Conocimientos, percepciones y actitudes que intervienen en la adherencia al tratamiento en pacientes ancianos polimedicados desde una perspectiva cualitativa

Inappropriate Use of Medication by Elderly, Polymedicated, or Multipathological Patients with Chronic Diseases

The growth of the aging population leads to the increase of chronic diseases, of the burden of multimorbility, and of the complexity polypharmacy. The prevalence of medication errors rises in patients with polypharmacy in primary care, and this is a major concern to healthcare systems. This study reviews the published literature on the inappropriate use of medicines in order to articulate recommendations on how to reduce it in chronic patients, particularly in those who are elderly, polymedicated, or multipathological. A systematic review of articles published from January 2000 to October 2015 was performed using MEDLINE, EMBASE, PsychInfo, Scopus, The Cochrane Library, and Index Medicus databases. We selected 80 studies in order to analyse the content that addressed the question under consideration. Our literature review found that half of patients know what their prescribed treatment is; that most of elderly people take five or more medications a day; that in elderly, polymedicated people, the probability of a medication error occurring is higher; that new tools have been recently developed to reduce errors; that elderly patients can understand written information but the presentation and format is an important factor; and that a high percentage of patients have remaining doubts after their visit. Thus, strategies based on the evidence should be applied in order to reduce medication errors.

Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness

Polypathological patients are usually elderly and take numerous drugs. Polypharmacy affects 85% of these individuals and is not associated with greater survival. On the contrary, polypharmacy exposes these individuals to more adverse effects, such as weight loss, falls, functional and cognitive impairment and hospitalisations. The complexity of a drug regimen covers more aspects than the simple number of drugs consumed. The galenic form, the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions. Both polypharmacy and therapeutic complexity are associated with poorer adherence by patients. To prevent polypharmacy, reduce complexity and improve adherence, the appropriate use of drugs is needed. Proper prescribing consists of selecting drugs that have clear evidence for their use in the indication, which are appropriate for the patient's circumstances, are well tolerated and cost-effective and whose benefits outweigh the risks. To improve the drug prescription, periodic reviews of the drugs need to be conducted, especially when the patient changes doctor and during healthcare transitions. The Beers and STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria are effective tools for this improvement. Deprescription for polymedicated polypathological patients that considers their clinical circumstances, prognosis and preferences can contribute to a more appropriate use of drugs.

[Evaluation of adherence to treatment with calcium and vitamin D in the elderly in a basic health area]

BACKGROUND AND OBJECTIVE

The vitamin D deficiency is high in the elderly population. Calcium and vitamin D supplements is a frequently used measure in individuals at risk for falls and/or fractures. However, this practice has achieved a low level of compliance. The aim is to assess the adherence to treatment with calcium and vitamin D in elders with hypovitaminosis D in an urban area of Madrid.

PATIENTS AND METHODS

Intervention study performed on 438 individuals ≥65years from the 'Peñagrande Cohort' with hypovitaminosis D that were treated with calcium and vitamin D. Adherence at 3 and 12 months was assessed using the Morisky-Green and counting of prescriptions written.

RESULTS

A total of 413 of the 438 individuals with hypovitaminosis D were analysed (18 patients were not treated because of contraindications, and 7 were considered lost). At 3 and 12 months, 63.9% and 47.2%, respectively, were adherents. After a brief educational intervention, 19.3% of individuals without adherence at 3 months became good compliers when measured at one year. Comorbidity was associated with lower rates of adherence to treatment after one year (46.3% versus 35.2%, P=.027). The main cause of non-adherence to calcium was digestive intolerance, and due to oversights for vitamin D. Concordance between adherence assessed by the Morisky test and counting of prescriptions written was high (Kappa index=69.8%).

CONCLUSIONS

Non-adherence to chronic treatment with calcium and vitamin D is a relevant problem in elderly. It is important to assess adherence and implement health education strategies in clinical practice.

Relación entre estados de salud y riesgos de no adherencia al tratamiento en pacientes en rehabilitación cardiaca

<p><strong>Objetivo:</strong> Describir el estado de salud de personas con enfermedad coronaria que asisten a un programa de rehabilitación cardiaca en una institución especializada de Bogotá y su relación con el grado de riesgo de no adherencia a tratamientos farmacológicos y no farmacológicos.</p><p><strong>Metodología:</strong> Estudio correlacional descriptivo transversal, con<br />abordaje cuantitativo. Para recoger los datos, se utilizó la tercera versión del Instrumento que evalúa los factores que influyen en la adherencia a tratamientos farmacológicos y no farmacológicos en pacientes con factores de riesgo cardiovascular. Asimismo se usó una lista de chequeo de estados de salud, con base en las metas de prevención secundaria de la Asociación Americana del Corazón (1), los resultados de los estudios de Framingham y su modelo de predicción de riesgo (2-5) a una muestra de 260 pacientes adultos en rehabilitación cardiaca, durante los meses de septiembre de 2012 a abril de 2013.</p><p><strong>Resultados:</strong> La mayoría de los sujetos fueron hombres entre los 45 y 66 años de edad, todos con alguna manifestación de enfermedad coronaria. Se obtuvo igualdad numérica entre los grupos, aunque en general se observaron buenos niveles de<br />adherencia. Al analizar cada dimensión, se observó que la dimensión relacionada con el proveedor era la de mayor riesgo de no adherencia. A través del índice de relación de<br />Pearson, se concluyó que no existe relación entre los estados de salud y riesgos de no adherencia a tratamientos, con un índice <em>r</em> = 0,06961.</p>

[Assessment of two applications of medication self-management in older patients. Qualitative study]

INTRODUCTION

The aging population and the growing use of technology are two realities of modern society. Developing tools to support medication self-management to polymedicated elderly may contribute to increase their safety.

OBJECTIVE

To know how patients polymedicated and older than 64 years manage dose their medication and assessment the utility of two medication self-management applications, specifically analyzing management systems, medication errors and positive and improvable aspects of each of the tools presented.

PATIENTS AND METHODS

Seven focal groups with 59 patients from associations and health departments were conducted. In such meetings, they received the applications and they were encouraged to use it. Then, a several group questions were asked them about their health status, how they managed their medication and their assessment about the applications.

RESULTS

Most participants reported to use memory strategies to take correctly their medication. They assessed positively the applications although some of them showed resistance to incorporate it in their daily routine. The simple interface and ease of use were the characteristics of the applications most appreciated by patients.

CONCLUSIONS

Is possible to foster among elderly patients the use of technological tools to support the proper administration of medications with purpose is to decrease errors and increase safety. When designing health applications is necessary to take into account the preferences of those who are targeted.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

[Adherence to treatment, by active ingredient, in patients over 65 years on multiple medication]

AIM

To assess the level of adherence, by active ingredient, to treatment and associated factors in polymedicated patients over 65 years-old.

DESIGN

Observational, descriptive and cross-sectional study over polymedicated patients over 65 years of the Costa del Sol Health District and the North Malaga Health Area. The study was performed between January 2011 and September 2012 on 375 subjects obtained by simple random sampling from lists provided by each health centre. Data was collected by means of an interview with structured questions. Informed consent was given and signed by all patients before interview.

STUDY VARIABLES

Main results variable adherence to treatment (Morisky-Green's test).

PREDICTABLE VARIABLES

Prescription by active ingredient, socio-demographic variables, health care centre variables, and treatment associated variables. A descriptive analysis of variables was performed. Statistical inference was determined using univariate analysis (t test of Student or Mann-Whitney U, and Chi-squared), and controlling for confounding factors by multivariate analysis (linear and logistic regression).

RESULTS

The result for therapeutic compliance was 51.7%. No statistically significant differences were observed as regards sex and age. A relationship was found in those who resided in rural areas (P=.001), lived with family (P<.05), and were not at risk of suffering from anxiety (P=.046).

CONCLUSIONS

We found similar patient adherence to treatment despite the prescribing generic drugs. Failure to therapeutic compliance was greater in those patients who lived by themselves, in a city close to the coast, or in those patients who were at risk of suffering from anxiety.