach pharmacotherapy in geriatrics

OBJECTIVE

To describe the development, implementation, and assessment of a geriatric pharmacotherapy elective course emphasizing a patient-centered approach and active, self-directed learning strategies.

DESIGN

The course content included fundamental concepts in aging, geriatric syndromes, activities involving assessment of medically complex older adults, presentation of controversies in clinical geriatrics, book and film clubs, an Adopt-a-Patient project, and scientific and reflective writing. Students participated in site visits to interview and interact with older adults.

ASSESSMENT

Student evaluation of the course was assessed with the teaching evaluation tool, an end-of-semester survey, a follow-up P4 survey, and reflective writings. Students strongly agreed that course goals were achieved. Learning how to communicate with older adults and assess complex medication regimens were the areas of highest importance to students. P4 students strongly agreed that skills learned in the course were important to their success in advanced pharmacy practice experiences (APPEs).

CONCLUSION

A pharmacotherapy course emphasizing active and self-directed learning in geriatrics through innovative teaching was adaptable to doctor of pharmacy (PharmD) students at various stages of their training and improved students' perceptions of aging.

Standardised assessment of patients' capacity to manage medications: a systematic review of published instruments

BACKGROUND

Older people are commonly prescribed complex multi-drug regimens while also experiencing declines in the cognitive and physical abilities required for medication management, leading to increased risk of medication errors and need for assisted living. The purpose of this study was to review published instruments designed to assess patients' capacity to self-administer medications.

METHODS

Searches of Medline, EMBASE, CINAHL, PsycINFO, International Pharmaceutical Abstracts, Health and Psychosocial Instruments, Google, and reference lists of identified publications were conducted to identify English-language articles describing development and validation of instruments designed to assess patients' capacity to self-administer medications. Methodological quality of validation studies was rated independently against published criteria by two reviewers and reliability and validity data were reviewed.

RESULTS

Thirty-two instruments were identified, of which 14 met pre-defined inclusion criteria. Instruments fell into two categories: those that used patients' own medications as the basis for assessment and those that used a simulated medication regimen. The quality of validation studies was generally low to moderate and few instruments were subjected to reliability testing. Most instruments had some evidence of construct validity, through associations with tests of cognitive function, health literacy, activities of daily living or measures of medication management or adherence. Only one instrument had sensitivity and specificity data with respect to prediction of medication-related outcomes such as adherence to therapy. Only three instruments had validity data from more than one independent research group.

CONCLUSION

A number of performance-based instruments exist to assess patients' capacity to manage their own medications. These may be useful for identifying physical and cognitive barriers to successful medication management, but further studies are needed to determine whether they are able to accurately and reliably predict medication outcomes.