The use of nonprescription medicines among elderly patients with chronic illness and their need for pharmacist interventions

Patterns of self-medication and intention to seek pharmacist guidance among older adults during the COVID-19 pandemic in Macao: a cross-sectional study

INTRODUCTION

Self-medication was remarkably popular during the COVID-19 pandemic. In older populations, the risk of self-medication is higher. Pharmacists are well positioned to provide public health education and disease prevention. This study aims to explore the self-medication patterns and intention to seek pharmacist guidance among older adults in Macao.

METHODS

A face-to-face cross-sectional survey was subsequently performed in March-April 2023 among older adults in Macao. The questionnaire was designed based on the Theory of Planned Behavior (TPB) framework. Multiple logistic regression was used to analyze predictors of self-medication behavior and multiple linear regression analysis to determine whether the TPB construct was the predictor of older adults' intention to seek guidance from pharmacists.

RESULTS

A total of 412 participants completed the questionnaire. The self-medication rate among older adults in Macao was 64.2%. The most commonly used types of medications were over-the-counter and traditional Chinese medicine, mainly from government anti-pandemic packages. The majority of individuals engaged in self-medication to treat COVID-19 symptoms or prevent COVID-19 infection. The prevalent reasons for self-medication were the perceived non-seriousness of the illness. 85 years old or older and university degree were significantly associated with self-medication behavior. Older adults had moderate intention to seek pharmacist guidance on medication use. The average scores (standard deviation) were 3.43 (1.10) for Attitude, 2.69 (0.99) for Subjective Norm, 3.56 (1.04) for Perceived Behavioral Control, and 3.07 (1.43) for Intention. Attitude, Subjective Norm, and Perceived Behavioral Control were all strong predictors of intention, which explained 53% of the variance in intention. In demographic factors, age was identified as a significant predictor of intentions.

CONCLUSIONS

Self-medication was widely practiced in Macao during the COVID-19 pandemic. To better control the risks associated with self-medication, the role of pharmacists is paramount. Enhancing the recognition and trust of pharmacists within society, modifying pharmacy management models, and strengthening pharmacists' self-perception of their profession are all pivotal directions areas to further enhance their role.

Effectiveness and sustainment of a tailored over-the-counter medication safety intervention in community pharmacies: A randomized controlled trial

INTRODUCTION

The Senior Section is a continuation of a previous intervention that aims to address a gap in medication safety, specifically related to older adult selection and use of over-the-counter medications. The purpose of this paper is to describe the protocol of this study.

METHODS

This study will occur in three phases: an adaptation phase, an effectiveness phase using a randomized controlled trial, and a sustainment phase. This study will take place in conjunction with administrative leadership and pharmacy sites of a regional Midwest integrated health system. Eye tracking technology will inform the adaptation of the intervention and demonstrate effectiveness in the randomized controlled trial. Following the randomized controlled trial, the health system will implement the intervention without research team support. Fidelity and long-term effectiveness outcomes will be collected to demonstrate sustainment.

DISCUSSION

The potential implications of this study are a complete and sustained redesign of the pharmacy setting to include educational and directional materials on medication safety, leading to a decrease in over-the-counter medication misuse in older adults. This project could provide a road map for pharmacy organizations to tailor and adopt the Senior Section, to ultimately reduce inappropriate over-the-counter medication use in older adults.

Based on the Beers Criteria 2019 Edition Over-the-Counter Drugs Risk Confirmation of Elderly Chinese

OBJECTIVE

To explore OTC (over-the-counter drugs) in Chinese community pharmacies often causes ADE (adverse drug event) in elderly patients.

METHODS

Use the drugs in the Beers Criteria 2019 potentially inappropriate medication use (PIM) list as search terms. Search for drugs registered on the National Medical Products Administration of China website before December 2019 to determine the drugs containing PIM active ingredients and, then, search the Chinese OTC selection and conversion catalog database to determine it as OTC. Two databases are considered to be the same drug if they have the same drug composition.

RESULTS

The incidence of PIM in elderly patients in our community is relatively high, and the management of OTC may be related to risk factors. Statistics found that 71 OTC contained the Beers Criteria ingredients, including 65 chemicals and six Chinese patent medicines. Varieties of compound preparations accounted for 78.9% and cold medicines accounted for 47.9%.

CONCLUSIONS

The high detection rate of the Beers Criteria in Chinese OTC suggests that medical practitioners in China, especially community pharmacists, should pay attention to the rational use of OTC in the elderly.

Using an Information Package to Reduce Patients' Risk of Renal Damage: Protocol for a Randomized Feasibility Trial

Background

Non-steroidal anti-inflammatory drugs (NSAIDs) are a common cause of renal damage, especially when taken together with angiotensin-converting enzyme inhibitors (ACE-i) or angiotensin II receptor blockers (ARBs) plus a diuretic — a combination known as the “triple whammy.” New Zealand patients are at high risk of the “triple whammy” because they can easily purchase NSAIDs without a prescription and in nonpharmacy retail settings (eg, the supermarket), there is no legal requirement to include patient information sheets with medication, and direct-to-consumer drug advertising is permitted. A patient information package has been developed for those at greatest risk of the “triple whammy,” consisting of a printable PDF and an interactive online learning activity. This information package aims to inform patients about their elevated risk of harm from NSAIDS and discourage use of NSAIDs. A randomized control trial was planned to assess the effect of the information package.

Objective

This study aims to pilot the trial procedures for recruiting patients and providing patient information online and to assess the acceptability of the patient information package.

Methods

A two-armed randomized feasibility trial will be undertaken in Northland, New Zealand. We will recruit 50 patients who are at least 18 years old from those who have signed up to receive email alerts through their general practice. Patients eligible for this study have been prescribed an ACE-i or ARB plus a diuretic in the past 3 months. They will be randomly allocated to 2 study arms. The intervention arm will receive access to an information package plus usual care; the control arm will receive usual care alone. Online surveys will be used to assess NSAID knowledge and NSAID use at baseline and after 2 weeks for both arms. The intervention arm will also evaluate the information package in an additional survey based on Normalization Process Theory (NPT) concepts. We will report the number and proportion of participants who are eligible and consent to participate in the trial. Response and drop-out rates will be reported for each trial arm. The numbers of patients who interact with the education package will be reported together with the patient evaluation of it.

Results

Funding has been obtained from the Health Research Council of New Zealand (HRC 18-031). The University of Otago Human Research Ethics Committee (H21/016) has approved this trial. Consultation has been undertaken with The Ngai Tahu research consultation committee. The trial commenced on April 12, 2021.

Conclusions

This feasibility trial will test the study processes prior to commencing a randomized controlled trial and will determine the acceptability of the patient information package. We anticipate this work will provide useful information for other researchers attempting similar work.

International Registered Report Identifier (IRRID)

PRR1-10.2196/29161

Developing and Verifying the Efficacy of "Educational Program for Promoting Appropriate Self-medication via Pharmacies and Pharmacists": A Randomized Controlled Trial

Utilization of community pharmacies/pharmacists is important for promoting appropriate self-medication; however, appropriate self-medication via pharmacies/pharmacists has not been well-implemented in Japan. Based on the transtheoretical model of health behavior change, we constructed an Educational Program for Promoting Appropriate Self-medication via Pharmacies and Pharmacists to inform the public about the assistive services of pharmacies/pharmacists regarding self-medication and the use of medication notebooks for self-medications. We then tested the efficacy of the program through a randomized controlled trial. The subjects were residents living around Gifu City, aged 20 years and above, and recruited through posters and pamphlets. The subjects were randomly allocated to a group that received only a medication/health class (control group) or one that received the medication/health class, as well as the educational program (intervention group). A questionnaire was administered immediately before the medication/health class (T1) and 2 months afterwards (T2), which allowed us to evaluate and compare the changes in the two groups' behavior regarding performing appropriate self-medication via pharmacies/pharmacists. The percentage of people who began consulting with pharmacists concerning self-medication was significantly higher among the intervention group (38.2%, 13/34) than the control group (14.3%, 4/28) (p = 0.047). The percentage of people who began recording details of self-medication in their medication notebooks was significantly higher among the intervention group (38.2%, 13/34) than the control group (10.7%, 3/28) (p = 0.019). The educational program effectively encouraged the public to adopt appropriate self-medication practices to avail the services provided by pharmacies/pharmacists.

Exploring how pharmacists engage with patients about over-the-counter medications

OBJECTIVE

This study used an innovative information-gathering approach to provide insight into the nature and structure of pharmacy staff encounters with patients seeking over-the-counter (OTC) medications and revealed specific activities of pharmacy staff around these encounters.

METHODS

A multistep process was used to develop and standardize an 8-item OTC Encounter Form to document the characteristics of pharmacy staff-patient encounters. The OTC Form contained several domains, including topics discussed and the problems or symptoms identified during the encounter, staff functions during the encounter, and approximate time spent with the patient. Nine pharmacists and 8 technicians used the OTC Form to document patient encounters over 7 consecutive days. Frequency distributions for each OTC Form item are reported.

RESULTS

One hundred eleven OTC Forms were completed. Adults aged 65 years or older were involved in 46% of all encounters. Pharmacists provided the only assistance in 41% of encounters and worked in partnership with other pharmacy staff for another 25% of encounters. Many encounters required the pharmacy staff to leave the prescription department, involved discussions about a variety of problems or symptoms, and lasted less than 3 minutes. Although the most prevalent encounter topic was locations of a particular product, about one-third of encounters involved either recommendations about a product or providing information about a product, and 41% involved communications about 2 or more topics. Finally, 11% of encounters generated a nondrug recommendation, and 8% resulted in a referral to a physician.

CONCLUSION

Pharmacists play a key role in ensuring that the benefits of OTC medications outweigh the risks, thereby providing an important resource for patient engagement about safe medication selection and use. Examining the features of OTC encounters creates an evidence base to promote best practices for OTC encounters, increasing pharmacists' ability to help people, especially older adults, navigate the intricacies of OTC medication use, without significantly increasing pharmacy staff workload.

Key stakeholder perspectives on the barriers and solutions to pharmacy practice towards complementary medicines: an Australian experience

BACKGROUND

Although pharmacists are entrusted to play a role in ensuring the safe and appropriate use of all medicines, in general, the inclusion of complementary medicines (CMs) into their professional practice has not been observed. The purpose of this study was to explore the perceptions and opinions of pharmacists and 8 key stakeholder leaders regarding the barriers that hinder pharmacists from providing care related to the use of CMs by patients/consumers and to identify solutions that would support pharmacists' in extending their role in this area.

METHODS

Semi-structured key informant interviews were conducted with 2 practicing pharmacists, 1 pharmacy owner, 1 key representative of a pharmacist professional organization, 1 key representative of a consumer advocacy group, 1 key representative of a medical professional organization, 1 key representative from a complementary medicine practitioner professional organization, 1 leader within a pharmacy school, 2 senior staff from a regulatory authority, and 1 key representative of the complementary medicine industry in Australia.

RESULTS

A total of 9 barriers were identified in this study. Barriers including a lack of CMs knowledge, doubts about the evidence-base, a lack of research skills and access to reliable and reputable information dominated the discussions. A total of 7 solutions were proposed. Of those, the integration of CMs curricula into under-graduate and professional pharmacy education, and defining a clearer role for pharmacists' standard of practice were considered the most important. Apposing opinions about the role of naturopaths in pharmacies were identified..

CONCLUSION

It is anticipated that pharmacists will be required to formalise a role in ensuring the safe and appropriate use of complementary medicines to fulfil their professional and ethical responsibilities. However, pharmacists in general are not ready to take up this extended role. Individual key stakeholder groups have considered the existing barriers and have proposed solutions that are isolated measures. To facilitate further developments related to CMs and the professional practice of pharmacy, collaborative efforts between key stakeholders are needed to strategically plan and execute an extended role in a unified manner.

Receipt and use of spoken and written over-the-counter medicine information: insights into Australian and UK consumers' experiences

OBJECTIVES

To explore Australian and UK consumers' receipt and use of spoken and written medicine information and examine the role of leaflets for consumers of over-the-counter (OTC) medicines.

METHODS

Semistructured interviews were conducted with 37 Australian and 39 UK consumers to explore information received with their most recent OTC medicine purchase, and how information was used at different times post-purchase. Interviews were audio-recorded, transcribed verbatim and thematically analysed.

KEY FINDINGS

Similarities were evident between the key themes identified from Australian and UK consumers' experiences. Consumers infrequently sought spoken information and reported that pharmacy staff provided minimal spoken information for OTC medicines. Leaflets were not always received or wanted and had a less salient role as an information source for repeat OTC purchases. Consumers tended not to read OTC labels or leaflets. Product familiarity led to consumers tending not to seek information on labels or leaflets. When labels were consulted, directions for use were commonly read. However, OTC medicine information in general was infrequently revisited.

CONCLUSIONS

As familiarity is not an infallible proxy for safe and effective medication use, strategies to promote the value and use of these OTC medicine information sources are important and needed. Minimal spoken information provision coupled with limited written information use may adversely impact medication safety in self-management.

Improving over-the-counter medication safety for older adults: A study protocol for a demonstration and dissemination study

BACKGROUND

Adverse drug events (ADEs) associated with over-the-counter (OTC) medications cause 178,000 hospitalizations each year. Older adults, aged 65 and older, are particularly vulnerable to ADEs. Of the 2.2 million older adults considered at risk for a major ADE, more than 50% are at risk due to concurrent use of an OTC and prescription medication.

OBJECTIVES

To refine the intervention and implementation strategy through diagnostic and formative evaluation; to evaluate the effectiveness of the intervention for preventing misuse of high-risk OTC medications by older adults; and to evaluate the implementation of the intervention in community pharmacies.

METHODS

A system redesign intervention to decrease high-risk OTC medication misuse will be tested to reduce misuse by improving communication between older adults and community pharmacists via the following features: a redesign of the physical environment to sensitize older adults to high-risk OTC medications, and the implementation of a clinical decision tool to support the pharmacist when critically evaluating the older adult's health status. The study will be conducted in three phases: a participatory design phase, a beta phase, and a test phase. The test phase will be conducted in three mass-merchandise stores. A total of 144 older adults will be recruited. A pre (control)/post (intervention) test will determine the effectiveness of the intervention. The primary outcome will be a comparison of proportion of older adults who misuse OTC medication from baseline to post-intervention. The process of implementation in the community pharmacy setting will be evaluated using the taxonomy proposed by Proctor et al. The participatory design phase has been approved by the institution's IRB (2016-0743).

PROJECTED IMPACT

It is anticipated that this project, which focuses on achieving systems-based improvement in an underemphasized area of the medication use process, will reduce ADEs associated with inappropriate OTC medication use in older adults.

A systematic review in select countries of the role of the pharmacist in consultations and sales of non-prescription medicines in community pharmacy

BACKGROUND

Much has been studied in regard to non-prescription medicines (NPMs), but the impact of greater emphasis toward patient self-selection of such agents is still not well understood, and evidence in the literature might be equivocal.

OBJECTIVE

The aim was to examine whether or not pharmacist interventions are important in the sale of NPMs and to summarize the evidence of pharmacists' contribution in maintaining patient safety and improving the quality of consultations involving NPMs.

METHODS

Seven online databases were searched to identify the literature on studies conducted within the UK and in countries comparable to the UK reporting on consultations and selling of NPMs published between 1980 and 2013. All study designs except for quantitative surveys were eligible for inclusion into the review. The data extraction and quality assessment were performed according to the National Institute for Health and Care Excellence guidelines. The data extracted from the studies were analyzed and presented qualitatively.

RESULTS

Eighty-three studies from an original 12,879 citations were included in this review. Just under half of the studies were published between 2000 and 2009 (n = 38; 46%). Thirty-three (44%) of the studies were conducted in the UK. The review showed that in terms of the contribution of community pharmacy staff in consultations for NPMs, non-pharmacist staff dealt with a large proportion of the consultations and pharmacists were usually involved in the consultation through referral from non-pharmacist staff member. Counseling was not consistently offered to everyone. Where counseling was provided it was not always of sufficient quality. Consultations were performed much better when symptoms were presented compared to when people made a direct product request. Pharmacists were reported to conduct better consultations than non-pharmacist staff. There was evidence to suggest that where counseling was appropriately provided this afforded the person a safe environment to utilize their NPMs.

CONCLUSIONS

Seeking methods to develop better engagement with customers accessing pharmacy services for NPMs is necessary to enhance the interaction between these two parties. Efforts to enhance the community pharmacy environment to bring about a more positive experience for people using pharmacy is needed at present and will be important if the model for the selection of NPMs is modified in the UK. More studies are needed to allow a better understanding of the impact self-selection may have on patient safety in the community pharmacy context.

A preliminary examination of over-the-counter medication misuse rates in older adults

BACKGROUND

Older adults are the largest consumers of over the counter (OTC) medications. Of the older adults who are at risk of a major adverse drug event, more than 50% of these events involve an OTC medication.

OBJECTIVE

To explore how older adults select and hypothetically use OTC medications and if the selected medications would be considered safe for use.

METHODS

Walking interviews were conducted with 20 community-dwelling older adults in a community pharmacy. Each participant selected an OTC medication for a hypothetical pain and sleep scenario. Data were analyzed for four types of misuse: drug-drug interaction, drug-disease interaction, drug-age interaction, and excess usage.

RESULTS

At least one instance of potential misuse was found in 95% of participants. For sleep medications, drug-drug interactions and drug-age interactions were more common, affecting 50% and 65% of participants respectively. The most common type of misuse noted in the pain products selected was that of drug-drug interaction, with a total of 39 occurrences, affecting 60% of the participants.

CONCLUSIONS

OTC misuse is common among older adults, and it is important for older adults to seek out resources, such as a pharmacist, to help them make safe OTC decisions.

Year in review: medication mishaps in the elderly

OBJECTIVE

This paper reviews articles from 2010 that examined medication mishaps (ie, medication errors and adverse drug events [ADEs]) in the elderly.

METHODS

The MEDLINE and EMBASE databases were searched for English-language articles published in 2010 using a combination of search terms including medication errors, medication adherence, medication compliance, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failures, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Five studies of note were selected for annotation and critique. From the literature search, this paper also generated a selected bibliography of manuscripts published in 2010 (excluding those previously published in the American Journal of Geriatric Pharmacotherapy or by one of the authors) that address various types of medication errors and ADEs in the elderly.

RESULTS

Three studies focused on types of medication errors. One study examined underuse (due to prescribing) as a type of medication error. This before-and-after study from the Netherlands reported that those who received comprehensive geriatric assessments had a reduction in the rate of undertreatment of chronic conditions by over one third (from 32.9% to 22.3%, P < 0.05). A second study focused on reducing medication errors due to the prescribing of potentially inappropriate medications. This quasi-experimental study found that a computerized provider order entry clinical decision support system decreased the number of potentially inappropriate medications ordered for patients ≥ 65 years of age who were hospitalized (11.56 before to 9.94 orders per day after, P < 0.001). The third medication error study was a cross-sectional phone survey of managed-care elders, which found that more blacks than whites had low antihypertensive medication adherence as per a self-reported measure (18.4% vs 12.3%, respectively; P < 0.001). Moreover, blacks used more complementary and alternative medicine (CAM) than whites for the treatment of hypertension (30.5% vs 24.7%, respectively; P = 0.005). In multivariable analyses stratified by race, blacks who used CAM were more likely than those who did not to have low antihypertensive medication adherence (prevalence rate ratio = 1.56; 95% CI, 1.14-2.15; P = 0.006). The remaining two studies addressed some form of medication-related adverse patient events. A case-control study of Medicare Advantage patients revealed for the first time that the use of skeletal muscle relaxants was associated significantly with an increased fracture risk (adjusted odds ratio = 1.40; 95% CI, 1.15-1.72; P < 0.001). This increased risk was even more pronounced with the concomitant use of benzodiazepines. Finally, a randomized controlled trial across 16 centers in France used a 1-week educational intervention about high-risk medications and ADEs directed at rehabilitation health care teams. Results indicated that the rate of ADEs in the intervention group was lower than that in the usual care group (22% vs 36%, respectively, P = 0.004).

CONCLUSION

Information from these studies may advance health professionals' understanding of medication errors and ADEs and may help guide research and clinical practices in years to come.

Public perception on the role of community pharmacists in self-medication and self-care in Hong Kong

BACKGROUND

The choices for self-medication in Hong Kong are much diversified, including western and Chinese medicines and food supplements. This study was to examine Hong Kong public knowledge, attitudes and behaviours regarding self-medication, self-care and the role of pharmacists in self-care.

METHODS

A cross-sectional phone survey was conducted, inviting people aged 18 or older to complete a 37-item questionnaire that was developed based on the Thematic Household surveys in Hong Kong, findings of the health prorfessional focus group discussions on pharmacist-led patient self management and literature. Telephone numbers were randomly selected from residential phone directories. Trained interviewers invited eligible persons to participate using the "last birthday method". Associations of demographic characteristics with knowledge, attitudes and beliefs on self-medication, self-care and role of pharmacists, and spending on over-the-counter (OTC) products were analysed statistically.

RESULTS

A total of 1, 560 phone calls were successfully made and 1, 104 respondents completed the survey which indicated a response rate of 70.8%. 63.1% had adequate knowledge on using OTC products. Those who had no formal education/had attended primary education (OR = 3.19, 95%CI 1.78-5.72; p < 0.001), had attended secondary education (OR = 1.50, 95%CI 1.03-2.19; p = 0.035), and aged ≥ 60 years (OR = 1.82, 95% CI 1.02-3.26; p = 0.042) were more likely to have inadequate knowledge on self-medication. People with chronic disease also tended to spend more than HKD100 on western (OR = 3.58, 95%CI 1.58-8.09; p = 0.002) and Chinese OTC products (OR = 2.94, 95%CI 1.08-7.95; p = 0.034). 94.6% believed that patients with chronic illnesses should self-manage their diseases. 68% agreed that they would consult a pharmacist before using OTC product but only 45% agreed that pharmacists could play a leading role in self-care. Most common reasons against pharmacist consultation on self-medication and self-care were uncertainty over the role of pharmacists and low acceptance level of pharmacists.

CONCLUSIONS

The majority of respondents supported patients with chronic illness to self-manage their diseases but less than half agreed to use a pharmacist-led approach in self-care. The government should consider developing doctors-pharmacists partnership programs in the community, enhancing the role of pharmacists in primary care and providing education to patients to improve their awareness on the role of pharmacists in self-medication and self-care.

Australian community pharmacists' practice in complementary medicines: a structural equation modeling approach

OBJECTIVE

This survey tested a model of factors influencing pharmacists' practice in relation to complementary medicines (CMs).

METHODS

Self-administered questionnaires were used to collect data from 212 community pharmacists in New South Wales. Structural equation modeling with AMOS version 6.0, was used to model two practices in relation to CMs: an evaluation of appropriateness of CM use and the decision to sell.

RESULTS

Pharmacists' perceptions of their responsibilities in ensuring the safe use of CMs predicted the comprehensiveness of an evaluation for appropriateness of CM use (P=0.002). When level of comprehensiveness of evaluation increased, pharmacists were less likely to sell CMs in situations where the use of the products was not considered appropriate (P=0.021). Pharmacists' confidence in their CM knowledge, attitudes towards CMs, concern about pharmacy income and pharmacists' characteristics did not significantly affect their practice.

CONCLUSION

Pharmacists' acceptance of their counseling responsibility with respect to CMs was the strongest predictor of both comprehensiveness of an evaluation and the decision to sell a CM.

PRACTICE IMPLICATIONS

Pharmacists must be encouraged to recognise and accept their responsibility in ensuring the safe and effective use of CMs.