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

Medication review in hospitalised patients to reduce morbidity and mortality

BACKGROUND

Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug-related harms and less favourable effectiveness. The concept of medication review is a key element in improving the quality of prescribing and in preventing adverse drug events. Although there is no generally accepted definition of medication review, it can be broadly defined as a systematic assessment of pharmacotherapy for an individual patient that aims to optimise patient medication by providing a recommendation or by making a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes.

OBJECTIVES

We examined whether delivery of a medication review by a physician, pharmacist or other healthcare professional leads to improvement in health outcomes of hospitalised adult patients compared with standard care.

SEARCH METHODS

We searched the Specialised Register of the Cochrane Effective Practice and Organisation of Care (EPOC) Group; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to November 2014, as well as International Pharmaceutical Abstracts and Web of Science to May 2015. In addition, we searched reference lists of included trials and relevant reviews. We searched trials registries and contacted experts to identify additional published and unpublished trials. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of medication review in hospitalised adult patients. We excluded trials of outclinic and paediatric patients. Our primary outcome was all-cause mortality, and secondary outcomes included hospital readmissions, emergency department contacts and adverse drug events.

DATA COLLECTION AND ANALYSIS

Two review authors independently included trials, extracted data and assessed trials for risk of bias. We contacted trial authors for clarification of data and for additional unpublished data. We calculated risk ratios for dichotomous data and mean differences for continuous data (with 95% confidence intervals (CIs)). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall certainty of evidence for the most important outcomes.

MAIN RESULTS

We identified 6600 references (4647 references in our initial review) and included 10 trials (3575 participants). Follow-up ranged from 30 days to one year. Nine trials provided mortality data (3218 participants, 466 events), with a risk ratio of 1.02 (95% CI 0.87 to 1.19) (low-certainty evidence). Seven trials provided hospital readmission data (2843 participants, 1043 events) with a risk ratio of 0.95 (95% CI 0.87 to 1.04) (high-certainty evidence). Four trials provided emergency department contact data (1442 participants, 244 events) with a risk ratio of 0.73 (95% CI 0.52 to 1.03) (low-certainty evidence). The estimated reduction in emergency department contacts of 27% (with a CI ranging from 48% reduction to 3% increase in contacts) corresponds to a number needed to treat for an additional beneficial outcome of 37 for a low-risk population and 12 for a high-risk population over one year. Subgroup and sensitivity analyses did not significantly alter our results.

AUTHORS' CONCLUSIONS

We found no evidence that medication review reduces mortality or hospital readmissions, although we did find evidence that medication review may reduce emergency department contacts. However, because of short follow-up ranging from 30 days to one year, important treatment effects may have been overlooked. High-quality trials with long-term follow-up (i.e. at least up to a year) are needed to provide more definitive evidence for the effect of medication review on clinically important outcomes such as mortality, readmissions and emergency department contacts, and on outcomes such as adverse events. Therefore, if used in clinical practice, medication reviews should be undertaken as part of a clinical trial with long-term follow-up.

Cost and Consequences of Nonadherence With Oral Bisphosphonate Therapy: Findings From a Real-World Data Analysis

BACKGROUND

Adherence to osteoporosis treatment remains poor despite available treatments and physician and patient education. This study aims to determine the effect of low adherence in real-world data.

OBJECTIVE

To examine the association between adherence with oral bisphosphonate therapy and fracture risk as well as health care resource utilization.

METHODS

Women included in this retrospective analysis were 55 years or older and had started oral bisphosphonate therapy between 2005 and 2011 in a large not-for-profit health care center in Israel. Adherence to therapy was measured by the medication possession ratio (MPR) during the first year from therapy initiation. Patients with MPR lower than 70% were considered nonadherent. Study outcomes were osteoporotic fracture events and health care utilization (including physician visits and hospitalizations) during the second year from therapy initiation.

RESULTS

Among the 17 770 women included in the analysis (mean age = 66.5 years; SD = ±8.3 years), 48.9% were nonadherent to therapy during the first year of treatment. Osteoporotic fracture risks during the second year among adherent and nonadherent patients were 2.1% and 2.5%, respectively (P = 0.1). When analysis was limited to patients 75 years or older, nonadherence with bisphosphonates was associated with an adjusted odds ratio of 1.49 (95% CI = 1.08-2.04) for osteoporotic fractures compared with adherent patients. Nonadherent patients had 13.4% higher medical costs than their adherent counterparts among patients 75 years and older (P = 0.002).

CONCLUSIONS

In patients 75 years and older, nonadherence with oral bisphosphonates can be associated with significantly greater short-term risk of osteoporotic fractures and higher utilization of health care services.

Initial development of the Systems Approach to Home Medication Management (SAHMM) model

BACKGROUND

Adverse drug events and medication nonadherence are two problems associated with prescription medication use for chronic conditions. These issues often develop because patients have difficulty managing their medications at home. To guide patients and providers for achieving safe and effective medication use at home, the Systems Approach to Home Medication Management (SAHMM) model was derived from a systems engineering model for health care workplace safety.

OBJECTIVE

To explore how well concepts from the SAHMM model can represent home medication management by using patient descriptions of how they take prescription medications at home.

METHODS

Twelve patients were interviewed about home medication management using an interview guide based on the factors of the SAHMM model. Each interview was audio-taped and then transcribed verbatim. Interviews were coded to identify themes for home medication management using MAXQDA for Windows.

RESULTS

SAHMM concepts extracted from the coded interview transcripts included work system components of person, tasks, tools & technology, internal environment, external environment, and household. Concepts also addressed work processes and work outcomes for home medication management.

CONCLUSIONS

Using the SAHMM model for studying patients' home medication management is a promising approach to improving our understanding of the factors that influence patient adherence to medication and the development of adverse drug events.

Adherence to Oral Antihyperglycemic Agents Among Older Adults With Mental Disorders and Its Effect on Health Care Costs, Quebec, Canada, 2005-2008

Introduction

Nonadherence to oral antihyperglycemic agents (OHAs) leads to an increase in use of health care resources and overall expenditures due to type 2 diabetes and its complications. People with type 2 diabetes are almost twice as likely to have anxiety and depression as the general population. Our aim was to examine health care costs associated with adherence to OHAs and the effect of depression and anxiety disorders on these in older adults with type 2 diabetes.

Methods

We used data from a representative sample (N = 2,811) of community-dwelling adults in Quebec aged 65 years or older who participated in the Étude sur la Santé des Aînés survey. The final sample consisted of 301 participants who were diagnosed with type 2 diabetes and who were taking OHAs. Total health care costs were calculated as the sum of the costs of hospitalizations and outpatient clinic services. Adherence to OHAs was measured using the medication possession ratio. Depression and anxiety disorders were assessed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. We also analyzed data by the Charlson Comorbidity Index, age, sex, education, and marital status, using generalized linear models.

Results

Nonadherence among people without depression or anxiety was associated with higher total health care costs ($4,477; 95% confidence interval [CI], $3,754–$5,201; P < .001), as was nonadherence among people with depression or anxiety ($11,124; 95% CI, $9,685–$12,562; P < .001).

Conclusion

Improving adherence to OHAs among people with type 2 diabetes, particularly those with underlying mental disorders such as depression or anxiety, can decrease health care costs.

Geriatric assessment for oncologists

The world is experiencing aging of its population. Age-specific incidence rates of cancer are higher and cancer is now recognized as a part of aging. Treating older patients can be challenging. The clinical behavior of some tumors changes with age and the aging process itself brings physiological changes leading to decline in the function of organs. It is essential to identify those patients with longer life expectancy, potentially more likely to benefit from aggressive treatment vs. those that are more vulnerable to adverse outcomes. A primary determination when considering therapy for an older cancer patient is a patient's physiologic, rather than chronologic age. In order to differentiate amongst patients of the same age, it is useful to determine if a patient is fit or frail. Frail older adults have multiple chronic conditions and difficulties maintaining independence. They may be more vulnerable to therapy toxicities, and may not have substantial lasting benefits from therapy. Geriatric assessment (GA) may be used as a tool to determine reversible deficits and devise treatment strategies to mitigate such deficits. GA is also used in treatment decision making by clinicians, helping to risk stratify patients prior to potentially high-risk therapy. An important practical aspect of GA is the feasibility of incorporating it into a busy oncology practice. Key considerations in performing the GA include: available resources, patient population, GA tools to use, and who will be responsible for using the GA results and develop care plans. Challenges in implementing GA in clinical practice will be discussed.

Self-reported medication adherence and beliefs among elderly in multi-treatment: a cross-sectional study

AIM

To evaluate the association between adherence to treatment and beliefs about medications in multi-treated elderly patients.

BACKGROUND

A large body of evidence documented the importance of adherence to therapy in predicting clinical outcomes, and the association between adherence and medication beliefs in patients of various ages and with different health conditions. However, so far only a few studies have specifically investigated the associations between medication beliefs and adherence among elderly in polypharmacy.

METHODS

In this multicenter cross-sectional study we used the MMAS-8 and BMQ Scales to assess medication adherence and beliefs about medications, respectively.

RESULTS

The final sample consisted of 567 patients. Patients reporting higher levels of necessity or concerns about their medicines showed higher adherence (OR: 1.61, and 2.02, respectively; both p<.001). Accepting patients (high necessity and low concerns) were less likely (OR: 0.24; p<.001) to report adherence than ambivalent ones (high necessity and concerns).

CONCLUSIONS

Medication adherence is related to high necessity and concern about treatment. In nursing practice it is important to understand the specific barriers to adherence and to engage patients in the implementation of strategies to improve adherence.

Pharmacotherapy and Adherence Issues in Treating Elderly Patients with Glaucoma

Glaucoma is a leading cause of visual morbidity throughout the world and is an age-related condition, the prevalence of which rises significantly with increasing age. Glaucoma, a condition affecting the optic nerve, has a variety of subtypes with multiple aetiological factors, the most important of which are intraocular pressure (IOP) and increasing age. Treatment by lowering of IOP is the only current method, for which there is evidence, by which the rate of progressive visual deterioration can be slowed or halted. Although there are surgical and laser treatments that are efficacious in lowering IOP, the most common manner in which patients with glaucoma control their IOP is with administration of daily topical ocular hypotensive drugs (eye drops). The variety of topical drugs utilised in the management of glaucoma all have the potential to have adverse effects and/or interactions with concomitant medications, many of which may be used for other age-related conditions. Adherence with appropriate medicines has a major effect on the outcome of medical conditions and this aspect applies to the management of glaucoma. There are certain specific issues that relate to the administration of topical agents, with respect to both adverse effects and adherence. Although many suspect poor adherence in elderly patients with glaucoma, relative to younger patients, adequate evidence for this is lacking. Furthermore, the manner by which adherence issues could be improved remains inadequately understood and poorly addressed. The aims of this article were to review, from a clinical perspective, the medical therapies currently used for glaucoma and discuss adherence issues with respect to the population of patients with glaucoma, who tend to be relatively elderly.

The Differential Outcomes Procedure Enhances Adherence to Treatment: A Simulated Study with Healthy Adults

Memory for medical recommendations is a prerequisite for good adherence to treatment, and therefore to ameliorate the negative effects of the disease, a problem that mainly affects people with memory deficits. We conducted a simulated study to test the utility of a procedure (the differential outcomes procedure, DOP) that may improve adherence to treatment by increasing the patient's learning and retention of medical recommendations regarding medication. The DOP requires the structure of a conditional discriminative learning task in which correct choice responses to specific stimulus-stimulus associations are reinforced with a particular reinforcer or outcome. In two experiments, participants had to learn and retain in their memory the pills that were associated with particular disorders. To assess whether the DOP improved long-term retention of the learned disorder/pill associations, participants were asked to perform two recognition memory tests, 1 h and 1 week after completing the learning phase. The results showed that compared with the standard non-differential outcomes procedure, the DOP produced better learning and long-term retention of the previously learned associations. These findings suggest that the DOP can be used as a useful complementary technique in intervention programs targeted at increasing adherence to clinical recommendations.

Real-world evaluation of compliance and preference in Alzheimer's disease treatment

Purpose

Rivastigmine transdermal patch has shown higher caregiver satisfaction and greater preference than oral formulation in patients with Alzheimer’s disease. However, there is limited literature available related to caregiver preference or treatment compliance in real-world clinical settings. To date, no such data are available from Asia and the Middle East, which account for a sizeable proportion of patients with Alzheimer’s disease. The objective of this study was to evaluate treatment preference and compliance with oral and transdermal medications in daily clinical practice in an ethnically diverse patient population from Asia and the Middle East with mild-to-moderate Alzheimer’s disease.

Patients and methods

RECAP (Real-world Evaluation of Compliance And Preference in the treatment of Alzheimer’s disease) was a 24-week, multicenter, prospective, noninterventional study. Two treatment cohorts were observed during the study: oral (cholinesterase inhibitors or memantine) and transdermal (rivastigmine patch). Caregiver preference, physician preference, and patient compliance were evaluated at week 24.

Results

A total of 978 of 1,931 enrolled patients (mean age: 72.8 years; 50.5% female) were in the transdermal cohort. For patients with exposure to both oral and transdermal monotherapy (n=330), a significant caregivers’ preference for the transdermal monotherapy was observed (82.7%; P<0.0001). Of the 89 participating physicians, 71 indicated preference for transdermal monotherapy. Patient compliance was also significantly higher for transdermal than oral monotherapy (P<0.0001).

Conclusion

Our study showed higher caregiver and physician preference and greater patient compliance with transdermal monotherapy in daily practice.

Suboptimal inhaler medication adherence and incorrect technique are common among chronic obstructive pulmonary disease patients

Patients with chronic obstructive pulmonary disease (COPD) are routinely prescribed one or more inhaled medications. Adherence to inhaler medications and correct inhaler device technique are crucial to successful COPD management. The goals of this study were to estimate adherence and inhaler technique in a cohort of COPD patients. This was an observational study conducted on a sample of 150 COPD patients. Medication adherence was assessed using the Medication Adherence Report Scale (MARS). Inhaler technique was assessed using standardized checklists. Clinical data were collected using a proforma. Of the 150 patients (mean age 70.3 years, 52% male), 58% reported suboptimal adherence (MARS ≤ 24). High adherence to therapy (MARS = 25) was associated with older age (p = 0.001), but not any of the other studied variables. Medication non-adherence was not associated with COPD exacerbations. Errors (≥ 1) in inhaler technique were common across all of the types of inhaler devices reportedly used by patients, with the highest proportion of errors among Turbuhaler users (83%) and the least proportion of errors among Handihaler users (50%). No clinical variables were associated with errors in inhaler technique. Suboptimal adherence and errors in inhaler technique are common among COPD patients. No clinical variables to assist in the prediction of medication non-adherence and poor inhaler technique were identifiable. Consequently, regular assessment of medication adherence and inhaler technique should be incorporated into routine clinical practice to facilitate improved health outcomes among patients with COPD.

Medication Underuse in Aging Outpatients with Cardiovascular Disease: Prevalence, Determinants, and Outcomes in a Prospective Cohort Study

BACKGROUND

Cardiovascular disease is a leading cause of death in older people, and the impact of being exposed or not exposed to preventive cardiovascular medicines is accordingly high. Underutilization of beneficial drugs is common, but prevalence estimates differ across settings, knowledge on predictors is limited, and clinical consequences are rarely investigated.

METHODS

Using data from a prospective population-based cohort study, we assessed the prevalence, determinants, and outcomes of medication underuse based on cardiovascular criteria from Screening Tool To Alert to Right Treatment (START).

RESULTS

Medication underuse was present in 69.1% of 1454 included participants (mean age 71.1 ± 6.1 years) and was significantly associated with frailty (odds ratio: 2.11 [95% confidence interval: 1.24-3.63]), body mass index (1.03 [1.01-1.07] per kg/m2), and inversely with the number of prescribed drugs (0.84 [0.79-0.88] per drug). Using this information for adjustment in a follow-up evaluation (mean follow-up time 2.24 years) on cardiovascular and competing outcomes, we found no association of medication underuse with cardiovascular events (fatal and non-fatal) (hazard ratio: 1.00 [0.65-1.56]), but observed a significant association of medication underuse with competing deaths from non-cardiovascular causes (2.52 [1.01-6.30]).

CONCLUSION

Medication underuse was associated with frailty and adverse non-cardiovascular clinical outcomes. This may suggest that cardiovascular drugs were withheld because of serious co-morbidity or that concurrent illness can preclude benefit from cardiovascular prevention. In the latter case, adapted prescribing criteria should be developed and evaluated in those patients.

Developing technologies for the elderly: To whom are we really developing?

The increasing number of older adults worldwide boosted the proposal of applications specifically targeting their needs. While the elderly serve as the target audience, this article argues that in many cases they are being treated as any other age group, disregarding their unique characteristics and expectations, which might eventually result in applications that, despite being used by the elderly, are adapted applications to cope with their disabilities, instead of approaches that leverage their abilities and views. As a first step of this discussion, this article aims to show how, in different stages of design and development, we are jump-starting the whole process putting our own assumptions and views where those of the elderly should be.

[Self-medication among black African hypertensive patients: Factors and consequences]

INTRODUCTION

Self-medication practice is under-evaluated among black African hypertensive patients.

AIM

To assess the level of self-medication among black African hypertensive patients and to determine the factors favoring this practice and their consequences.

METHODS

Prospective study during a 3-month period including 612 hypertensive patients followed in Abidjan cardiology institute.

RESULTS

Mean age was 55.1. The patients had a self-medication use in 60.1% of cases. Medicinal plants and derived products were commonly involved. Self-medication use reasons were: influence of relatives (89.8%) and the fear of antihypertensive drugs adverses effects (54.9%). Multivariate analysis shows that factors of self-medication were age (56.6 years vs. 50.3 years, P<0.001), income less than 762 euros/month (88% vs. 75.4%; OR=2.73; 95% CI: 1.62-4.6; P<0,0001), obesity (70.4% vs. 35.6%; OR=1.24; 95% CI: 0.75-1.15; P=0.037), dyslipidemia (40.8% vs. 27.9%; OR=6.72; 95% CI: 0.57-2.13; P=0.043), antihypertensive association therapy (61.7% vs. 51.4%; OR=2.27; 95% CI: 0.25-0.97; P=0.037). Poor control of high blood pressure (HBP) was a consequence of self-medication (6.5% vs. 47.1%; OR=10.27; 95% CI: 4.65-56.4; P=0.034), repercussions of HBP on major organ (75% vs. 17.2%; OR=12.9; 95% CI: 8.5-19.6; P=0.0001).

CONCLUSION

Self-medication is a common practice in African hypertensive patients. It has many consequences.

Adherence to therapy and adverse drug reactions: is there a link?

INTRODUCTION

Advances in biomedical technology and access to effective medications have resulted in significant improvements in patient survival and quality of life. Patient adherence is crucial to quality healthcare outcomes; however, achievement of consistent adherence remains difficult. Patient non-adherence represents an important health problem, from a clinical/economic viewpoint, being associated with reduced treatment benefits and significant financial burden. Non-adherence potentially leads to adverse drug events (ADEs), which are generally responsible for poorer health outcomes and avoidable resource misuse. Further, adverse drug reactions (ADRs) exemplify one of the most significant barriers to patients' medication-taking behavior with further detrimental clinical/economic outcomes.

AREAS COVERED

The authors review adherence definitions and its measurement, emphasizing the consequences of the New European Pharmacovigilance Legislation on ADR definition. They analyzed the causes and the clinical/economic consequences of non-adherence and ADEs/ADRs in order to highlight a possible causal link.

EXPERT OPINION

Careful assessment of this harmful relationship is crucial in planning for the interventions needed to improve effectiveness of pharmacological care and to safeguard the sustainability of healthcare systems. Finally, through the 'deactivation' of this link, there will be more chance that advances in healthcare technologies will realize their potential to reduce the burden of chronic illness.

What is patient adherence? A terminology overview

It is well known that patient adherence to appropriately prescribed medications is essential for treatment efficacy and positive therapeutic outcomes. It is also understood that patients who are prescribed medications do not necessarily take them as prescribed. Indeed, variation in patients' medication-taking is an age old conundrum which remains the focus of much interest amongst researchers and clinicians owing to its far-reaching consequences. Despite the extensive adherence-related research over the last four decades and a recent surge in this field, there remains a lack of uniformity in the terminology used to describe adherence and its related concepts. In turn, it is often difficult to conduct comparisons between adherence-related studies, which may be associated with the non-cumulative nature of work in this field. The purpose of this commentary is to provide an overview of key terminology relating to the field of adherence research.

Antihypertensive medication persistence 1-year post-stroke hospitalization

To optimize the translation of clinical trial evidence that antihypertensive treatment reduces recurrent stroke risk into clinical practice, it is important to assess the frequency of long-term antihypertensive drug persistence after stroke and identify the factors associated with low persistence. Structured telephone interviews to determine antihypertensive regimen persistence 1-year post-stroke hospitalization were conducted in 270 stroke survivors, of which 212 (78.5%) were discharged on antihypertensive therapy (two thirds on >1 drug class). Continued use of any antihypertensive agent at 1 year of follow-up was relatively high (87.3%); however, persistence on all or two or more drug classes prescribed at discharge was relatively low (38.7%). Continued use varied by drug class, with the highest rates among angiotensin-converting enzyme inhibitor (69.1%) and the lowest rates among diuretic (24.4%) users. Black patients (adjusted odds ratio, 0.35; 95% confidence interval, 0.16-0.78) and those with a high comorbidity burden (adjusted odds ratio , 0.39; 95% confidence interval, 0.18-0.86) were less likely to exhibit persistence on prescribed treatments 1-year post-stroke hospitalization. These results indicate the need for further study to identify appropriate persistence of antihypertensive therapies for secondary stroke prevention and to investigate reasons for racial disparities in persistence on prescribed treatments in a real-world clinical setting.

Attitudes toward psychotropic medications among patients with chronic psychiatric disorders and their family caregivers

AIM

To examine attitudes towards psychotropic medications among patients with chronic psychiatric disorders as well as their family caregivers by using factor analysis.

MATERIALS AND METHODS

The study included 200 patients and their family caregivers with chronic psychiatric disorders who are attending the psychiatry outpatient services. A self-designed 18-item self-rated questionnaire was used to evaluate the attitude toward psychotropics and factor analysis was done to study the different models of attitudes.

RESULTS

In general both patients and caregivers had positive attitude toward the psychotropic medications and there was no significant difference between the patients and caregivers on the various items of the questionnaire assessing the attitude. Factor analysis of the questionnaire indicated that either two-factor or four-factor models explained the attitude of the patients and caregivers. In the two-factor model there was one positive and one negative attitude factor, whereas the four-factor model comprised of two positive and two negative attitude factors. The four-factor model of attitudes provided a more comprehensive solution to how attitudes might be formed among patients and their family caregivers. Factors one and four in the four-factor solution still reflected positive attitudes, but appeared to portray a risk-benefit approach, in which benefits such as the efficacy of psychotropic medications in treating mental illnesses and preventing relapse, and medications being better than other options were being contrasted with the risks of side effects and permanent damage or harm.

CONCLUSION

Attitudes of patients with chronic psychiatric disorders and their caregivers toward psychotropic medications appear to be shaped by factors such as perceived efficacy or benefit from medicines, the necessity for taking treatment and concerns such as side effects, harm or expense.

Characteristics of patients with COPD newly prescribed a long-acting bronchodilator: a retrospective cohort study

Introduction

This study aimed to characterize patients with chronic obstructive pulmonary disease (COPD) newly prescribed a long-acting bronchodilator (LABD), and to assess changes in medication over 24 months.

Methods

A cohort of patients with COPD aged ≥40 years newly prescribed an LABD between January 1, 2007 and December 31, 2009 were identified from the Truven Marketscan^® Commercial Database (Truven Health Analytics, Ann Arbor, MI, USA) and followed for 24 months. Inclusion criteria included no prior prescription for an LABD or inhaled corticosteroids for 12 months prior to the LABD index date (baseline). Patient characteristics were examined. As LABDs were mainly long-acting muscarinic antagonists (LAMAs), additions, switches, discontinuation, adherence to (medication possession ratio), and persistence (proportion of days covered) with LAMA monotherapy were assessed for 24 months following the index date. Adherence and persistence with long-acting β₂-agonists (LABAs) were also assessed.

Results

A cohort of 3,268 patients aged 40–65 years was identified (mean age 55.8 years, 48% male). LAMA monotherapy was prescribed to 93% of patients who received an LABD. During the 24-month follow-up, 16% of these patients added COPD medication, 10% switched to an inhaled corticosteroid-containing medication, and 25% discontinued after one LAMA prescription at baseline. Over 12 and 24 months, adherence to LAMA was 40% and 33%, respectively, and adherence to LABA was 29% and 24%, respectively. Over the same time periods, persistence with LAMA monotherapy was 19% and 15%, respectively, and persistence with LABA was 9% and 7%, respectively.

Conclusion

Adherence to newly initiated LAMA monotherapy was low, with one in four patients adding to or switching from LAMA and many patients discontinuing therapy. Adherence to LABA was also low. These results suggest that additional medication to a single LABD may be required in some patients with COPD to achieve optimal disease control.

Attitudes and preferences on the use of mobile health technology and health games for self-management: interviews with older adults on anticoagulation therapy

Background

Older adults are at substantial risk for cardiovascular disorders that may require anticoagulation therapy. Those on warfarin therapy report dissatisfaction and reduced quality of life (QOL) resulting from the treatment. Advances in the area of mobile health (mHealth) technology have resulted in the design and development of new patient-centric models for the provision of personalized health care services to improve care delivery. However, there is a paucity of research examining the effectiveness of mHealth tools on knowledge, attitudes, and patient satisfaction with treatment, as well as self-management, adherence to therapy, and QOL in older adults with chronic illness conditions requiring long-term warfarin therapy.

Objective

The objective of the study was to explore the attitudes and preferences of older adults on warfarin therapy regarding the use of mHealth technology and health games to gain skills for self-management.

Methods

We conducted group and individual interviews with patients (60 years or older) on warfarin therapy at two anticoagulation clinics affiliated with an academic medical center. We held 4 group and 2 individual interviews, resulting in 11 patient participants and 2 family caregiver participants. We used structured questions on three topic areas including medication self-management strategies, mHealth technology use, and health games for exercise. We demonstrated some commercial health apps related to medication management, vitamin K content of food, and a videogame for balance exercise. Discussions were audiotaped and transcribed verbatim. Common themes were drawn using content analysis.

Results

The participants reported awareness of the importance of staying on schedule with warfarin therapy. They also acknowledged that negative experiences of friends or family members who were taking warfarin influenced their desire to keep on schedule with warfarin therapy. In addition, the participants expressed that the use of mHealth technology may be helpful for medication management. They also expressed the need for family support in the use of health technology devices. Moreover, the participants discussed concerns and challenges to use health technology and health games, and provided suggestions on ways to make mHealth technology and health games elder-friendly.

Conclusions

These findings indicate that our older adults on warfarin therapy are interested in mHealth technology specific to warfarin medication management and health games. Further research needs to be done to validate these findings. Elder-friendly designs, technology support, and physical safety using mHealth technology may be useful in this population. These findings can be used to inform a larger study to design and test an elder-centered mHealth technology in this target population.

Medicines management support to older people: understanding the context of systems failure

OBJECTIVES

Changing demographics and pressures on the healthcare system mean that more older people with complex medical problems need to be supported in primary and community care settings. The challenge of managing medicines effectively in frail elderly patients is considerable. Our research investigates what can go wrong and why, and seeks insight into the context that might set the scene for system failure.

SETTING

North London; a district general hospital and surrounding health authorities.

PARTICIPANTS

7 patients who had been admitted to hospital and 16 informants involved in their care.

DESIGN

Patients with preventable medication-related admissions were identified in an occurrence screening study. An accident investigation approach was used to create case studies from accounts of staff involved in each patient's care prior to their admission. Structured analysis of case studies according to the accident investigation approach was complemented by a separate analysis of interviews using open coding with constant comparison to identify and illustrate higher-level contextual themes.

OUTCOMES

The study sheds light on care management problems, their causes and the context in which care management problems and their causes have occurred.

RESULTS

Care management problems were rooted in issues with decision-making, information support and communications among staff members and between staff, patients and carers. Poor judgement, slips and deviations from best practice were attributed to task overload and complexity. Within general practice, at the interface with community services and with hospitals, we identified disruption to traditional intraprofessional and interprofessional roles, assumptions, channels and media of communication which together created conditions that might compromise patient safety.

CONCLUSIONS

New ways of working driven by the ethos of productivity are disrupting traditional intraprofessional and interprofessional roles, assumptions, channels and media of communication. Concomitant improvements in communications technology, process and protocol are urgently required to offset potentially serious risks to patient safety.

What’s in a name? Compliance, adherence and concordance in chronic psychiatric disorders

About half or more of the patients with chronic psychiatric illnesses, either do not take their medications correctly, or completely stop taking them. The problem of poor initial compliance or adherence is often compounded by a continued decline in compliance/adherence over time. The failure to take medicines, adversely affects the outcome of treatment, and places a huge burden of wasted resources on the society. Three terms have been used to describe medication-taking among patients with chronic psychiatric disorders. Compliance is defined as “the extent to which the patient’s behaviour matches the prescriber’s recommendations”. Though compliance has been frequently employed to describe medication-taking behaviour, it has proved problematic because it refers to a process where the clinician decides on a suitable treatment, which the patient is expected to comply with unquestioningly. Studies over the past few decades have emphasized the importance of patients’ perspectives in medication-taking, based on their own beliefs, their personal circumstances, the information and resources available for them. Adherence has been used as a replacement for compliance in an effort to place the clinician-patient relationship in its proper perspective. Adherence refers to a process, in which the appropriate treatment is decided after a proper discussion with the patient. It also implies that the patient is under no compulsion to accept a particular treatment, and is not to be held solely responsible for the occurrence of non-adherence. Adherence has been defined as “the extent to which a person’s behaviour, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider”. To overcome certain problems in the concept of adherence, a third term concordance has been used. The concept of concordance has evolved from a narrower view, emphasizing an agreement between the clinician and the patient, which takes into account each other’s perspective on medication-taking, to a broader process consisting of open discussions with the patient regarding medication-taking, imparting information and supporting patients on long-term medication. It is a process, which entertains patients’ views on medication-taking, and acknowledges that patients’ views have to be respected even if they make choices, which appear to be in conflict with the clinician’s views. Although none of these terms are ideal solutions to understanding the complex process of medication-taking behaviour of patients, the move from compliance to adherence and concordance represents genuine progress in this field, which puts the patient’s perceptions at the centre of the whole process.

Adherence to premixed insulin in a prefilled pen compared with a vial/syringe in people with diabetes in Singapore

BACKGROUND

The real-world clinical effectiveness of exogenous insulin is limited by nonadherence. Various insulin delivery systems have been developed to help improve adherence, with prefilled pens gaining popularity among adult Singaporeans with diabetes. However, adherence to insulin in people with diabetes in Singapore and most of Asia has not been studied.

OBJECTIVES

This study aimed to compare adherence to premixed insulin formulated in a prefilled pen versus a vial/syringe and to identify predictors of adherence in 955 patients managed at the outpatient clinics of the largest acute care hospital in Singapore.

METHODS

In this retrospective longitudinal study, electronic medical and pharmacy refill records were used to determine adherence to insulin over 24 months, measured in terms of compliance and persistence. Compliance is expressed as the medication possession ratio (used as continuous and categorical variables), and persistence is reported as a dichotomous variable with a permissible refill gap of 30 days before discontinuation of therapy is considered. Multivariate linear or logistic regression analysis was used to identify predictors of adherence.

RESULTS

Compared with prefilled pen users, vial/syringe users were older (mean [SD] age, 64.1 [10.6] vs 62.4 [11.9] years; P = 0.032), and more were undergoing polypharmacy (69.6% vs 54.1%; P < 0.001). The mean (SD) medication possession ratio was comparable in vial/syringe versus prefilled pen users (83.8% [26.9%] vs 86.0% [23.2%]; P = 0.266). Prefilled pen users were more persistent with therapy compared with vial/syringe users (odds ratio = 1.36; 95% CI, 1.01-1.86) after adjusting for sociodemographic and clinical covariates. Median time to discontinuation of therapy was comparable (vial/syringe vs prefilled pen: 409 vs 532 days; P = 0.076). Being managed by an endocrinologist and not receiving government subsidies were significant predictors of persistence.

CONCLUSIONS

Compared with other studies that found strong associations between adherence and insulin devices, the findings of this study suggest that persistence but not compliance varies by insulin device. The willingness to pay for health care, in addition to affordability, may affect insulin therapy adherence. Patients with uncontrolled diabetes due to suspected nonadherence may benefit from referral to a multidisciplinary care team comprising endocrinologists, diabetes nurse educators, dietitians, and allied health professionals. These findings are applicable to outpatients with similar demographic features managed at other acute care hospitals in Singapore. The impact of insulin devices on glycemic control needs to be investigated in future larger studies.

A comparison of usual care, a patient-centred education intervention and motivational interviewing to improve medication adherence and readmissions of adults in an acute-care setting

AIM

To compare medication adherence and readmissions in patients who received usual care vs. patient-centred interventions.

BACKGROUND

Medication adherence is a complex behaviour that may be improved with patient-centred strategies.

METHOD

A non-concurrent convenience sample of 303 hospitalised patients received either usual care (n = 98) or patient-centred interventions (n = 205). Intervention patients received teach-back and medication tools (n = 137) or motivational interviewing (n = 68). Data were collected at discharge (T1), at 48-72 hours (T2) and 30 days after discharge (T3).

RESULTS

No significant differences were found in medication adherence, therapeutic alliance, patients' experience and readmissions between groups. Patients in the motivational interview group reported lower confidence with medication adherence at T1 (P = 0.01) and T2 (P = 0.00) than the patient-centred intervention group. Motivational interviewing was a significant predictor (β = -1.55, P = 0.01, OR 0.21, 95% CI 0.06, 0.72) of fewer readmissions.

CONCLUSION

Overall, patients reported very low levels of non-adherence and very high levels of confidence and importance of medication adherence.

IMPLICATIONS FOR NURSING MANAGEMENT

Medication adherence continues to be an important area for clinical inquiry. For those patients who lack confidence for medication adherence, comprehensive patient-centred strategies such as motivational interviewing may improve treatment outcomes.

Intentional non-adherence to medications by older adults

'The extent to which an individual's medication-taking behaviour and/or execution of lifestyle changes, corresponds with agreed recommendations from a healthcare provider', is a highly complex behaviour, defined as adherence. However, intentional non-adherence is regularly observed and results in negative outcomes for patients along with increased healthcare provision costs. Whilst this is a consistent issue amongst adults of all ages, the burden of chronic disease is greatest amongst older adults. As a result, the absolute prevalence of intentional non-adherence is increased in this population. This non-systematic review of intentional non-adherence to medication highlights the extent of the problem amongst older adults. It notes that age, per se, is not a contributory factor in intentionally non-adherent behaviours. Moreover, it describes the difference in methodology required to identify such behaviours in contrast to reports of non-adherence in general: the use of focus groups, semi-structured, one-to-one interviews and questionnaires as opposed to pill counts, electronic medication monitors and analysis of prescription refill rates. Using Leventhal's Common-Sense Model of Self-Regulation, it emphasizes six key factors that may contribute to intentional non-adherence amongst older adults: illness beliefs, the perceived risks (e.g. dependence, adverse effects), benefits and necessity of potential treatments, the patient-practitioner relationship, inter-current physical and mental illnesses, financial constraints and pharmaceutical/pharmacological issues (poly-pharmacy/regimen complexity). It describes the current evidence for each of these aspects and notes the paucity of data validating Leventhal's model in this regard. It also reports on interventions that may address these issues and explicitly acknowledges the lack of evidence-based interventions available to healthcare practitioners. As a result, it highlights five key areas that require urgent research amongst older adults: (1) the overlap between intentional and unintentional non-adherence, particularly amongst those who may be frail or isolated; (2) the potential correlation between symptomatic benefit and intentional vs. unintentional non-adherence to medication; (3) an evaluation of the source of prescribing (i.e. a long-standing provider vs. an acute episode of care) and the patient-prescriber relationship as determinants of intentional and unintentional non-adherence; (4) the decision-making processes leading to selective intentional non-adherence amongst older adults with multiple medical problems; and (5) the development and evaluation of interventions designed to reduce intentional non-adherence, specifically addressing each of the aspects listed above.

Factors influencing adherence to cancer treatment in older adults with cancer: a systematic review

BACKGROUND

Cancer is a disease that mostly affects older adults. Treatment adherence is crucial to obtain optimal outcomes such as cure or improvement in quality of life. Older adults have numerous comorbidites as well as cognitive and sensory impairments that may affect adherence. The aim of this systematic review was to examine factors that influence adherence to cancer treatment in older adults with cancer.

PATIENTS AND METHODS

Systematic review of the literature published between inception of the databases and February 2013. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of cancer treatment adherence were included. Data sources included MEDLINE, EMBASE, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, ASSIA, Ageline, Allied and Complementary Medicine (AMED), SocAbstracts and the Cochrane Library. Two reviewers reviewed abstracts and abstracted data using standardized forms. Study quality was assessed using the Mixed Methods Appraisal Tool 2011.

RESULTS

Twenty-two manuscripts were identified reporting on 18 unique studies. The quality of most studies was good. Most studies focused on women with breast cancer and adherence to adjuvant hormonal therapy. More than half of the studies used data from administrative or clinical databases or chart reviews. The adherence rate varied from 52% to 100%. Only one qualitative study asked older adults about reasons for non-adherence. Factors associated with non-adherence varied widely across studies.

CONCLUSION

Non-adherence was common across studies but little is known about the factors influencing non-adherence. More research is needed to investigate why older adults choose to adhere or not adhere to their treatment regimens taking into account their multimorbidity.

Correlation between the use of ‘over-the-counter’ medicines and adherence in elderly patients on multiple medications

BACKGROUND

Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC)medicines. The use of OTC medicine has been reported as common amongst elderly patients.

OBJECTIVE

To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients.

SETTING

Non-institutionalised elderly patients in Denmark.

METHODS

Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the me an adherence rate for all drugs consumed was\80 %. Different sensitivity analyses were made where adherence was defined different.

MAIN OUTCOME MEASURE

Medication adherence based on pill-count.

RESULTS

A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 %confidence interval 0.18–0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore,separate analyses of herbal medicines, dietary supplements,or non-prescribed drugs did not correlate with adherence to prescriptions.

CONCLUSION

Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

[Structured medication management in primary care - a tool to promote medication safety]

Patients with chronic disease usually need to take multiple medications. Drug-related interactions, adverse events, suboptimal adherence, and self-medication are components that can affect medication safety and lead to serious consequences for the patient. At present, regular medication reviews to check what medicines have been prescribed and what medicines are actually taken by the patient or the structured evaluation of drug-related problems rarely take place in Germany. The process of "medication reconciliation" or "medication review" as developed in the USA and the UK aim at increasing medication safety and therefore represent an instrument of quality assurance. Within the HeiCare(®) project a structured medication management was developed for general practice, with medical assistants playing a major role in the implementation of the process. Both the structured medication management and the tools developed for the medication check and medication counselling will be outlined in this article; also, findings on feasibility and acceptance in various projects and experiences from a total of 200 general practices (56 HeiCare(®), 29 HiCMan,115 PraCMan) will be described. The results were obtained from questionnaires and focus group discussions. The implementation of a structured medication management intervention into daily routine was seen as a challenge. Due to the high relevance of medication reconciliation for daily clinical practice, however, the checklists - once implemented successfully - have been applied even after the end of the project. They have led to the regular review and reconciliation of the physicians' documentation of the medicines prescribed (medication chart) with the medicines actually taken by the patient.

A review of the mechanisms and effectiveness of dietary polyphenols in reducing oxidative stress and thrombotic risk

Dietary sources of polyphenols, which are derivatives and/or isomers of flavones, isoflavones, flavonols, catechins and phenolic acids, possess antioxidant properties and therefore might be important in preventing oxidative-stress-induced platelet activation and attenuating adverse haemostatic function. Free radicals, including reactive oxygen and nitrogen species, promote oxidative stress, leading to platelet hyperactivation and the risk of thrombosis. The consumption of antioxidant/polyphenol rich foods might therefore impart anti-thrombotic and cardiovascular protective effects via their inhibition of platelet hyperactivation or aggregation. Most commonly-used anti-platelet drugs such as aspirin block the cyclooxygenase (COX)-1 pathway of platelet activation, similar to the action of antioxidants with respect to neutralising hydrogen peroxide (H2 O2 ), with a similar effect on thromboxane production via the COX-1 pathway. Polyphenols also target various additional platelet activation pathways (e.g. by blocking platelet-ADP, collagen receptors); thus alleviating fibrinogen binding to platelet surface (GPIIb-IIIa) receptors, reducing further platelet recruitment for aggregation and inhibiting platelet degranulation. As a result of the ability of polyphenols to target additional pathways of platelet activation, they may have the potential to substitute or complement currently used anti-platelet drugs in sedentary, obese, pre-diabetic or diabetic populations who can be resistant or sensitive to pharmacological anti-platelet therapy.

Correlation between the use of 'over-the-counter' medicines and adherence in elderly patients on multiple medications

Background Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC) medicines. The use of OTC medicine has been reported as common amongst elderly patients. Objective To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients. Setting Non-institutionalised elderly patients in Denmark. Methods Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the mean adherence rate for all drugs consumed was <80 %. Different sensitivity analyses were made where adherence was defined different. Main outcome measure Medication adherence based on pill-count. Results A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 % confidence interval 0.18-0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore, separate analyses of herbal medicines, dietary supplements, or non-prescribed drugs did not correlate with adherence to prescriptions. Conclusion Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Problems experienced by older people when opening medicine packaging

OBJECTIVE

Medicine packages can cause problems in daily practice, especially among older people. This study aimed to investigate the prevalence of problems experienced by older people when opening medicine packaging and to investigate how patients manage these problems.

METHODS

A convenience sample of 30 community pharmacies participated in this study. They selected a systematic sample of 30 patients over 65 years old with a recent omeprazole prescription, and a questionnaire was administered by telephone for at least 10 patients per pharmacy.

KEY FINDINGS

A total of 317 patients completed the questionnaire. They received their omeprazole in a bottle (n = 179, 56.5%), push-through blister pack (n = 102, 32.2%) or peel-off blister pack (n = 36, 11.4%). Some 28.4% of all patients experienced one or more problems with opening their omeprazole packaging; most problems occurred with peel-off blisters (n = 24, 66.7% of all respondents using peel-off blisters), followed by push-through blisters (n = 34, 33.3%) and finally bottles (n = 32, 17.9%). The risk of experiencing problems with peel-off blisters and push-through blisters was higher [relative risk 3.7 (95% confidence interval 2.5-5.5) and 1.9 (1.2-2.8), respectively] than the risk of experiencing problems with opening bottles. Two-thirds of respondents reported management strategies for their problems. Most were found for problems opening bottles (n = 24, 75%), followed by push-through blisters (n = 24, 70.6%) and peel-off blisters (n = 14, 58.3%).

CONCLUSIONS

One in four patients over 65 experienced difficulties opening their omeprazole packaging and not all of them reported a management strategy for their problems. Manufacturers are advised to pay more attention to the user-friendliness of product packaging. In addition, it is important that pharmacy staff clearly instruct patients on how to open their medicine packaging, or assist them in choosing the most appropriate packaging.

Older adults' satisfaction with a medication dispensing device in home care

INTRODUCTION

Older adults with multiple chronic conditions face the complex task of medication management involving multiple medications of varying doses at different times. Advances in telehealth technologies have resulted in home-based devices for medication management and health monitoring of older adults. We examined older adults' perceptions of a telehealth medication dispensing device as part of a clinical trial involving home healthcare clients, nurse coordination and use of the medication dispensing device.

METHODS

Ninety-six frail older adult participants who used the medication dispensing device for 12 months completed a satisfaction survey related to perceived usefulness and reliability. Results were analyzed and grouped by themes in the following areas: Ease of Use, Reliability, Medication Management Assistance, Routine Task Performance and Acceptability.

RESULTS

Nearly all participants perceived the medication dispensing device as very easy to use, very reliable and helpful in the management of their medications. Eighty-four percent of participants expressed a desire to use the machine in the future.

CONCLUSION

The technology-enhanced medication management device in this study is an acceptable tool for older adults to manage medication in collaboration with home care nurses. Improved usability and cost models for medication dispensers are areas for future research.

The economic burden of inappropriate drug prescribing, lack of adherence and compliance, adverse drug events in older people: a systematic review

Adverse drug events (ADEs) are an increasingly relevant issue for healthcare systems as they are associated with poorer health outcomes and avoidable misuse of resources. The rates of ADEs are higher in the elderly population, as many older patients have comorbidities, multiple drug prescriptions and deteriorated physical and cognitive functioning. The occurrence of ADEs can lead to a perceived lack of therapy efficacy and further underuse or suboptimal adherence in elderly people, with detrimental clinical outcomes. The present article systematically reviews the studies evaluating the economic impact of ADEs occurring as consequence of poor therapy adherence, inappropriate drug use, underuse of effective treatments and poor adherence, medication errors, drug-drug and drug-disease interactions.A Medline systematic literature review of studies evaluating the economic consequences of inappropriate drug prescribing, lack of adherence and compliance, ADEs in older people was performed. English-language articles were screened through a three-step approach (title review, abstract review, full article review) to select pertinent studies quantitatively evaluating costs. We systematically reviewed evidence from767 articles. After title, abstract and full text review, 21 articles were found to measure economic implications ofADEs, inappropriate drug prescribing and poor adherence in elderly patients. Studies suggested that the economic impact of these undesired effects is substantial: hospital costs were the main cost driver, with a relevant part of them being preventable (consequences of inappropriate prescribing). Healthcare costs for unused drug wastage and destruction were also surprisingly high.Although economic evidence in elderly patients is still limited, all studies seemed to confirm that the financial burden due to pharmacological treatment issues is relevant in elderly people. Including economic effects of adverse events in pharmacoeconomic analysis would be beneficial to improve the reliability of results. Preliminary evidence suggests that programmes aimed at comprehensively assessing geriatric conditions, detecting 'high-risk' prescriptions and training patients to comply with prescribed therapies could be costeffective measures to reduce the burden of ADEs.

Medication adherence: a complex behavior of medication and illness beliefs

Medication nonadherence is a public health issue costing an estimated US$290 billion in the USA. The paper discusses the key facts known about medication nonadherence based on past research including predictors, measurements and interventions; and the recent research developments in medication nonadherence. Recent research has shown the need to approach medication adherence as a complex behavior of a patient’s beliefs regarding illnesses and medications; and how it varies across each medication for each patient. The paper concludes with the call to develop tailored interventions that match with the reasons for nonadherence for each medication.

The safety, tolerability, and efficacy of once-daily memantine (28 mg): a multinational, randomized, double-blind, placebo-controlled trial in patients with moderate-to-severe Alzheimer's disease taking cholinesterase inhibitors

INTRODUCTION

Immediate-release memantine (10 mg, twice daily) is approved in the USA for moderate-to-severe Alzheimer's disease (AD). This study evaluated the efficacy, safety, and tolerability of a higher-dose, once-daily, extended-release formulation in patients with moderate-to-severe AD concurrently taking cholinesterase inhibitors.

METHODS

In this 24-week, double-blind, multinational study (NCT00322153), outpatients with AD (Mini-Mental State Examination scores of 3-14) were randomized to receive once-daily, 28-mg, extended-release memantine or placebo. Co-primary efficacy parameters were the baseline-to-endpoint score change on the Severe Impairment Battery (SIB) and the endpoint score on the Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus). The secondary efficacy parameter was the baseline-to-endpoint score change on the 19-item Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL19); additional parameters included the baseline-to-endpoint score changes on the Neuropsychiatric Inventory (NPI) and verbal fluency test. Data were analyzed using a two-way analysis of covariance model, except for CIBIC-Plus (Cochran-Mantel-Haenszel test). Safety and tolerability were assessed through adverse events and physical and laboratory examinations.

RESULTS

A total of 677 patients were randomized to receive extended-release memantine (n = 342) or placebo (n = 335); completion rates were 79.8 and 81.2 %, respectively. At endpoint (week 24, last observation carried forward), memantine-treated patients significantly outperformed placebo-treated patients on the SIB (least squares mean difference [95 % CI] 2.6 [1.0, 4.2]; p = 0.001), CIBIC-Plus (p = 0.008), NPI (p = 0.005), and verbal fluency test (p = 0.004); the effect did not achieve significance on ADCS-ADL19 (p = 0.177). Adverse events with a frequency of ≥5.0 % that were more prevalent in the memantine group were headache (5.6 vs. 5.1 %) and diarrhea (5.0 vs. 3.9 %).

CONCLUSION

Extended-release memantine was efficacious, safe, and well tolerated in this population.