Medication non-adherence in the elderly: how big is the problem?

Longitudinal Medication Adherence in Older Adults With Multimorbidity and Association With Health Care Utilization: Results From the Irish Longitudinal Study on Ageing

BACKGROUND

The association between objectively measured nonadherence and health care utilization in multimorbid older people is unclear.

OBJECTIVE

To measure medication adherence across multiple chronic conditions, identify adherence patterns, and estimate the association between adherence and self-reported health care utilization.

METHODS

This is a retrospective cohort study of multimorbid participants aged ≥70 years in the Irish LongituDinal Study on Ageing (TILDA). Eligible participants had linked pharmacy claims data and completed TILDA wave 2 (2 years after wave 1). The RxRisk-V tool was used to identify multimorbidity. Average adherence (AA) across RxRisk-V conditions was estimated using the CMA7 function (AdhereR). Group-based trajectory models (GBTMs) identified adherence patterns in the 12 months following wave 1. Negative binomial regression was used to estimate the association between adherence and the rate of subsequent self-reported general practitioner [GP] visits, emergency department (ED) visits, outpatient visits, and hospitalizations in the 12 months following adherence measurement (reported at wave 2). Adjusted Incident Rate Ratios (aIRR) and 95% CIs are presented.

RESULTS

Higher AA (CMA7) was associated with a small significant decrease in GP visit rate (aIRR = 0.70; CI = 0.53-0.94) and outpatient visit rate (aIRR = 0.44; CI = 0.23-0.81). GBTM identified 6 adherence groups (n = 1050). Compared with high adherers, group 1 (rapid decline, modest increase) membership (aIRR = 1.72; CI = 1.09-2.73) and group 4 (high adherence, delayed decline) membership (aIRR = 1.92; CI = 1.19-3.05) significantly increased ED visit rate.

CONCLUSION AND RELEVANCE

Suboptimal medication adherence in multimorbid older adults is associated with increased health care utilization. Identification of suboptimal adherence groups for medication management interventions may help decrease the health system burden and health care costs.

District nurses' use of a decision support and assessment tool to improve the quality and safety of medication use in older adults: a feasibility study

Aim:

To investigate whether district nurses (DNs) can identify factors related to the quality and safety of medication use among older patients via a clinical decision support system (CDSS) for medication and an instrument for assessing the safety of drug use [the Safe Medication Assessment tool (SMA)]. A secondary aim was to describe patients’ experiences of the assessment.

Background:

DNs in Stockholm County have the opportunity to establish special units at primary health care centers (PHCCs) for patients aged 75 years and older. The units conduct drug utilization reviews and create care plans for older adults.

Methods:

Nine DNs at 7 PHCCs in Stockholm County used the tools with 45 patients aged 75 years and older who used one or more drugs. Outcome measures were the number of drugs, potential drug-related problems, nursing interventions, and patient satisfaction. Prevalences of drug-related problems and nursing interventions were calculated. Eleven patients answered a telephone questionnaire on their experiences of the assessment.

Findings:

DNs identified factors indicative of drug-related problems, including polypharmacy (9.8 drugs per person), potential drug–drug interactions (prevalence 40%), potential adverse drug reactions (2.7 per person), and prescribers from more than two medical units (60%). DNs used several nursing interventions to improve the safety of medication use (e.g., patient education, initiating a pharmaceutical review). The patients thought it was meaningful to receive information about their drug use and important to identify potential drug-related problems. With the support of the CDSS and the SMA tool, the DNs could identify several factors related to inappropriate or unsafe medication and initiated a number of interventions to improve medication use. The patients were positive toward the assessments. Using these tools, the DNs may help promote safe medication use in older patients.

An exploration of the experiences of professionals supporting patients approaching the end of life in medicines management at home. A qualitative study

Background

The management of medicines towards the end of life can place increasing burdens and responsibilities on patients and families. This has received little attention yet it can be a source of great difficulty and distress patients and families. Dose administration aids can be useful for some patients but there is no evidence for their wide spread use or the implications for their use as patients become increasing unwell. The study aimed to explore how healthcare professionals describe the support they provide for patients to manage medications at home at end of life.

Methods

Qualitative interview study with thematic analysis. Participants were a purposive sample of 40 community healthcare professionals (including GPs, pharmacists, and specialist palliative care and community nurses) from across two English counties.

Results

Healthcare professionals reported a variety of ways in which they tried to support patients to take medications as prescribed. While the paper presents some solutions and strategies reported by professional respondents it was clear from both professional and patient/family caregiver accounts in the wider study that rather few professionals provided this kind of support. Standard solutions offered included: rationalising the number of medications; providing different formulations; explaining what medications were for and how best to take them. Dose administration aids were also regularly provided, and while useful for some, they posed a number of practical difficulties for palliative care. More challenging circumstances such as substance misuse and memory loss required more innovative strategies such as supporting ways to record medication taking; balancing restricted access to controlled drugs and appropriate pain management and supporting patient choice in medication use.

Conclusions

The burdens and responsibilities of managing medicines at home for patients approaching the end of life has not been widely recognised or understood. This paper considers some of the strategies reported by professionals in the study, and points to the great potential for a more widely proactive stance in supporting patients and family carers to understand and take their medicines effectively. By adopting tailored, and sometimes, ‘outside the box’ thinking professionals can identify immediate, simple solutions to the problems patients and families experience with managing medicines.

Evaluation of the French National Program on Home Return of Patients with Chronic Heart Failure (PRADO-IC): Pilot Study of 91 Patients During Its Deployment in the Bas Rhin Area

Objective: The main objective of this study was to evaluate the impact of the French national program on home return of chronic heart failure patients (PRADO-IC) in terms of re-hospitalizations for heart failure (HF) during its deployment in the Bas-Rhin (France). Patients and methods: This was a pilot, descriptive, quantitative, retrospective, and bi-centric study (University Hospitals of Strasbourg and Haguenau Hospital Center, France). It included all patients included in the PRADO-IC program from these centers between January 1, 2015 and December 31, 2015. The primary endpoint of our study was the evaluation of the number of 1-year, 6-month, and 30-day re-admissions to the hospital in relation to an acute HF episode, before and after the inclusion of patients in the PRADO-IC program. The secondary endpoints were the number of overall re-hospitalizations (all-cause); the number of days of hospitalization for HF; the time to first re-hospitalization and the average length of hospital stay, before and after inclusion in PRADO-IC; and the overall and cardiovascular mortality rates. Results: 91 patients out of 271 (33,6%) with a mean age of 79.2 years (67–94) were included. They all had chronic HF, essentially class II-III NYHA (90.1%), mostly of ischemic origin (41.9%), with altered left ventricular ejection fraction in 71.4% of cases. A reduction in the mean number of hospitalizations for HF per patient at 30 days, 6 months and 1 year was observed, respectively, from 0.18 ± 0.42 per patient before inclusion to 0.15 ± 0.36 after inclusion (p = 0.56); 0.98 ± 1.04 hospitalizations to 0.53 ± 0.81 at 6 months (p < 0.01); and 1.64 ± 1.14 hospitalizations 1.04 ± 1.05 at 1 year (p < 0.001). Patients were hospitalized less overall after inclusion in the PRADO-IC program. The number of days of hospitalization for HF was reduced after inclusion of patients from 18.02 ± 7.78 days before inclusion to 14.28 ± 11.57 days for the 6 month follow-up (p = 0.006), and from 22.07 ± 10.33 days before inclusion to 16.39 ± 15.94 days for the 1 year follow-up (p < 0.001). In contrast, inclusion in PRADO-IC statistically increased the mean time to first re-hospitalization for HF from mean 99.36 ± 72.39 days before inclusion to 148.11 ± 112.77 days after inclusion (p < 0.001). Conclusion: This study seems to demonstrate that the PRADO-IC program could improve the management of chronic HF patients in ambulatory care, particularly regarding HF re-hospitalization. However, due to the limitations of the methodology used and the small number of patients, it is advisable to consolidate its initial results with a randomized controlled study on a larger number of patients. In our opinion, its results need to be communicated because, to our knowledge, no equivalent study exists.

Hypertension and Drug Adherence in the Elderly

Hypertension is highly prevalent after the age of 65 years affecting more than 60% of individuals in developed countries. Today, there is sufficient evidence from clinical trials that treating elderly subjects with hypertension with antihypertensive medications has a positive benefit/risk ratio even in very elderly patients (>80 years). In recent years, partial or total non-adherence has been recognized as major issues in the long-term management of hypertension in all age categories. However, whether non-adherence is more frequent in hypertensive patients older than 65 years or not is still a matter of debate and the common belief is that adherence is lower in older than in younger patients. Are clinical data supporting this belief? In this brief review, we discuss the topic of drug adherence in elderly in the context of the medical treatment of hypertension. Studies show that drug adherence is actually better in patients aged 65 to 80 years when compared to younger hypertensive patients (<50 years). However, in very old patients (>80 years) the prevalence of non-adherence does increase. In this patients' group, there are specific risk factors for non-adherence such as cognitive ability, depression, and health believes, in addition to classical risk factors for non-adherence. One important aspect in the elderly is the prescription of potentially inappropriate medications that will interfere with the adherence to necessary treatments. In this context, an interesting new concept was developed few years ago, i.e., the process of deprescribing. Thus, today, in addition to conventional guidelines recommendations (use of single pill combinations, individualization of treatments), the evaluation of cognitive abilities, the regular assessment of potentially inappropriate medications, and the process of deprescribing appear to be three new additional steps to improve drug adherence in the elderly and thereby ameliorate the global management of hypertension.

Platelet-Rich Plasma (PRP) is a Potential Self-Sourced Cognition Booster in Elderly Mice

Background: A complex set of neurotrophic growth factors participates in neuroplasticity in the aging brain. Platelets are a copious source of growth factors, most of which display also the neurotropic activity. On this basis, we investigated behavioral and cognitive consequences of the administration of intravenous allogeneic platelet-rich plasma (PRP) in senescent mice.Methods: The animals (16-18 months old) were injected with either physiological saline or PRP which was acquired from age-matched counterparts and subjected to a battery of tests comprised of open-field, elevated-plus maze, tail suspension, and Morris water maze test.Results: We found that PRP treatment increases locomotion and improves learning and memory in elderly mice. Importantly, the PRP-treated animals did not exhibit any anxiety- or depression-like behaviors.Conclusion: The present study is the first to demonstrate that allogeneic PRP possesses beneficial effects against cognitive aging and it signifies that PRP may be used as a novel self-sourced treatment in age-related cognitive decline.

Assessment of post discharge medication prescription among Lebanese patients with cerebral infarction: Results of a cross-sectional study

OBJECTIVES

The study objective was to investigate the degree of physician adherence with the international guidelines for post-stroke discharge medications among Lebanese hospitals.

PATIENT AND METHODS

This retrospective observational study was conducted in three Lebanese hospitals between January 2016 and December 2017.

RESULTS

Out of 200 patients with stroke, 64.7 % were males. The difference of systolic blood pressure from baseline, 2 h, and after 24 h showed significant decrease by mean value 25.18 ± 33.45 (P < 0.001), and 6.44 ± 22.11 (P = 0.019) respectively. Also diastolic blood pressure showed significant decrease between baseline and after 24 h by a mean value 12.17 ± 13.63 (P value <0.001). Concerning post discharge medications adherence, antithrombotic drugs showed the highest percentage (73 %) followed by antihypertensive and lipid lowering agents by comparable results (47.5 % and 40.7 % respectively). The physician adherence for the three medications together showed (30.4 %).

CONCLUSION

Secondary prevention for critical diseases such as stroke appears to be inadequate in the study area.

Group-Based Trajectory Modeling to Identify Patterns of Adherence and Its Predictors Among Older Adults on Angiotensin-Converting Enzyme Inhibitors (ACEIs)/Angiotensin Receptor Blockers (ARBs)

PURPOSE

Commonly prescribed medications among patients with comorbid diabetes mellitus and hypertension include ARBs and ACEIs. However, these medications are associated with suboptimal adherence leading to inadequately controlled blood pressure. Unlike traditional single estimates of proportion of days covered (PDC), group-based trajectory modeling (GBTM) can graphically display the dynamic nature of adherence. The objective of this study was to evaluate adherence using GBTMs among patients prescribed ACEI/ARBs and identify predictors associated with each adherence trajectory.

PATIENTS AND METHODS

Patients with an ACEI/ARBs prescription were identified between July 2017 and December 2017 using a Medicare Advantage dataset. PDC was used to measure monthly patient adherence during the one-year follow-up period. The monthly PDC was added to a logistic group-based trajectory model to provide distinct patterns of adherence. Further, a multinomial logistic regression was conducted to determine predictors of each identified adherence trajectory. Predictors included various socio-demographic and clinical patient characteristics.

RESULTS

A total of 22,774 patients were included in the analysis and categorized into 4 distinct adherence trajectories: rapid decline (12.6%); adherent (58.5%); gaps in adherence (12.2%), and gradual decline (16.6%). Significant predictors associated with all lower adherence trajectories included 90 days refill, >2 number of other medications, ≥1 hospitalizations, and prevalent users. Significant predictors associated with the rapid decline trajectory included male sex, comorbidities, and increased CMS risk score. Further, significant predictors associated with the gaps in adherence trajectory included increasing age, and comorbidities. Lastly, significant predictors associated with the gradual decline trajectory included increasing age, no health plan subsidy, comorbidities, and increasing CMS risk score.

CONCLUSION

Identifying various patient characteristics associated with non-adherent trajectories can guide the development of tailored interventions to enhance adherence to ACEI/ARBs.

Daily Medication Management and Adherence in the Polymedicated Elderly: A Cross-Sectional Study in Portugal

The presence of age-related comorbidities prone elderly patients to the phenomenon of polypharmacy and consequently to a higher risk of nonadherence. Thus, this paper aims to characterize the medication consumption profile and explore the relationship of beliefs and daily medication management on medication adherence by home-dwelling polymedicated elderly people. A questionnaire on adherence, managing, and beliefs of medicines was applied to polymedicated patients with ≥65 years old, in primary care centers of the central region of Portugal. Of the 1089 participants, 47.7% were considered nonadherent. Forgetfulness (38.8%), difficulties in managing medication (14.3%), concerns with side effects (10.7%), and the price of medication (9.2%) were pointed as relevant medication nonadherence-related factors. It was observed that patients who had difficulties managing medicines, common forgetfulness, concerns with side effects, doubting the need for the medication, considered prices expensive, and had a lack of trust for some medicines had a higher risk of being nonadherent. This study provides relevant information concerning the daily routine and management of medicines that can be useful to the development of educational strategies to promote health literacy and improve medication adherence in polymedicated home-dwelling elderly.

Knowing What Others Know: Younger and Older Adults' Perspective-Taking and Memory for Medication Information

Health-related information can be important to communicate and remember, but we may not understand our own or others' memory abilities. In this study, younger and older adults estimated their performance before and after a cued-recall memory task in which they studied medication : side effect pairs. Participants also estimated the performance of a peer their own age, a medical student, and a person in the other age group (i.e., younger adults estimated older adults' performance and vice versa). In Experiment 1, participants completed four study-test cycles, each with new pairs. In Experiment 2, the same pairs were presented throughout. Overall, participants initially overestimated their memory performance, but after the task, several judgments were closer to participants' actual performance and that of their peers. Thus, people may not initially have accurate representations of how they and others remember health-related information, but these misconceptions may be ameliorated by testing and task experience.

The association between medication non-adherence and adverse health outcomes in ageing populations: A systematic review and meta-analysis

AIMS

The aim of this systematic review and meta-analysis was to synthesise the evidence relating to medication non-adherence and its association with health outcomes in people aged ≥50 years.

METHODS

Seven databases were searched up to February 2019 for observational studies that measured medication (non-)adherence as a predictor of the following health outcomes in adults aged ≥50 years: healthcare utilisation (hospitalisation, emergency department visits, outpatient visits and general practitioner visits), mortality, adverse clinical events and quality of life. Screening and quality assessment using validated criteria were completed by 2 reviewers independently. Random effects models were used to generate pooled estimates of association using adjusted study results. The full methodological approach was published on PROSPERO (ID: CRD42017077264).

RESULTS

Sixty-six studies were identified for qualitative synthesis, with 11 of these studies eligible for meta-analyses. A meta-analysis including 3 studies measuring medication non-adherence in adults aged ≥55 years showed a significant association with all-cause hospitalisation (adjusted odds ratio 1.17, 95% confidence interval [CI] 1.12, 1.21). A meta-analysis including 2 studies showed that medication non-adherence was not significantly associated with an emergency department visit (adjusted odds ratio 1.05, 95% CI 0.90, 1.22). Good adherence was associated with a 21% reduction in long-term mortality risk in comparison to medication non-adherence (adjusted hazard ratio 0.79, 95% CI 0.63, 0.98).

CONCLUSION

Medication non-adherence may be significantly associated with all-cause hospitalisation and mortality in older people. Medication adherence should be monitored and addressed in this cohort to minimise hospitalisation, improve clinical outcomes and reduce healthcare costs.

Adherence to anti-osteoporosis medication associated with lower mortality following hip fracture in older adults: a nationwide propensity score-matched cohort study

Background

We investigated the association of anti-osteoporosis medication with mortality risk in older adults with hip fractures and evaluated the influence of medication adherence on mortality.

Methods

We conducted a population-based cohort study and identified a total of 13,123 patients aged 65 years or older with hip fracture from the Taiwan National Health Insurance Database during the period 2001–2010. Individuals with (n = 2092) and without (n = 2092) receiving anti-osteoporosis medication were matched using propensity score matching (1:1 ratio). The 1-, 3- and 5-year survival rates after the index fracture were compared between patients with and without treatment. In the treated group, survival rate was compared between those with good and non-adherence. Good adherence was defined as the medication possession ratio of ≥80% and non-adherence as a ratio < 80%.

Results

The 1-, 3- and 5-year mortality rates were significantly lower in the treated vs. the non-treated group (all p < 0.0001). In the treated group, the estimated 1-, 3- and 5-year survival rates were higher in those with good adherence than in those with non-adherence (all p < 0.0001). Regarding all-cause mortality, the adjusted hazard ratio in the treated vs. the non-treated group was 0.63 (95% confidence interval 0.58–0.68, p < 0.0001). The good adherence subgroup showed a significantly lower mortality risk than that in the non-adherence subgroup (hazard ratio 0.41, 95% confidence interval 0.32–0.51, p < 0.0001).

Conclusions

The 1-, 3- and 5-year survival rates were significantly higher in patients receiving anti-osteoporosis medication than in the untreated group. All-cause mortality rates were lower in patients with good adherence to anti-osteoporosis medication.

Future Perspectives for Patient-Centric Pharmaceutical Drug Product Design with Regard to Solid Oral Dosage Forms

Purpose

Additional costs for healthcare provision are expected for cases where the level of care provided is not according to the patient’s needs and demands. To address these issues and reduce costs, fundamental changes need to be made on how healthcare provision is administered to patients, which raises the opportunity for the implementation of patient-centric systems.

Methods

This review addresses the importance of implementing a patient-centric approach in current healthcare provision and emphasizes the need to adjust current development and business models for a successful application of patient-centric care.

Results

To increase awareness and avoid confusion, the purpose of patient-centric pharmaceutical drug product design is reviewed in detail and future market opportunities for patient-centric drug products are discussed.

Conclusions

With regard to solid oral dosage forms, the subject of patient-centric pharmaceutical drug product design will focus more on the customization of existing technologies (e.g., dosage form size reduction) to address the needs of specific patient populations such as pediatrics, geriatrics, dysphagia patients, or the cognitively impaired.

Improving Medication Understanding and Adherence Using Principles of Memory and Metacognition: In Press - Policy Insights from Behavioral and Brain Sciences

More than half of older adults regularly take multiple medications. Rates of medication non-adherence are high, which undermines both patients' health and the economy. Memory and metacognitive factors (such as misplaced confidence) help explain why patients across the lifespan may not understand or follow prescribed regimens. These factors include difficulties in remembering confusing information; patients' and practitioners' potential overconfidence in memory; and misunderstandings about memory. Patients, practitioners, and the public can use these principles to improve memory, enhance understanding, and promote metacognitive accuracy with respect to complex medication information, which may increase the likelihood of adherence.

[Management of cancer patients with oral therapy at home in Brittany and Pays de la Loire areas: Survey (end of 2016) and cartography]

INTRODUCTION

The Cancer Observatory, from the OMEDITs (Observatory for Medicines and Medical Devices and Treatment Innovations) of Bretagne and Pays de la Loire areas has conducted a survey aiming to know and map the current practices of management of patients by Oral Anti-cancer Drug (OAD) in inter-region.

METHODS

Forty eight cancer centers received by e-mail in July and October 2016 a questionnaire concerning the management of OADs : from prescription by the specialist of oncology, to the intervention of the pharmacist (analysis and pharmaceutical consulting), to follow-up by nurse, as well as the financing of this activity and the feelings of the actors about this organizational set up.

RESULTS

Fifty-seven professionals from 31 centers, including the most important ones, responded to the survey. As a result, half of the establishments carry out a pharmaceutical analysis for some or all of the OAD prescriptions and only 30% carry out a pharmaceutical consulting. The nurse consultation is, on the other hand, more largely implanted (74% of the centers) as well as the telephone follow-up (6%). More than 90% of professionals believe that the organizational set up could be improved and more secure by, at least, the stronger involvement of pharmacists, the development of tools for nurse (for monitoring, therapeutic education…) and by improving the city-hospital link.

CONCLUSION

This survey shows the variability in the management of patients under OAD because of the lack of resources to ensure the fairness and sustainability of the organizational set up. The hospital/city link could still be optimized to secure patient care.

Cost-Related Medication Nonadherence Among Older Adults: Findings From a Nationally Representative Sample

OBJECTIVES

To estimate the rate of and risk factors associated with cost-related medication nonadherence among older adults.

DESIGN

Cross-sectional analysis of the 2017 National Health Interview Survey (NHIS).

SETTING

Nationally representative health interview survey in the United States.

PARTICIPANTS

Survey respondents, aged 65 years or older (n = 5701 unweighted) in the 2017 wave of the NHIS.

MEASUREMENTS

Self-reported, cost-related medication nonadherence (due to cost: skip dose, reduce dose, or delay or not fill a prescription) and actions taken due to cost-related medication nonadherence (ask for lower-cost prescription, use alternative therapy, or buy medications from another country) were quantified. We used a series of multivariable logistic regression analyses to identify factors associated with cost-related medication nonadherence. We also reported analyses by chronic disease subgroups.

RESULTS

In 2017, 408 (6.8%) of 5901 older adults, representative of 2.7 million older adults nationally, reported cost-related medication nonadherence. Among those with cost-related medication nonadherence, 44.2% asked a physician for lower-cost medications, 11.5% used alternative therapies, and 5.3% bought prescription drugs outside the United States to save money. Correlates independently associated with a higher likelihood of cost-related medication nonadherence included: younger age, female sex, lower socioeconomic levels (eg, low income and uninsured), mental distress, functional limitations, multimorbidities, and obesity (P < .05 for all). Similar patterns were found in subgroup analyses.

CONCLUSION

Cost-related medication nonadherence among older adults is increasingly common, with several potentially modifiable risk factors identified. Interventions, such as medication therapy management, may be needed to reduce cost-related medication nonadherence in older adults. J Am Geriatr Soc 67:2463-2473, 2019.

Medication Adherence: does Patient Participation in Randomized Clinical Trials Affect on it?

The article focuses on the problem of low adherence to treatment among patients, in general, and provides data on the high adherence among patients in randomized controlled trials. Low adherence remains one of the most debated and difficult problems to solve nowadays. Poor medication adherence of the patient can significantly worsen the effectiveness of treatment and leads to increased health care costs. And although the factors that improve adherence are varied, and include the skills of the doctor, the patient’s personal characteristics, the external environment, an individual approach to each patient and etc., the absence of a “gold standard” for assessing adherence in clinical practice makes it difficult to predict and significantly improve it among patients. Nevertheless, the article discusses the existing doctor-patient interaction model, which strictly regulates the algorithms and technical means to achieve the best medication adherence. Randomized clinical trials (RCT) are the basis of evidence-based medicine, the results obtained in RCT form the basis of existing clinical guidelines. While participating in RCT patients can receive comprehensive information about the disease, the effectiveness of drug therapy, possible side effects of the therapy being conducted, the research objectives and prognosis from their attending physician; patients are trained to be disciplined and adhere to the recommendations of the doctor. The RCT, for a number of objective reasons, uses a variety of methods for assessing adherence and ways to improve it, which leads to higher patient adherence then among patients in general.

Association between adherence to antihypertensive medications and health outcomes in middle and older aged community dwelling adults; results from the Irish longitudinal study on ageing

PURPOSE

To examine the association between antihypertensive medication (AHTM) implementation adherence and healthcare utilisation in community-dwelling adults aged ≥ 50 years in Ireland.

METHODS

This was a prospective cohort study. The Irish Longitudinal Study on Ageing (TILDA) was linked to pharmacy claims data for participants aged ≥ 50 years. Participants were included if they had ≥ 3 pharmacy claims for one or more AHTM (ATC codes 'C02', 'C03', 'C07', 'C08' or 'C09') within the year preceding the year of self-reported healthcare utilisation outcome occurrence. Outcomes included self-reported general practitioner (GP), emergency department (ED), outpatient department visits and hospital admissions. Implementation adherence was measured using proportion of days covered (PDC), with participants classified as adherent if the average PDC ≥ 0.8. Negative binomial models were used to analyse the association between AHTM adherence and number of GP, ED, outpatient visits and hospitalisations (adjusted IRR and 95% CI are presented).

RESULTS

One thousand four hundred thirty-one participants were included. The majority of participants (72.6%) were considered adherent. Good implementation adherence to AHTM was associated with a significant decrease in self-reported GP visits (adjusted IRR 0.91, 95% CI 0.83-0.99). Adherence had no significant impact on the number of ED visits, outpatient visits or hospitalisations reported by TILDA participants.

CONCLUSIONS

Good adherence to AHTM was associated with less self-reported GP visits in this population, suggesting improved overall health status. However, the impact of medication non-adherence on the other self-reported healthcare utilisation outcomes (ED, outpatient visits and hospitalisations) was not evident in this study.

HIV-infected patients aged above 75years

BACKGROUND

Little data is available on HIV-infected patients aged over 75years.

METHODS

A descriptive study of HIV-infected patients aged over 75years was conducted in six hospitals of the Pays de la Loire region, France. Socio-demographic, immuno-virological, and therapeutic characteristics were collected via an electronic medical record software (Nadis®). To assess frailty, a simplified geriatric assessment was conducted during an HIV routine visit.

RESULTS

Among the 3965 patients followed in the six centers, 65 (1.6%) were aged over 75years. From January to May 2016, 51 patients were included in the study: median age 78.7years, male patients 74.5%, homosexual transmission 41.2%, living at home 98% and single in 54.5% of cases, median duration of HIV infection 18.8years, median CD4 nadir 181 cells/mm³; CDC stage C 36.4%. All patients were on antiretroviral therapy and 98% of them had an HIV RNA<50c/mL; 82% of patients had at least one comorbidity and 58% at least two comorbidities. Eleven of 51 patients (21.6%) were diagnosed as at risk of frailty and 2/51 (3.9%) were considered frail. Cognitive disorders were diagnosed in 60.8%, depression in 35.3%, malnutrition in 25.5%, and vitamin D deficiency in 45.9%.

CONCLUSIONS

HIV-infected patients aged above 75years are well-managed, but the prevalence of geriatric comorbidities is high.

Pharmacokinetic and pharmacodynamic considerations in the treatment of the elderly patient with hypertension

INTRODUCTION

Hypertension is an important risk factor for developing cardiovascular diseases. It is more prevalent in the elderly population. Recently updated American and European guidelines recommend treating every elderly patient with hypertension independent of age, starting with a low dose of antihypertensive drugs. However, little information is available on the optimal dosages of antihypertensive drugs to treat the elderly safely. Areas covered: Comorbidities, co-medication and frailty status can alter the clinical outcome of drug treatment and can cause adverse events in the elderly. Also, due to pharmacokinetic and pharmacodynamic changes the interpatient variability when using antihypertensive drugs is considerable. In this review, an overview is given on the extent to which the previously mentioned parameters are changed in elderly patients and what this means for the exposure to antihypertensive medication. Also, recommendations on the starting dose of the most frequently used antihypertensive drugs are given based on literature data. Expert opinion: We believe that recommendations on starting dosages followed by a stepwise increase of dosages will lead to improved blood pressure control and less adverse drug reactions in the elderly patient. This may improve adherence to antihypertensive therapy.

[The monitoring of oral anticancer medicines administered at home]

Anticancer medicines evolve in terms of their mode of action as well as their galenics. The advent of oral therapies has multiple benefits such as the possibility of taking the treatments at home. However, what are the implications with regard to compliance, the management of side effects and the community-hospital relationship? Elderly patients, often isolated, taking several medicines and frail, are disorientated faced with all these medications and their side effects. A study was undertaken to evaluate the benefit of visits by private practice nurses to support patients taking oral cancer drugs.

Inhaler Technique and Adherence to Inhaled Medications among Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Vietnam

Sub-optimal chronic obstructive pulmonary disease (COPD) management has been found largely due to patients' medication non-adherence and incorrect inhaler technique. This study aimed to examine inhaler use technique and medication adherence among Vietnamese COPD patients as well as potential associated factors. A cross-sectional study involving 70 COPD exacerbators was conducted. Inhaler technique and adherence were evaluated by the 10-item and 12-item Test of Adherence to Inhaler (TAI). Data on the history of COPD, home prescription of inhalers and duration of hospitalization were also collected. Generalized linear regression models were used to determine the associated factors with inhaler use and medication adherence. The results showed that the proportion of patients with good inhaler technique was 22.7% for metered-dose inhalers (MDI), 30.4% for dry powder inhalers (DPI) and 31.8% for soft-mist inhalers (SMI). Full exhalation was the most common mistake. The rates of non-compliance patterns were: "ignorant" (77.1%), "sporadic" (58.6%), and "deliberate" (55.7%). Worse dyspnea, greater health condition impairment, and an increased frequency of exacerbations and hospitalizations were found to be associated negatively with correct inhaler use and treatment adherence. Instructions to COPD patients about using inhalers should focus on correct inhaler technique and adherence even when feeling healthy.

Predictive factors of adherence to urinary self-catheterization in older adults

AIMS

The primary aim is to explore the adherence predicting factors in clean intermittent self-catheterization (CISC) in patients aged over 65 years. The secondary aim is to assess whether in this population, the non-adherence risk is greater, compared with patients under 65.

METHODS

All patients older than 65 that successfully learned CISC between January 2011 and January 2016 were included. A control population younger than 65 matched with sex, body mass index, and pathology was selected.

RESULTS

One hundered and thirteen (66.9%) out of the 169 patients older than 65 included were adherent at 1 month, and 80 (47.3%) at 6-12 months. Obesity (P = 0.027), a low PP test (Pencil and Paper test) score (P = 0.037), significant urinary stress incontinence (SUI) (P = 0.048), and prescription of CISC less than three per day (P = 0.03) were the risk factors predicting stopping CISC at 1 month, but none was associated with non-adherence at 6-12 months. Compared with the younger group, age was a risk factor for poor adherence at 1 month.

CONCLUSION

Obesity, low PP test score, and important SUI are factors of poor adherence to CISC at 1 month in older adults. Necessity of more than three CISC per day is in favor of treatment continuation, possibly due to absence of spontaneous voiding in these patients. Long-term adherence to CISC in older adults in this study remains close to adherence to other treatments prescribed in urinary disorders, and thus shows that CISC could be an easily purposed therapeutic option in this population, either on a long-term or transitory basis.

Electrospun fixed dose formulations of amlodipine besylate and valsartan

Increasing numbers of elderly people require multi-drug therapies. One route to improve adherence rates is to prepare fixed dose combinations (FDCs), in which multiple active ingredients are loaded into a single formulation. Here, we report the use of electrospinning to prepare fast-dissolving oral FDCs containing amlodipine besylate and valsartan, two drugs prescribed as FDCs for the treatment of hypertension. Electrospun fibers were prepared loaded with one or both drugs, using polyvinylpyrrolidone as the polymer matrix. The fibers were largely cylindrical in morphology and comprise amorphous solid dispersions except with the highest loadings of amlodipine besylate. HPLC demonstrated drug entrapment efficiencies of >85% of the theoretical dose. The mats have folding endurances and thicknesses suitable for use as oral films. The amlodipine besylate-loaded systems are fast-dissolving, with >90% release obtained within 120 s. In contrast, valsartan release from its single-drug formulations took longer, ranging from 360 s to 24 min. With the FDC formulations, rapid release within 360 s was achieved when the loading was 5% w/w of each drug, but again the release time increased with drug loading. Electrospun fibers therefore have significant promise as FDCs, but the target drug and its loading need to be carefully considered.

Memantine ER Maintains Patient Response in Moderate to Severe Alzheimer's Disease: Post Hoc Analyses From a Randomized, Controlled, Clinical Trial of Patients Treated With Cholinesterase Inhibitors

Memantine extended release (ER) significantly outperformed placebo on co-primary endpoints of Clinician's Interview-based Impression of Change Plus Caregiver Input (CIBIC-Plus) and baseline to endpoint changes on the Severe Impairment Battery (SIB) in a 24-week, randomized trial (NCT00322153) in patients with moderate to severe Alzheimer's disease taking a cholinesterase inhibitor (ChEI). A post hoc analysis compared patients receiving memantine ER/ChEI to placebo/ChEI for time to onset of response and if the response was maintained (achieving improvement at weeks 8, 12, or 18 and maintaining through endpoint/week 24) on the SIB, the Neuropsychiatric Inventory (NPI), CIBIC-Plus, and Activities of Daily Living (ADL) using Fisher exact test. A second post hoc analysis compared percentages of patients for all possible combinations of 2 to 4 assessments with either no decline or clinically notable response using Wald χ. Significantly greater percentages of memantine ER/ChEI patients achieved an early response that was maintained on SIB, NPI, and CIBIC-Plus (P<0.05) versus placebo/ChEI. Significantly greater percentages of memantine ER/ChEI-treated patients achieved and maintained a clinically notable response on ADL/NPI, SIB/ADL/NPI, and SIB/ADL/CIBIC-Plus, compared with placebo/ChEI (P<0.05). Memantine ER results in early, maintained improvement in patients with moderate to severe Alzheimer's disease concurrently taking ChEIs, compared with cholinesterase treatment alone.

I. INTRODUCTION: UNDERSTANDING MEDICINES AND MEDICAL INTERVENTIONS

We live in an increasingly pharmacological and medical world, where children and adults frequently encounter alleged treatments for an enormous range of illnesses. How do we come to understand what heals and why? Here, 15 studies explore how 1,414 children (ages 5-11) and 882 adults construe the efficacies of different kinds of cures. Developmental patterns in folk physics, psychology, and biology lead to predictions about which expectations about cures will remain relatively constant across development and which will change. With respect to stability, we find that even young school children (ages 5-7) distinguish between physical and psychological disorders and the treatments most effective for each. In contrast, young children reason differently about temporal properties associated with cures. They often judge that dramatic departures from prescribed schedules will continue to be effective. Young children are also less likely than older ages to differentiate between the treatment needs of acute versus chronic disorders. Young children see medicines as agent-like entities that migrate only to afflicted regions while having "cure-all" properties, views that help explain their difficulties grasping side effects. They also differ from older children and adults by judging pain and effort as reducing, instead of enhancing, a treatment's power. Finally, across all studies, optimism about treatment efficacy declines with age. Taken together, these studies show major developmental changes in how children envision the ways medicines work in the body. Moreover, these findings link to broader patterns in cognitive development and have implications for how medicines should be explained to children.

Social network, autonomy, and adherence correlates of future time perspective in patients with head and neck cancer

OBJECTIVE

Socioemotional selectivity theory proposes that, with more limited future time perspective (FTP), the meaning of individual life goals shifts from instrumental and long-term goals, such as autonomy, to emotionally meaningful and short-term life goals, especially concerning meaningful social relationships. Adverse side effects of cancer therapy may conflict with the realization of emotionally meaningful goals leading to nonadherence. In line with the theoretical assumptions, this study aimed to investigate (a) associations among disease symptoms, physical and cognitive limitations, and FTP and (b) among FTP, family network size, striving for autonomy, and treatment adherence.

METHOD

One hundred fifty-seven patients (43-90 years; 75% male) with head and/or neck cancer of a German University Medical Centre completed a questionnaire measuring FTP, age, disease symptoms, physical and cognitive functioning, family network size, and treatment adherence. Autonomy was assessed with a card sort task.

RESULTS

A structural equation model yielded an acceptable fit χ² (28) = 44.41, P = .025, χ² /df = 1.59, root mean square error of approximation = 0.06 (90% CI = 0.02, 0.09), Tucker-Lewis Index = 0.92, and Comparative Fit Index = 0.96. An increased level of disease symptoms and physical and cognitive limitations was related to a shorter subjective FTP. Furthermore, individuals with a limited FTP reported a smaller family network, a lowered quest for autonomy, and lower treatment adherence.

CONCLUSIONS

Hypotheses derived from socioemotional selectivity theory were supported by the data. Longitudinal investigations should follow to corroborate findings and to focus on underlying mechanisms as improving patients FTP may play a crucial role in future disease management programs.

Evaluating practical support stroke survivors get with medicines and unmet needs in primary care: a survey

OBJECTIVES

To design a questionnaire and use it to explore unmet needs with practical aspects of medicine taking after stroke, predictors of medicine taking and to estimate the proportion of survivors who get support with daily medication taking.

DESIGN

Four workshops with stroke survivors and caregivers to design the questionnaire.A cross-sectional postal questionnaire in primary care.

SETTING

18 general practitioner practices in the East of England and London. Questionnaires posted between September 2016 and February 2017.

PARTICIPANTS

1687 stroke survivors living in the community outside institutional long-term care.

PRIMARY OUTCOME MEASURES

The proportion of community stroke survivors receiving support from caregivers for practical aspects of medicine taking; the proportion with unmet needs in this respect; the predictors of experiencing unmet needs and missing taking medications.

RESULTS

A five-item questionnaire was developed to cover the different aspects of medicine taking. 596/1687 (35%) questionnaires were returned. 56% reported getting help in at least one aspect of taking medication and 11% needing more help. 35% reported missing taking their medicines. Unmet needs were associated with receiving help with medications (OR 5.9, P<0.001), being on a higher number of medications (OR 1.2, P<0.001) and being dependent for activities of daily living (OR 4.9, P=0.001). Missing medication was associated with having unmet needs (OR 5.3, P<0.001), receiving help with medications (OR 2.1, P<0.001), being on a higher number of medicines (OR 1.1, P=0.008) and being older than 70 years (OR 0.6, P=0.006).

CONCLUSIONS

More than half of patients who replied needed help with taking medication, and 1 in 10 had unmet needs in this regard. Stroke survivors dependent on others have more unmet needs, are more likely to miss medicines and might benefit from focused clinical and research attention. Novel primary care interventions focusing on the practicalities of taking medicines are warranted.

Heart failure in the elderly: ten peculiar management considerations

Chronic heart failure (HF) is a disease with significantly higher prevalence in the elderly or patients older than 65 years old. Typically, older patients have more risk factors for HF, more comorbidities, and are more likely to have recurrent admissions for acute decompensations. With HF burden on health care systems primarily related to hospital and nursing home costs, it is critical that elderly patients are approached with a clear understanding of certain unique clinical, laboratory, imaging, and pharmacokinetic differences that can alter their management and outcomes. Psychosocial factors have major implications on adherence to therapy as well as decisions on advanced care for elderly HF patients. In this article, we highlight ten peculiar management considerations when approaching older patients with HF. We discuss issues related to epidemiology, diagnostic challenges, pharmacotherapy, and palliative care; all of which can impact this unique population and, more importantly, the disease burden as a whole.

Care relationships at stake? Home healthcare professionals' experiences with digital medicine dispensers - a qualitative study

BACKGROUND

Although digital technologies can mitigate the burdens of home healthcare services caused by an ageing population that lives at home longer with complex health problems, research on the impacts and consequences of digitalised remote communication between patients and caregivers is lacking. The present study explores how home healthcare professionals had experienced the introduction of digital medicine dispensers and their influence on patient-caregiver relationships.

METHODS

The multi-case study comprised semi-structured interviews with 21 healthcare professionals whose home healthcare service involved using the digital medicine dispensers. The constant comparative method was used for data analyses.

RESULTS

Altogether, interviewed healthcare professionals reported three main technology-related impacts upon their patient-caregiver relationships. First, national and local pressure to increase efficiency had troubled their relationships with patients who suspected that municipalities have sought to lower costs by reducing and digitalising services. Participants reported having to consider such worries when introducing technologies into their services. Second, participants reported a shift towards empowering patients. Digital technology can empower patients who value their independence, whereas safety is more important for other patients. Healthcare professionals needed to ensure that replacing care tasks with technology implies safe and improved care. Third, the safety and quality of digital healthcare services continues to depend upon surveillance and control mechanisms that compensate for less face-to-face monitoring. Participants did not consider the possibility that surveillance exposes information about patients' everyday lives to be problematic, but to constitute opportunities for adjusting services to meet patients' needs.

CONCLUSIONS

Technologies such as digital medicine dispensers can improve the efficiency of healthcare services and enhance patients' independence when introduced in a way that empowers patients as well as safeguards trust and service quality. Conversely, the patient-caregiver relationship can suffer if the technology does not meet patients' needs and fails to offer safe and trustworthy services. Upon introducing technology, home healthcare professionals therefore need to carefully consider the benefits and possible disadvantages of the technology. Ethical implications for both individuals and societies need to be further discussed.

Understanding the Medication Adherence Strategies of Older Adults with Hypertension

Many older adults are living with at least one chronic disease and must adhere to prescribed medication to mitigate and control its impact. Hypertension is one chronic disease that affects a significant portion of the world’s population, especially older adults, and is responsible for a high number of annual deaths. It is asymptomatic, meaning that there are no perceptible symptoms and, as such, older adults may struggle with adhering to their prescribed antihypertensive medications. How one internalizes the disease may influence the degree of success in managing the condition. The current study analyzed archival data from a multifaceted prospective memory intervention for older adults with hypertension who were nonadherent to their medication. We coded their responses to self-management interview questions to identify the common themes regarding the knowledge and sense of control the older adults held relevant to managing their illness. Participants’ responses revealed how they internalized hypertension and their medication, as well as the strategies and goals they reportedly used to manage the illness. The association strategy was found to be the most commonly used within participants’ routines. In addition, many participants expressed a general lack of knowledge about the disease or their medication, and their goals regarding hypertension management were general and inexplicit (e.g., “to reduce their blood pressure). This information informs the design of more effective and longer-lasting interventions geared toward significantly improving the medication adherence of older adults diagnosed with hypertension.

Improving Medication Adherence and Health Outcomes in Older Adults: An Evidence-Based Review of Randomized Controlled Trials

BACKGROUND

Poor medication adherence is a major public health problem in older adults often resulting in negative health outcomes.

OBJECTIVE

The objective of this review was to provide an updated summary of evidence from randomized controlled studies to determine whether interventions aimed at improving medication adherence also improve the health outcomes of older adults residing in community-based settings.

METHODS

Articles that assessed medication adherence interventions and related health outcomes in elderly individuals were identified through searches of MEDLINE (1970-June 2016), the Cochrane Database of Systematic Reviews (through to June 2016), and Google Scholar. Across the 12 included studies, interventions were grouped into three main categories: behavioral/educational (n = 3), pharmacist-led (n = 7), and reminder/simplification (n = 2).

RESULTS

Among the behavioral/educational intervention studies, two showed improvements in both adherence and related health outcomes, whereas one found no changes in adherence or health outcomes. Among the pharmacist-led studies, three showed improvements in both adherence and related health outcomes, while three reported no changes in adherence or health outcomes. One found an improvement in adherence but not health outcomes. Among the reminder/simplification studies, both studies reported improvements in adherence without a significant impact on related health outcomes.

CONCLUSION

This evidence-based review of medication adherence interventions in older adults revealed promising strategies in the larger context of a largely mixed body of literature. Future patient-centered and multidisciplinary interventions should be developed and tested using evidence-based principles to improve medication adherence and health outcomes in older adults.

Antihypertensive Medication Adherence and Risk of Cardiovascular Disease Among Older Adults: A Population-Based Cohort Study

BACKGROUND

Antihypertension medication (antihypertensive) adherence lowers risk of cardiovascular disease (CVD); few studies have examined this association among older adults.

METHODS AND RESULTS

We assessed this association among Medicare fee-for-service beneficiaries aged 66 to 79 years who were newly diagnosed with hypertension and initiated on antihypertensives in 2008-2009 (n=155 597). We calculated proportion of days covered (PDC) during follow-up, using proportional subdistribution hazard models, to examine association between antihypertensive adherence and a composite CVD outcomes, including first incident of fatal/nonfatal acute myocardial infarction, ischemic heart disease, stroke/transient ischemic attack, and heart failure. During follow-up (median 5.8 years and 798 621 person-years), we documented 47 198 CVD events. Among beneficiaries, 60.8%, 30.3%, and 8.9% had PDC ≥80%, 40% to 79%, and <40%. Crude incidence of CVD events were 40.1 (95% CI, 40.0-40.1), 93.9 (93.8-93.9), and 98.1 (98.1-98.2) per 1000 person-years for PDC ≥80%, 40% to 79%, and <40%, respectively. Adjusted hazard ratios for CVD events were 1.0 (<40% as reference), 1.0 (0.97-1.03) for 40% to 79%, and 0.44 (0.42-0.45) for ≥80% (P<0.001). Dose-response analysis suggested a nonlinear relationship between PDC and risk for CVD events with a protective effect of ≥80%. The pattern of associations between PDC and ischemic heart disease, stroke/transient ischemic attack, and heart failure were largely consistent as for CVD events and across different groups.

CONCLUSIONS

Antihypertensive adherence was associated with a significantly lower risk of CVD events among older adults. There appeared to be a threshold effect in reducing CVD events at around PDC 80%, above which the risk for CVD reduced substantially.

Improving medication adherence among community-dwelling seniors with cognitive impairment: a systematic review of interventions

Background Medication non-adherence may lead to poor therapeutic outcomes. Cognitive functions deteriorate with age, contributing to decreased adherence. Interventions have been tested to improve adherence in seniors with cognitive impairment or Alzheimer disease (AD), but high-quality systematic reviews are lacking. It remains unclear which interventions are promising. Objectives We conducted a systematic review to identify, describe, and evaluate interventions aimed at improving medication adherence among seniors with any type of cognitive impairment. Methods Following NICE guidance, databases and websites were searched using combinations of controlled and free vocabulary. All adherence-enhancing interventions and study designs were considered. Studies had to include community dwelling seniors, aged 65 years or older, with cognitive impairment, receiving at least one medication for a chronic condition, and an adherence measure. Study characteristics and methodological quality were assessed. Results We identified 13 interventions, including six RCTs. Two studies were of poor, nine of low/medium and two of high quality. Seven studies had sample sizes below 50 and six interventions focused on adherence to AD medication. Six interventions tested a behavioral, four a medication oriented, two an educational and one a multi-faceted approach. Studies rarely assessed therapeutic outcomes. All but one intervention showed improved adherence. Conclusion Three medium quality studies showed better adherence with patches than with pills for AD treatment. Promising interventions used educational or reminding strategies, including one high quality RCT. Nine studies were of low/moderate quality. High quality RCTs using a theoretical framework for intervention selection are needed to identify strategies for improved adherence in these seniors.

Adherence to oral cancer therapy in older adults: The International Society of Geriatric Oncology (SIOG) taskforce recommendations

There is an increasing trend towards using oral systemic therapy in patients with cancer. Compared to parenteral therapy, oral cancer agents offer convenience, have similar efficacy, and are preferred by patients, consequently making its use appealing in older adults. However, adherence is required to ensure its efficacy and to avoid compromising treatment outcomes, especially when the treatment goal is curative, or in case of symptomatic/rapidly progressing disease, where dose-intensity is important. This opens a new challenge for clinicians, as optimizing patient adherence is challenging, particularly due to lack of consensus and scarcity of available clinical evidence. This manuscript aims to review the impact of age-related factors on adherence, summarize the evidence on adherence, recommend methods for selecting patients suitable for oral cancer agents, and advise monitoring interventions to promote adherence to treatment.

A systematic review of medication non-adherence in persons with dementia or cognitive impairment

Background

Adherence to medication is vital for disease management while simultaneously reducing healthcare expenditure. Older persons with cognitive impairment (CI) are at risk for non-adherence as cognitive processes are needed to manage medications. This systematic review focuses on the relationship between medication non-adherence and specific cognitive domains in persons with CI, and explores determinants of medication non-adherence. When available, relationships and factors are compared with cognitively intact populations.

Methods

A seven database systematic search of studies published between 1 January 1949–31 December 2015 examining medication non-adherence in community dwelling persons with CI or dementia was conducted. Articles reporting medication non-adherence in people with CI or dementia in the community, with or without caregiver supports were eligible for inclusion. Papers reporting adherence to treatments in cognitively intact populations, populations from hospital or institutional settings, for non-prescribed medication or those describing dementia as a factor predicting medication non-adherence were excluded. Data on study and population characteristics, research design, data sources and analysis, specific cognitive domains, non-adherence prevalence, measurement of adherence, salient findings, factors associated with adherence and strategies to improve medication adherence were extracted. Study limitations included inconsistencies between data sources and definitions, resulting in a loss of fidelity in the value and comprehensiveness of data, as well as exclusion of non-pharmacological treatments and regimens.

Findings

Fifteen studies met inclusion criteria. Adherence among CI subjects ranged from 10.7%-38% with better rates of adherence in non-CI individuals. Medication non-adherence definitions varied considerably. New-learning, memory and executive functioning were associated with improved adherence and formed the focus of most studies. Multiple factors were identified as modulators of non-adherence.

Conclusion

This review highlights a gap in knowledge on how specific cognitive domains contribute to medication non-adherence amongst CI populations, and demonstrates the current focus is limited to two domains: memory and executive functioning.

Search For The Ideal Antithrombotic Drug: Utopian Task Likely Is Implemented Already

Atrial fibrillation is the most prevalent cardiac arrhythmia with a high risk of ischemic stroke. Thromboprophylaxis plays a key role in prevention of cardioembolic and non-cardioembolic events. Oral antithrombotic drugs are most often used to reduce hypercoagulable state. Patients may suffer from both under- and overtreatment compromising the outcomes. Medication peculiarities at large are well-known and widely debated. Non-adherence to antithrombotic drug regimen poses a significant risk of stroke. There is a pressing need for more detailed delineation of risk factors, namely by incorporation of the letter "N" (meaning "Non-adherence to drug therapy") into the well-known risk score alphanumeric display: CHA₂DS₂N-VASc. Better delineation of risk factors related to antithrombotic treatment as well as those related to treatment for congestive heart failure, hypertension, diabetes are desirable. Similarly, the bleeding risk score formula HAS-BLED might be improved by an additional risk factor, marked as the symbol "E", meaning "Excessive antithrombotic dosing" i.e. HAS-BLEDE. Improved formulas would help raise the predictive scores value and awareness for clinicians facing the problem of non-adherence to treatment regimen. If patients properly followed the prescribed drug therapy regimen it would potentially reveal that we already have ideal or near ideal antithrombotic drug(s). These drugs, herein non-specified, are widely used, but due to non-adherence they are not categorized as the best ones. That is why considerable efforts are focused on continued research and new developments.

Characterization of drug and alcohol use among senior drivers fatally injured in U.S. motor vehicle collisions, 2008-2012

OBJECTIVE

Adults 65 years of age and older comprise the fastest growing demographic in the United States. As substance use is projected to increase in this population, there is concern that more seniors will drive under the influence of impairing drugs. The purpose of this analysis was to characterize the drug and alcohol usage among senior drivers fatally injured (FI) in traffic collisions.

METHODS

Data from the Fatality Analysis Reporting System were analyzed from 2008 to 2012. Commonly used classes and specific drugs were explored. Rates of drug use, multiple drugs, concomitant drug and alcohol use, and alcohol use alone were generated using Poisson regression with robust error variance estimation. Rates were compared to a reference population of FI middle-aged drivers (30 to 50 years old) using rate ratios.

RESULTS

Drug use among FI senior drivers occurred in 20.0% of those tested. Among drug-positive FI senior drivers, narcotics and depressants were frequent. The prevalence of testing positive for any drug, multiple drugs, combined drug and alcohol, and alcohol use alone among FI seniors were 47% less (relative risk [RR] = 0.53, 95% confidence interval [CI], 0.47, 0.62), 59% less (RR = 0.41, 95% CI, 0.34, 0.51), 87% less (RR = 0.13, 95% CI, 0.09, 0.19), and 77% less (RR = 0.23, 95% CI, 0.19, 0.28), respectively, compared to FI middle-aged drivers.

CONCLUSIONS

Though overall drug use is less common among FI senior drivers relative to FI middle-aged drivers, driving under the influence of drugs may be a relevant traffic safety concern in a portion of this population.

[Safety of antirheumatic drug treatment in the elderly]

Mainly due to the general demographic changes and decreasing mortality in rheumatic diseases based on therapeutic progress, the proportion of older patients treated by rheumatologists is growing. Drug treatment in the elderly, however, harbors certain risks including age-specific pharmacokinetic features and high rates of multimorbidity and polypharmacy resulting in a risk of drug interactions and adherence problems. Nevertheless, older patients suffering from rheumatic diseases ought to be treated with the same intensity and same targets as the younger counterparts. Bearing all these facts in mind it is a balancing act for rheumatologists to find an optimal treatment for the individual elderly patient. Fear of risks should not lead to hesitant use of drugs leaving these patients alone with treatment deficits, as some studies have suggested.

Influence of inhaler technique on asthma and COPD control: a multicenter experience

BACKGROUND

The successful management of asthma and chronic obstructive pulmonary disease (COPD) mostly depends on adherence to inhalation drug therapy, the usage of which is commonly associated with many difficulties in real life. Improvement of patients' adherence to inhalation technique could lead to a better outcome in the treatment of asthma and COPD.

OBJECTIVE

The aim of this study was to assess the utility of inhalation technique in clinical and functional control of asthma and COPD during a 3-month follow-up.

METHODS

A total of 312 patients with asthma or COPD who used dry powder Turbuhaler were enrolled in this observational study. During three visits (once a month), training in seven-step inhalation technique was given and it was practically demonstrated. Correctness of patients' usage of inhaler was assessed in three visits by scoring each of the seven steps during administration of inhaler dose. Assessment of disease control was done at each visit and evaluated as: fully controlled, partially controlled, or uncontrolled. Patients' subjective perception of the simplicity of inhalation technique, disease control, and quality of life were assessed by using specially designed questionnaires.

RESULTS

Significant improvement in inhalation technique was achieved after the third visit compared to the first one, as measured by the seven-step inhaler usage score (5.94 and 6.82, respectively; P<0.001). Improvement of disease control significantly increased from visit 1 to visit 2 (53.9% and 74.5%, respectively; P<0.001) and from visit 2 to visit 3 (74.5% and 77%, respectively; P<0.001). Patients' subjective assessment of symptoms and quality of life significantly improved from visit 1 to visit 3 (P<0.001).

CONCLUSION

Adherence to inhalation therapy is one of the key factors of successful respiratory disease treatment. Therefore, health care professionals should insist on educational programs aimed at improving patients' inhalation technique with different devices, resulting in better long-term disease control and improved quality of life.

Impact of depression and anxiety disorders on adherence to oral hypoglycemics in older adults with diabetes mellitus in Canada

The prevalence of diabetes mellitus is increasing in Canada, and nonadherence to oral hypoglycemics is a common problem among older adults. This study aims to document the impact of depression and anxiety disorders on adherence to oral hypoglycemics in older adults with diabetes mellitus. Data used in this study came from the longitudinal Quebec survey on senior's health (Enquête sur la Santé des Ainés), using a representative sample of 2811 older adults aged 65 and over. The final sample for analysis consisted of 301 patients who received oral hypoglycemic pharmacotherapy. Medication adherence was measured with the medication possession ratio. An adapted version of Andersen's behavioral model was used to explain adherence to oral hypoglycemic medication while considering the following predisposing factors: age, gender, and level of education: enabling factors: marital status and income level: and need factors: physical and mental health status. Our explanatory model of oral hypoglycemic medication adherence was tested using a latent growth curve model. The results of the multiple-group analysis did not show any significant difference in oral hypoglycemic medication adherence (p > 0.05). Furthermore, individuals with higher levels of education were less adherent to oral hypoglycemics than those with lower levels of education (p < 0.05). Medication adherence to oral hypoglycemics did not show any significant difference between participants with and without depression and anxiety disorders. Future studies with larger samples are needed to fully explore the association between mental disorders and oral hypoglycemic medication adherence in the older adult populations.

Development of the Purposeful Action Medication-Taking Questionnaire

This three-phase study describes the development and psychometric properties of the Medication-Taking Questionnaire (MTQ) to measure the purposeful action domain (reasons individuals decide to accept medication treatment) in the medication adherence model for hypertension. During Phase I, items were evaluated for content validity and clarity. Item analysis, internal consistency, and exploratory factor analysis were preformed during Phase II to finalize the MTQ: Purposeful Action as 12 items and 2 subscales (treatment benefits and medication safety). Phase III evaluated the MTQ: Purposeful Action for temporal stability and construct validity. The final version MTQ: Purposeful Action demonstrated good internal consistency, temporal stability, and construct validity. The MTQ: Purposeful Action appears to have good psychometric characteristics that represent the decision-making process for adherence in medication treatment for hypertension.