Medicine-taking practices in community-dwelling people aged > or =75 years in New Zealand

Acute postoperative endophthalmitis after phacoemulsification in a private ophthalmic surgical group

PURPOSE

To analyze the incidence, causes, risk factors and treatment of acute postoperative endophthalmitis (POE) after phacoemulsification in a private ophthalmological group.

DESIGN

Uncontrolled retrospective observational study of all cases of POE over 22 years.

MATERIAL AND METHODS

369,476 eyes were included after phacoemulsification in 41 surgical centers of the Clínica Baviera-AIER EYE Group from 2002 to 2023. POE cases were reviewed.

RESULTS

The general group was divided into two: group A (2002-2007), with vancomycin in the intracameral irrigation flow (27,705 eyes); Group B (2008-2023), with intracameral cefuroxime (341,771 eyes). 31 cases of POE were found (incidence, 0.0084%); 5 in group A (0.018%) and 26 in group B (0.0076%) (P = .314), with a mean age of 67.3 years (14 men and 17 women). Cultures were positive in 14 cases in Groups A and B. Treatment was based on intravitreal antibiotics and vitrectomy. The mean time to symptom onset was 6.76 days and the mean time to resolution was 120.7 days. 12 eyes achieved corrected distance visual acuity ≥ 20/40.

CONCLUSIONS

The incidence of POEwas 0.0084% (0.0181% in group A and 0.0076% in group B). The probability of having POE in group A was 2.37 times greater than in group B (OR: 2.37; 95% CI: 0.71-6.2; P = .079). The only significant risk factor for POE was posterior capsular rupture.

VIDEOFLUOROSCOPIC EVALUATION OF THE IMPACT OF CAPSULE SIZE AND SUBJECT'S AGE AND GENDER ON CAPSULE SWALLOWING

BACKGROUND

People recurrently have difficulties swallowing solid medications, which can be associated with the size of the medication and the age and gender of individuals.

OBJECTIVE

To evaluate the impact of capsule size and adults' age and gender on oral and pharyngeal capsule transit during capsule swallows.

METHODS

Videofluoroscopy was used to measure capsule oral and pharyngeal transit during swallows in 49 healthy individuals (17 men and 32 women), with a mean age of 46 years (ranging from 23 to 88 years). Smaller capsules were filled with 0.50 mL of barium sulfate, and larger capsules were filled with 0.95 mL of barium sulfate; the volume of liquid ingested with the capsules was also quantified in each ingestion. The measurements included the oral preparation time, oral transit time, swallowing reaction time, time to laryngeal vestibule closure, laryngeal vestibule closure duration, pharyngeal transit time, and upper esophageal sphincter opening duration.

RESULTS

The capsule size did not influence either the oral or pharyngeal transit time. Increased liquid volume was ingested with larger capsules and by people older than 40 years. The oral transit time was shorter in older adults (60-88 years), and the time to laryngeal vestibule closure was longer in women.

CONCLUSION

The size of large capsules did not make a difference in oral or pharyngeal transit when compared with smaller capsules. The capsule size and the participant's age influenced the volume of liquid ingested - larger capsules and older individuals required a larger volume. The capsule oral transit was faster in individuals older than 60 years.

BACKGROUND

•Swallowing is influenced by the characteristics of what is being swallowed.

BACKGROUND

•There was no difference in swallowing capsules containing 0.50 mL or 0.95 mL.

BACKGROUND

•Larger capsules need more liquid ingestion to make swallowing easier.

BACKGROUND

•Individuals older than 40 years need a greater volume of liquid to swallow capsules than younger adults.

Multidose Drug Dispensing in Community Healthcare Settings for Patients With Multimorbidity and Polypharmacy

Multidose drug dispensing (MDD) is the dispensing of different drugs in dose bags containing one, some, or all units of medicine that a patient needs to take at specific times. The aim of this narrative review is to provide an overview of the literature describing the use of MDD systems in community healthcare settings in patients with multimorbidity and polypharmacy. A literature search identified 14 studies examining adherence, medication knowledge, quality of drug prescription (including inappropriate drug use, drug-drug interactions), medication incidents, and drug changes after MDD initiation, as well as healthcare professional (HCP) and patient perspectives. There are limited data on MDD in community healthcare settings, particularly on outcomes such as adherence. Studies are mostly from Northern Europe. Patients selected for MDD are more likely to be older, female, cognitively impaired, and have a higher number of disease diagnoses and drugs than those who do not receive drugs through MDD. MDD is generally initiated for patients who have decreased capacity for medication management. Several advantages of MDD have been reported by patients and HCPs, and studies indicate that MDD can be improved by medication review, defining clear roles and responsibilities of HCPs in the medication management chain, and comprehensive follow-up of patients. Future development, implementation, and assessment of MDD systems in community healthcare should be designed in collaboration with HCPs and patients, to identify ways to optimize the systems and improve patient outcomes.

Perceived Usability of Tablet Crushers: Comparison of Devices by People with and without Limited Hand Functions

Tablet crushing is a common practice used by patients and their carers, mainly to facilitate swallowing. Various tablet-crushing devices with different designs are currently available on the market. This study aimed to compare the usability of different tablet-crushing devices in people with and without limited hand functions. The hand function of 100 adults recruited from the general community (40 of whom self-reported a limited hand function) was assessed using the hand and finger function subscale of the Arthritis Impact Measurement Scale version 2. The hand strength was measured using a dynamometer. Participants crushed tablets using 11 crushing devices and completed a Rapid Assessment of Product Usability and Universal Design questionnaire for each device. Hand-held twist-action crushers with an ergonomic grip received the highest usability scores among both groups, irrespective of the cost (p < 0.05). Crushers with bags were scored lower by those with limited hand functions, although the score improved if the device was automatic. Preferences regarding electronic crushers significantly changed once the cost was revealed. Economical twist-action crushers with ergonomic grips and without bags or cups were the most favoured crushers.

Do Thickening Agents Used in Dysphagia Diet Affect Drug Bioavailability?

Swallowing oral solid dosage forms is challenging in patients with dysphagia who are at risk of aspiration or choking. The most common method to facilitate drug administration in dysphagia patients is to mix the powdered drug with a small amount of thickened water, however little is known about the effects of this method on in vivo bioavailability of drugs. This study aimed to evaluate the impact of thickened liquids on dissolution rate and bioavailability of levetiracetam as a model drug. Powdered commercial tablets of levetiracetam, carbamazepine, atenolol and cefixime were mixed with water thickened with two commercial thickeners, modified maize starch (MS) and xanthan gam (XG), at three thickness levels: nectar, honey and pudding in test groups, and mixed with only water in the control group. At the first stage, the effects of thickened water on in vitro drug release of 4 drugs (levetiracetam, carbamazepine, atenolol and cefixime) were tested by using dialysis membrane method. Addition of both thickeners significantly reduced the release of three drugs compared to the control group, except carbamazepine. Levetiracetam which had the highest solubility was chosen as the model drug for in vivo experiments. In the second stage, New Zealand albino female rabbits (n=24) were divided into two groups as: control group (water+drug, n=6) and test group (thickened water+drug, n=18). Powdered levetiracetam tablets were mixed with water thickened with XG (n=9, 1.2 %, 2.4 %, 3.6 %) and MS (n=9, 4 %, 6%, 8 %) at three thickness levels and administered to the rabbits by intragastric gavage. Blood samples were collected at 9 time points following administration. After two-weeks of wash-out, test groups were crossed over and sample collection was repeated. Blood samples were analysed using liquid chromatography with tandem mass spectrometry (LC-MS/MS). An in vitro-in vivo correlation (IVIVC) model was developed using in vitro drug dissolution (%) and in vivo plasma concentrations of levetiracetam for control group and test groups. The peak plasma concentration (C_max) was lower and time to reach C_max (t_max) was relatively higher in test groups compared to control group. The lowest C_max was detected at the highest thickness level, however, the differences between groups were not statistically significant (p=0.117 and p=0.495 for C_max and t_max, respectively). No significant difference in total amount of levetiracetam absorbed (AUC) was found between groups (p=0.215 and p=0.183 for AUC_infinity and AUC_last, respectively). The comparisons according to the type of thickener also revealed that pharmacokinetic parameters did not significantly differ between groups, except for a significantly lower C_max when drug was mixed with MS-thickened water at nectar consistency (1.2 %) compared to drug mixed with XG (4 %) at the same thickness level (p=0.038). A good correlation was observed between in vitro and in vivo data, which was characterized by higher r² values as the concentration of the thickening agents was increased, but not for all thickness levels studied, indicating an inability of this in vitro model to fully predict the in vivo response. These results suggest that regardless of the thickness level, the administration of levetiracetam with two commercial thickening agents commonly used in dysphagia for safe swallowing, do not affect the pharmacokinetic efficiency and thus, the bioavailability of the drug.

Key factors of the functional ability of older people to self-manage medications

Daily medication use can be affected by the gradual loss of functional ability. Thus, elderly patients are at risk for nonadherence due to functional decline, namely, decreases in cognitive skills and visual and manual dexterity. The main objective was to assess the ability of older people to self-manage their medication and to identify the main predictors for unintentional nonadherence. A cross-sectional study was conducted (2014-2017) in community centers and pharmacies. Functional assessment was performed with the Portuguese versions of the Drug Regimen Unassisted Grading Scale (DRUGS-PT) and the Self-Medication Assessment Tool (SMAT-PT). A purposive sample including 207 elderly patients was obtained. To identify the main predictors, binary logistic regression was performed. The average DRUGS-PT score was slightly lower than that in other studies. On the SMAT-PT, the greatest challenge for patients was identifying medications by reading labels/prescriptions. The main difficulties identified were medication memorization and correct schedule identification. The scores were higher with the real regimen than with the simulated regimen, underlining the difficulties for patients in receiving new information. Regarding the predictors of an older individual's ability to self-manage medications, two explanatory models were obtained, with very high areas under the curve (> 90%). The main predictors identified were cognitive ability, level of schooling and daily medication consumption.

Potentially inappropriate medicine prescribing by nurse practitioners in New Zealand

BACKGROUND AND PURPOSE

Nurse practitioners (NPs) in New Zealand (NZ) prescribe a broad range of medicines; little is known about their prescribing practice for older adults. Potentially inappropriate medicines (PIMs) can cause more harm than benefit. This study reports on the prescribing of PIMs to older adults (≥65 years) by NPs in NZ.

METHODS

A subset analysis using data from NZ Ministry of Health pharmaceutical collection from 2013 to 2015 was completed. Data included NP registration number, medicines dispensed, patient age, sex, and NZ Deprivation level. Those <65 years were excluded. Beers 2015 criteria were used to identify the PIMs.

RESULTS

There were 106 NPs that prescribed medicines to 12,410 patients aged ≥65 years. One third of the patients were prescribed ≥1 PIMss. Most (68.4%) were prescribed one PIM; 21.9% two PIMs; 7.1% three PIMs; and 2.6% were prescribed ≥4 PIMs. NPs prescribed an average of 14.9% PIMs. Primary care NPs were more likely to prescribe PIMs, compared to those with a scope of older adults and long-term conditions (p ≤ 0.001). The most common Beers 2015 PIMs prescribed were proton pump inhibitors, non-steroidal anti-inflammatory drugs, alpha blockers, hypnotics, tricyclic antidepressants, and benzodiazepines.

IMPLICATIONS FOR PRACTICE

NPs prescribe lower rates of PIMs to older adults than other prescribers in NZ. However, prescribing practices can be improved and the findings indicate that a more specific educational focus on prescribing to older adults is required. The findings provide an important baseline internationally for NP PIM prescribing and can be used by NPs, and educationally to review and improve practices.

Effect of multidose drug dispensing on the time in therapeutic range in patients using vitamin-K antagonists: A randomized controlled trial

BACKGROUND

A high number of vitamin K antagonist (VKA) users have a low proportion of time in therapeutic range (TTR) resulting in a high number of bleeding and thromboembolism events.

OBJECTIVE

Can the quality of anticoagulation be improved by dispensing VKAs via multidose drug dispensing (MDD).

METHOD

A randomized controlled trial in the Netherlands. Patients who used VKAs, ≥65 years of age with a TTR <65% were eligible for inclusion. All oral drugs were dispensed via MDD. In MDD systems, all oral chronic medication intended for one dosing moment is packed in plastic disposable pouches. Controls received VKAs by manual dispensing. The difference in TTR between the 6 months after- and 6 months before the index date. A mixed-effects model with the intervention, TTR before the index date, MDD system at baseline as covariates, and pharmacy as random effect. A per-protocol analysis was performed with all patients who completed the study as intended.

RESULTS

One hundred and seventy-nine patients were included. Mean age was 80.0 (SD 6.9) years. Mean TTR during the study was 79.2 ± 18.0% in the intervention group and 72.5 ± 20.1% in the control group. The intervention resulted in a 5.6% (95% CI: 0.1-11.1) increase in TTR compared to the control group. Per-protocol analysis resulted in an 8.3% (95% CI: 0.99-15.61) increase in TTR compared to the control group. No differences in reduction were observed between the intervention and control group.

CONCLUSION

The quality of anticoagulation can be improved with the use of MDD systems.

Psychometric properties of the scale for non-adherence to antiretroviral medication (NAME) among HIV-infected patients

BACKGROUND

Adherence to HIV medication is necessary for long-term HIV disease management. The objective of this study was to develop and examine the psychometric properties of a scale for measuring the barriers of antiretroviral medication adherence among Iranian Patients.

METHOD

This was a sequential, exploratory mixed methods investigation composed of two phases. In the qualitative phase, item pool generation and questionnaire designing was carried out through in-depth individual interviews and group discussions; in the quantitative phase, psychometric properties of the questionnaire were assessed. In both phases, the participants were people who were living with HIV/AIDS and were taking antiretroviral medications.

RESULTS

In the first phase, an item pool containing 181 statements related to barriers of adherence to antiretroviral medication was generated. In the second phase, item reduction was applied, and a questionnaire containing 30 items was developed. The psychometric properties of the questionnaire were assessed, which indicated good validity and reliability of the instrument. In exploratory factor analysis, the items were loaded on six factors that altogether explain for 61.98 of the variance. The Cronbach's alpha and the intra class correlation coefficient of the questionnaire was 0.91 and 0.80, respectively.

CONCLUSION

This study provided a reliable and valid instrument to identify the barriers of adherence to antiretroviral medication in patients with HIV/AIDS. Identify these barriers and design of interventions to eliminate or reduce of barriers can be an effective means of enhancing adherence to antiretroviral medication among these patients.

Living environment, social support, and informal caregiving are associated with healthcare seeking behaviour and adherence to medication treatment: A cross-sectional population study

Despite the well-known associations between local environment and health, few studies have focused on environment and healthcare utilisation, for instance healthcare seeking behaviour or adherence. This study was aimed at analysing housing type, behaviour based on perceived local outdoor safety, social support, informal caregiving, demographics, socioeconomics, and long-term illness, and associations with health-seeking and adherence behaviours at a population level. This study used data from the Swedish National Public Health Survey 2004-2014, an annually repeated, large sample, cross-sectional, population-based survey study. In all, questionnaires from 100,433 individuals were returned by post, making the response rate 52.9% (100,433/190,000). Descriptive statistics and multiple logistic regressions were used to investigate associations between explanatory variables and the outcomes of refraining from seeking care and non-adherence behaviour. Living in rented apartment, lodger, a dorm or other was associated with reporting refraining from seeking care (adjusted OR 1.16, 95% CI 1.00-1.22), and non-adherence (adjusted OR 1.22; 95% CI 1.13-1.31). Refraining from going out due to a perceived unsafe neighbourhood was associated with refraining from seeking care (adjusted OR 1.59, 95% CI 1.51-1.67) and non-adherence (adjusted OR 1.26, 95% CI 1.17-1.36). Social support and status as an informal caregiver was associated with higher odds of refraining from seeking medical care and non-adherence. This study suggests that living in rental housing, refraining from going out due to neighbourhood safety concerns, lack of social support or informal caregiver status are associated with lower health-seeking behaviour and non-adherence to prescribed medication.

Factors associated with inappropriate prescribing among older adults with complex care needs who have undergone the interRAI assessment

AIM

To identify factors associated with prescribing potentially inappropriate medications (PIMs) in older adults (≥65 years) with complex care needs, who have undertaken a comprehensive geriatric risk assessment.

METHODS

A nationwide cross-sectional (retrospective, observational) study was performed. The national interRAI Home Care assessments conducted in New Zealand in 2015 for older adults were linked to the national pharmaceutical prescribing data (PHARMS). The 2015 Beers criteria were applied to the cross-matched data to identify the prevalence of PIMs. The factors influencing PIMs were analyzed using a multinomial logistic regression model.

RESULTS

In total, 16,568 older adults were included in this study. Individuals diagnosed with cancer, dementia, insomnia, depression, anxiety, and who were hospitalized in the last 90 days were more likely to be prescribed PIMs than those who were not diagnosed with the above disorders, and who were not hospitalized in the last 90 days. Individuals over 75 years of age, the Māori ethnic group among other ethnicities, individuals who were diagnosed with certain clinical conditions (diabetes, chronic obstructive pulmonary disease, stroke, or congestive cardiac failure), individuals requiring assistance with activities of daily living, and better self-reported health, were associated with a lesser likelihood of being prescribed PIMs.

CONCLUSION

The study emphasizes the identification of factors associated with the prescription of PIMs during the first completed comprehensive geriatric assessment. Targeted strategies to reduce modifiable factors associated with the prescription of PIMs in subsequent assessments has the potential to improve medication management in older adults.

Understanding the knowledge, attitudes and beliefs of community-dwelling older adults and their carers about the modification of oral medicines: A qualitative interview study to inform healthcare professional practice

BACKGROUND

Oral medicines are commonly modified (e.g. tablets split/crushed) to meet the dosing and swallowing requirements of older adults. However, there is limited research investigating the opinions of community-dwelling patients and carers about medicine modification.

OBJECTIVES

The aim of this study was to investigate the views of community-dwelling older adults and their carers about oral medicine modification.

METHODS

Semi-structured, face-to-face interviews were conducted with community-dwelling older adults and carers of older adults who experienced difficulty swallowing medicines, or who required medicines to be modified. Participants were recruited from purposively selected community pharmacies using a combination of purposive, convenience and snowball sampling. Interviews were audio-recorded, transcribed verbatim and analysed thematically. The Francis method governed when data saturation had been reached.

RESULTS

Twenty-six interviews (13 patients, 13 carers) were conducted (76.9% female, median length 11 min (IQR 8-16 min)). Four themes emerged from the data: variation in medical needs and preferences; balancing acceptance and resignation; healthcare professional engagement and; opportunities for optimising formulation suitability. The heterogeneity of medical conditions experienced by community-dwelling older adults resulted in a variety of modifications being required. Patients and carers are accepting of their medications and formulations. However, when challenges arise, they tend to feel resigned to coping within the constraints of the current medication regimen, resulting in a lack of focused communication with healthcare professionals. Thus, healthcare professionals were unaware of their difficulties and unable to offer advice or solutions.

CONCLUSION

Healthcare professionals must engage proactively with this group. Whilst a holistic approach to medication management is ideal, the disadvantage is that no single healthcare professional may identify this as their responsibility. Whilst the input and expertise of all healthcare professionals will be required, as medication experts, the pharmacy profession should take ownership and become the champion of, and for, the patient.

Exploring Medicines Burden Among Adults in New Zealand: A Cross-Sectional Survey

BACKGROUND

Using medicines regularly can be a burden for some people and can contribute to reduced adherence. In New Zealand, relatively few studies have examined people's medicine-taking experiences and most involved older people, although medicine burden is also an issue for younger people. The UK-developed "Living with Medicines Questionnaire" (LMQ-3) is an instrument designed to quantify medicine burden.

OBJECTIVE

The objective was to quantify medicines burden among New Zealand adults, using the LMQ-3, to identify any sub-populations with high medicine burden and to identify specific issues that may need to be addressed.

SETTING

The study was set in New Zealand and included seven national patient support group websites, and five community pharmacies in Dunedin.

METHODS

The survey was distributed to adults ≥18 years using ≥ one medicine for ≥3 months. LMQ-3 scores and domain scores were compared by patient characteristics using descriptive statistics and statistical tests.

RESULTS

In total, 472 responses were analysed: 327/417 (78.4%) from patient support group websites and 145/360 (40.3%) from community pharmacies. Most commonly participants were female (295, 62.5%), ≥65 years (236, 50.0%), European (422, 89.4%), retired (232, 49.2%), university educated (203, 43.0%), used medicines independently (449, 95.1%), and paid for prescriptions (429, 90.9%). Most used <10 medicines (415, 87.9%) and <three times daily (356, 75.4%). From LMQ scores, 30.5% had a high burden (≥111). Regression analysis indicated that higher LMQ-3 scores were associated with those who were unemployed, aged 18-29 years, using ≥5 medicines, or using medicines <3 times a day (p<0.01). Burden was mainly driven by a perceived lack of autonomy over medicine regimens, or concerns about medicines and side effects.

CONCLUSION

Three quarters of New Zealand participants experienced moderate or high medicine burden. Being unemployed, aged 18-29 years, or using more (or more frequent) medicines, were associated with higher burden. These groups should become the target for interventions seeking to reduce medicine burden.

Determinants of prescribing potentially inappropriate medications in a nationwide cohort of community dwellers with dementia receiving a comprehensive geriatric assessment

OBJECTIVE

To identify the prevalence and predictors of prescribing potentially inappropriate medications (PIMs) in a nationwide cohort of community dwellers with dementia requiring complex care needs.

METHODS

A cross-matched data of the International Resident Assessment Instrument-Home Care (9.1) (interRAI-HC) and prescribing data obtained from the Pharmaceutical Claims Data Mart (Pharms) extract files for older adults (≥65 y) requiring complex care needs were utilized for this study. The 2015 Beers criteria were applied to identify the prevalence of PIMs in older adults with dementia. Sociodemographic and clinical predictors of PIMs were analysed using a logistic regression model.

RESULTS

The study population consisted of 16 568 individuals who had their first interRAI assessment from 1 January 2015 to 31 December 2015. The estimated prevalence of dementia was 13.2% (2190/16 568). 66.9% (1465/2190) of the older adults diagnosed with dementia were prescribed PIMs, of which anticholinergic medications constituted 59.6% (873/1465). Males and individuals who were prescribed a greater number of medications were more likely to be prescribed PIMs. Individuals over 85 years of age, Māori ethnic group of individuals, older adults who were being supervised with respect to their activities of daily living, and individuals who reported good or excellent self-reported health had a lesser likelihood of being prescribed PIMs.

CONCLUSION

We found that PIMs are prescribed frequently in older adults with dementia. Comprehensive geriatric assessments can serve as a potential tool to decrease the occurrence of PIMs in vulnerable groups with poor functional and cognitive status.

Medication swallowing difficulties in people without dysphagia

ABSTRACT Objective: to assess the difficulty in swallowing medications and correlate it with age and gender in healthy adults and elderly. Methods: a total of 439 asymptomatic healthy volunteers (270 females and 169 males), who were not taking any medication on a regular basis, aged from 20 to 84 years, were questioned as for dysphagia, by using the Eating Assessment Tool (EAT-10). Question number five of the EAT-10, specifically, approached the difficulty in swallowing drugs, considering zero as “no swallowing problem” and 1 to 4 as “some degree of difficulty” (4 as great difficulty).The chi-square test (x2) was used for the statistical analysis. Results: a total of 365 (83%) volunteers reported having no difficulty in swallowing medications (89% of men and 80% of women), whereas 74 (17%) reported some degree of difficulty (11% of men and 20% of women)(p = 0.01). These represented 20% of those aged between 20 and 49, and 9% of those aged 50 and over (p = 0.02). Conclusion: in this study, it was observed that both age and gender influence on medication swallowing, a difficulty more frequent among women and young adults. Some degree of difficulty was reported by 17% of the volunteers.

Pill for this and a pill for that: A cross-sectional survey of use and understanding of medication among adults with multimorbidity

OBJECTIVE

To understand the challenges managing medication use and knowledge of people living with multimorbidity.

METHODS

A cross-sectional survey of 234 adults with multimorbidity, identified using retrospective hospital discharge data. Participants were recruited from two primary health organisations in New Zealand.

RESULTS

Three quarters of participants (75%) were prescribed four or more medications, and one in four (27%) were prescribed eight or more medications. Participants reported knowing what their medications were for (88%, 95% CI 81.4-93.8) and when to take them (99%, 95% CI 97.5-99.9). However, over a fifth (22%, 95% CI 13.7-30.4) reported some problems managing multiple medications, and 40% (95% CI 30.2-50.2) reported a problem with side effects.

CONCLUSION

The results highlight the need to consider how prescribing can be adapted for people with multimorbidity and move beyond the application of multiple disease-specific guidelines.

Dosage form modification and oral drug delivery in older people

Many people cannot swallow whole tablets and capsules. The cause ranges from difficulties overriding the natural instinct to chew solids/foodstuff before swallowing, to a complex disorder of swallowing function affecting the ability to manage all food and fluid intake. Older people can experience swallowing difficulties because of co-morbidities, age-related physiological changes, and polypharmacy. To make medicines easier to swallow, many people will modify the medication dosage form e.g. split or crush tablets, and open capsules. Some of the challenges associated with administering medicines to older people, and issues with dosage form modification will be reviewed. Novel dosage forms in development are promising and may help overcome some of the issues. However, until these are more readily available, effective interdisciplinary teams, and improving patient health literacy will help reduce the risk of medication misadventures in older people.

Medication compliance in Singaporean patients with Alzheimer's disease

INTRODUCTION

Singapore has a rapidly ageing population and an increasing prevalence of Alzheimer's disease (AD). Compliance to AD medications is associated with treatment effectiveness. We investigated compliance to acetylcholinesterase inhibitors (AChEIs) and N-methyl-D-aspartate (NMDA) receptor antagonist and treatment persistence among patients seen at the General Memory Clinic of National University Hospital, Singapore. We also identified the reasons for non-compliance.

METHODS

Patients seen at the General Memory Clinic between 1 January 2013 and 31 December 2014, who were prescribed AChEIs and NMDA receptor antagonist, were included in this retrospective cohort study. Non-compliance to medications was indirectly measured by failure to renew prescription within 60 days of the last day of medication supplied by the previous prescription. The reasons for non-compliance were identified.

RESULTS

A total of 144 patients were included. At one year, 107 patients were compliant to AD medications, while 37 patients were non-compliant. Around 60% of the non-compliant patients discontinued the use of AD medications within the first six months, and the mean persistent treatment period among this group of patients was 10.3 ± 3.5 months. The main reason for non-compliance was patients' and caregivers' perception that memory loss was of lower priority than other coexisting illnesses. Other reasons for non-compliance included side effects of medications (18.9%), perceived ineffectiveness of treatment (16.2%), inability to attend clinic (5.4%) and high cost of medications (2.7%).

CONCLUSION

Our findings suggest that the reasons for medication non-compliance can be identified early. Better compliance may be achieved through a multidisciplinary approach to patient education.

Association Between Adherence to Statins, Illness Perception, Treatment Satisfaction, and Quality of Life among Lebanese patients

OBJECTIVES

The main objective of this study was to evaluate treatment adherence to statin and health-related quality of life (QOL) in Lebanese patients with dyslipidemia. Secondary objectives were to examine associations between treatment adherence, QOL, treatment satisfaction, and illness perception.

METHODS

This cross-sectional study, conducted in 20 community pharmacies from all districts of Lebanon between August 2016 and April 2017, enrolled 247 adult patients taking any statin.

RESULTS

The mean age of the participants was 52.63 ± 11.92 years (57.5% males); the mean duration of treatment with a statin was 59.72 months. A significant association was found between adherence and marital status ( P < .0001), educational level ( P = .001), cigarette smoking ( P < .0001), and alcohol drinking ( P < .0001). A negative but significant correlation was found between the adherence score and the duration of dyslipidemia ( r = -0.199). A significant but negative correlation was also found between the side effect score and age ( r = -0.137). The monthly salary, the marital status, the educational level, smoking cigarettes or waterpipes, and drinking alcohol were all associated with the Illness Perception Questionnaire scores ( P < 0.0001 for all variables). Secondary level of education (β = 13.43), smoking more than 3 waterpipes per week (β = 14.06), global satisfaction score (β = 0.32), convenience score (β = 0.29), and effectiveness score (β = 0.27) would significantly increase the adherence score. Smoking more than 15 cigarettes per day (β = -11.15) and a divorced status (β = -14.81) would however significantly decrease the adherence score. Significant associations were found between the illness perception score, the QOL domains, and the satisfaction domains ( P < .05 for all variables).

CONCLUSION

This study showed that global satisfaction with treatment, convenience, and effectiveness are important factors that increase treatment adherence. Patient adherence results in patient satisfaction and improved QOL and is an important criterion for achieving desired therapeutic outcomes.

Becoming a 'pharmaceutical person': Medication use trajectories from age 26 to 38 in a representative birth cohort from Dunedin, New Zealand

Despite the abundance of medications available for human consumption, and frequent concerns about increasing medicalization or pharmaceuticalization of everyday life, there is little research investigating medicines-use in young and middle-aged populations and discussing the implications of young people using increasing numbers of medicines and becoming pharmaceutical users over time. We use data from a New Zealand longitudinal study to examine changes in self-reported medication use by a complete birth cohort of young adults. Details of medications taken during the previous two weeks at age 38 are compared to similar data collected at ages 32 and 26, and by gender. Major drug categories are examined. General use profiles and medicine-types are considered in light of our interest in understanding the formation of the young and middle-aging 'pharmaceutical person' - where one's embodied experience is frequently and normally mediated by pharmaceutical interventions having documented benefit/risk outcomes.

Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported barriers and facilitators

BACKGROUND

Medication adherence is vital to ensuring optimal patient outcomes, particularly amongst multimorbid older people prescribed multiple medications. Interventions targeting adherence often lack a theoretical underpinning and this may impact on effectiveness. The theoretical domains framework (TDF) of behaviour can aid intervention development by systematically identifying key determinants of medication adherence.

OBJECTIVES

This study aimed to (i) identify determinants (barriers, facilitators) of adherence to multiple medications from older people's perspectives; (ii) identify key domains to target for behaviour change; and (iii) map key domains to intervention components [behaviour change techniques (BCTs)] that could be delivered in an intervention by community pharmacists.

METHOD

Focus groups were conducted with older people (>65 years) receiving ≥4 medications. Questions explored the 12 domains of the TDF (eg "Knowledge," "Emotion"). Data were analysed using the framework method and content analysis. Identification of key domains and mapping to intervention components (BCTs) followed established methods.

RESULTS

Seven focus groups were convened (50 participants). A wide range of determinants were identified as barriers (eg forgetfulness, prioritization of medications) and facilitators (eg social support, personalized routines) of adherence to multiple medications. Eight domains were identified as key targets for behaviour change (eg "Social influences," "Memory, attention and decision processes," "Motivation and goals") and mapped to 11 intervention components (BCTs) to include in an intervention [eg "Social support or encouragement (general)," "Self-monitoring of the behaviour," "Goal-setting (behaviour)"].

CONCLUSION

This study used a theoretical underpinning to identify potential intervention components (BCTs). Future work will incorporate the selected BCTs into an intervention that will undergo feasibility testing in community pharmacies.

Avaliação da compreensão da farmacoterapia entre idosos atendidos na Atenção Primária à Saúde de Belo Horizonte, MG, Brasil

Resumo Os idosos apresentam maior número de doenças, levando a maior uso de medicamentos e a farmacoterapia mais complexa. O objetivo do estudo foi avaliar o nível de compreensão da farmacoterapia entre idosos e fatores associados. Realizou-se estudo transversal analítico em Unidades Básicas de Saúde. Foram investigadas as características sociodemográficas, clínicas, funcionais e relativas ao uso de medicamentos. O nível de compreensão foi obtido após a análise de concordância entre a resposta do entrevistado e a informação contida na prescrição para: nome do medicamento, dose, frequência, indicação, precauções e efeitos adversos. O nível global de compreensão foi classificado como insuficiente em caso de discordância ≥ 30%. Dos 227 idosos entrevistados, 51,1% apresentaram compreensão insuficiente em relação aos medicamentos. Realizou-se regressão logística multivariada para observar os fatores associados à compreensão da farmacoterapia, sendo menor escolaridade e dependência para uso dos medicamentos os que apresentaram associação com a compreensão insuficiente (p < 0,05). É necessário implementar estratégias para aumentar a qualidade das orientações fornecidas aos idosos e garantir seu cumprimento.

Is cost-related non-collection of prescriptions associated with a reduction in health? Findings from a large-scale longitudinal study of New Zealand adults

OBJECTIVE

To investigate whether cost-related non-collection of prescription medication is associated with a decline in health.

SETTINGS

New Zealand Survey of Family, Income and Employment (SoFIE)-Health.

PARTICIPANTS

Data from 17 363 participants with at least two observations in three waves (2004-2005, 2006-2007, 2008-2009) of a panel study were analysed using fixed effects regression modelling.

PRIMARY OUTCOME MEASURES

Self-rated health (SRH), physical health (PCS) and mental health scores (MCS) were the health measures used in this study.

RESULTS

After adjusting for time-varying confounders, non-collection of prescription items was associated with a 0.11 (95% CI 0.07 to 0.15) unit worsening in SRH, a 1.00 (95% CI 0.61 to 1.40) unit decline in PCS and a 1.69 (95% CI 1.19 to 2.18) unit decline in MCS. The interaction of the main exposure with gender was significant for SRH and MCS. Non-collection of prescription items was associated with a decline in SRH of 0.18 (95% CI 0.11 to 0.25) units for males and 0.08 (95% CI 0.03 to 0.13) units for females, and a decrease in MCS of 2.55 (95% CI 1.67 to 3.42) and 1.29 (95% CI 0.70 to 1.89) units for males and females, respectively. The interaction of the main exposure with age was significant for SRH. For respondents aged 15-24 and 25-64 years, non-collection of prescription items was associated with a decline in SRH of 0.12 (95% CI 0.03 to 0.21) and 0.12 (95% CI 0.07 to 0.17) units, respectively, but for respondents aged 65 years and over, non-collection of prescription items had no significant effect on SRH.

CONCLUSION

Our results show that those who do not collect prescription medications because of cost have an increased risk of a subsequent decline in health.

Practical problems with medication use that older people experience: a qualitative study

OBJECTIVES

To identify the practical problems that older people experience with the daily use of their medicines and their management strategies to address these problems and to determine the potential clinical relevance thereof.

DESIGN

Qualitative study with semistructured face-to-face interviews.

SETTING

A community pharmacy and a geriatric outpatient ward.

PARTICIPANTS

Community-dwelling people aged 70 and older (N = 59).

MEASUREMENTS

Participants were interviewed at home. Two researchers coded the reported problems and management strategies independently according to a coding scheme. An expert panel classified the potential clinical relevance of every identified practical problem and associated management strategy using a 3-point scale.

RESULTS

Two hundred eleven practical problems and 184 management strategies were identified. Ninety-five percent of the participants experienced one or more practical problems with the use of their medicines: problems reading and understanding the instructions for use, handling the outer packaging, handling the immediate packaging, completing preparation before use, and taking the medicine. For 10 participants, at least one of their problems, in combination with the applied management strategy, had potential clinical consequences and 11 cases (5% of the problems) had the potential to cause moderate or severe clinical deterioration.

CONCLUSION

Older people experience a number of practical problems using their medicines, and their strategies to manage these problems are sometimes suboptimal. These problems can lead to incorrect medication use with clinically relevant consequences. The findings pose a challenge for healthcare professionals, drug developers, and regulators to diminish these problems.

Virtual visits in home health care for older adults

BACKGROUND

This review identifies the content of virtual visits in community nursing services to older adults and explores the manner in which service users and the nurses use virtual visits.

DESIGN

An integrative literature review.

METHOD

Data collection comprised a literature search in three databases: Cinahl, Medline, and PubMed. In addition, a manual search of reference lists and expert consultation were performed. A total of 12 articles met the inclusion criteria. The articles were reviewed in terms of study characteristics, service content and utilization, and patient and health care provider experience.

RESULTS

Our review shows that in most studies the service is delivered on a daily basis and in combination with in-person visits. The findings suggest that older home-dwelling patients can benefit from virtual visits in terms of enhanced social inclusion and medication compliance. Service users and their nurses found virtual visits satisfactory and suitable for care delivery in home care to the elderly. Evidence for cost-saving benefits of virtual visits was not found.

CONCLUSIONS

The findings can inform the planning of virtual visits in home health care as a complementary service to in-person visits, in order to meet the increasingly complex needs of older adults living at home.

Prevalence and factors associated with polypharmacy in Victorian adults with intellectual disability

Although polypharmacy is a medication safety concern leading to increased risk of non-adherence, adverse drug reaction and drug-drug interactions, polypharmacy and associated risk factors has rarely been investigated involving people with ID at a population level. The purpose of this paper is to analyze the prevalence of polypharmacy and to evaluate the role of different factors associated with polypharmacy in a state-wide representative population of adults with ID. In a population-based survey in Victoria, Australia, 897 people with ID 18 years of age or older were selected by simple random sampling. The data were collected from proxy respondents on behalf of people with ID. Polypharmacy was defined as the concomitant use of five or more medications. The data were weighted to reflect the age/sex/geographic distribution of the population. Results revealed that more than 76% of adults with ID had used prescribed medicine and about 21% were exposed to polypharmacy in the last two weeks. In both univariate and multivariate analyses, polypharmacy was significantly associated with older age, unemployment and inability to get help from family and friends if needed. After controlling for age, sex and severity of intellectual disability, polypharmacy was associated with having a blood pressure, blood cholesterol and blood glucose level check. Polypharmacy was also associated with a greater number of visits to general practitioners, fair or poor reported health status and inability to walk unaided. Subjects with epilepsy, diabetes, stroke, osteoporosis and cancer had a higher probability of polypharmacy. None of the disease inducing behaviors was associated with polypharmacy. This study highlights the need that medication should be regularly reviewed overall in ID population and particularly when polypharmacy exists.

Retrospective examination of selected outcomes of Medicines Use Review (MUR) services in New Zealand

BACKGROUND

Poor adherence to medication can lead to suboptimal outcomes, and is reported to occur frequently. Pharmacists in some countries are funded to support the appropriate use of medications in patients and enhance medication adherence, by providing services such as Medicines Use Review (MUR).

OBJECTIVE

To describe and investigate factors that may influence patients' knowledge and perceptions of and adherence to medications as determined during MUR.

SETTING

Community pharmacies in a locality in New Zealand. Method Following consent from five MUR service providers, records of patients' MUR consultations conducted between November 2007 and December 2011 were retrospectively reviewed for information on patients, services, and outcomes. Using multilevel mixed-effects logistic regression, factors that predicted the providers' score of the patients' medication knowledge, and the patients' score of their adherence to and perceptions of medications, were investigated. Main outcome measure patients' knowledge, perceptions and adherence scores.

RESULTS

A total of 353 MUR patients' records were evaluated. The median (IQR) age of patients was 73 (63-81) years. About 41.1 % of patients were Māori. A total of 204 (57.8 %) patients had two MUR consultations and only 53 (15 %) had four. The mean score of patients' knowledge, perceptions of, and adherence to medications were found to increase in each visit which suggests that adherence support by pharmacists might improve patients' outcomes. Females had higher medication knowledge scores than males (OR 3.09, 95 % CI 1.29-7.44). There was some evidence to suggest Māori had lower scores for knowledge of medications than non-Māori (OR 0.092, 95 % CI 0.02-0.36). In addition, longer duration in the program predicted better scores for medication knowledge, adherence and perceptions of medications.

CONCLUSIONS

MUR was found to have the potential to improve the scores of patients' knowledge and perceptions of and adherence to medicines, and factors such as gender, ethnicity and longer duration in the services were found to predict these outcomes.

Older people's experiences of medicine changes on leaving hospital

BACKGROUND

Few qualitative studies have explored older patients' perspectives on medicine changes that resulted from a stay in hospital.

OBJECTIVE

To explore how older people aged ≥75 years, who had recently been discharged from hospital to their own home, understood and managed any changes to their medicines.

METHODS

Forty people aged ≥75 years were recruited from two internal medicine wards. Participants were included if they took four or more prescription medicines at admission, experienced a medicine change and were discharged to their own home. Participants were interviewed in person at home. Interviews were semi-structured and were recorded, transcribed verbatim, coded using NVivo, and analyzed thematically.

RESULTS

Participants experienced a median of four medicine changes per person and sixteen participants were unaware of the exact changes and the reasons for them. Some participants had concerns about their medicine changes. Twenty-nine participants could not recall anyone talking about their medicine changes just prior to them being discharged. The majority of participants trusted the decisions the hospital doctors made regarding their medicines and many participants spoke as if it was not their place to question doctors about their medicines.

CONCLUSION

Clear and understandable explanations of medicine changes are needed for older people on discharge from hospital. Health professionals should also be aware that older patients might not think it is acceptable for them to ask direct questions of staff members.

Medication adherence and knowledge of older patients with and without multidose drug dispensing

OBJECTIVE

we compared the self-reported medication adherence and knowledge of older patients receiving their drugs via multidose drug dispensing (MDD users) with patients receiving manually dispensed drugs (non-MDD users).

METHODS

MDD users (≥ 65 years, ≥ 5 oral chronic drugs) were randomly selected from eight Dutch community pharmacies. Non-MDD users (≥ 5 oral chronic drugs) were matched on age and gender. Medication adherence was assessed by using the Medication Adherence Reporting Scale (MARS) and medication knowledge by asking the indication of drugs. Cognitive function was measured with Mini-Mental State Examination (MMSE) for a sub selection of patients.

RESULTS

the percentage of patients being adherent to all drugs was higher for MDD users (n = 119, 81%) compared with non-MDD users (n = 96, 58%, P < 0.001).The percentage of patients with adequate knowledge was lower for MDD users (40%) compared with non-MDD users (79%, P < 0.001). The differences in adherence were independent of knowledge and MMSE scores.

CONCLUSION

this study shows that older patients receiving their drugs via MDD reported a higher medication adherence compared with patients receiving manually dispensed drugs, despite a lower knowledge and lower cognitive function among patients receiving MDD.

Risk factors for acute endophthalmitis following cataract surgery: a systematic review and meta-analysis

Background

Acute endophthalmitis is one of the most serious complications of cataract surgery and often results in severe visual impairment. Several risk factors for acute postoperative endophthalmitis (POE) following cataract surgery have been reported but the level of evidence and strength of association is varied. The purpose of this study was to critically appraise published reports on and to summarize clinical risk factors associated with acute POE which could be easily assessed by ophthalmologists for the introduction and implementation of preventive measure.

Methods

A systematic review and meta-analysis of observational studies was performed. Six databases were searched with no limits on the year or language of publication. Study-specific odds ratios (Ors) or relative risk (RR) of each risk factor were pooled using a random effect model.

Results

A total of 6 686 169 participants with 8 963 endophthalmitis in 42 studies were analyzed. Of the nine risk factors identified in our systematic review and meta-analysis, extra- or intracapsular cataract extraction, a clear corneal incision, without intracameral cefazolin (1 mg in 0.1 ml solution), without intracameral cefuroxime (1 mg in 0.1 ml solution), post capsular rupture, silicone intraocular lenses and intraoperative complications were found strongly associated with acute endophthalmitis. Other significant factors with a lower strength of association (risk estimates generally 1.5 or less) were male gender and old age (85 years and older).

Conclusions

Our study provides summary data on the risk factors for acute POE. Identifying patients at high risk of this sight-threatening eye disease is important from both the public health and clinical perspectives as this would facilitate detection of disease before the onset of irreversible visual loss enabling earlier intervention.

Adherence to and beliefs in lipid-lowering medical treatments: a structural equation modeling approach including the necessity-concern framework

OBJECTIVE

This study attempts to identify a structure among patient-related factors that could predict treatment adherence in statin patients, especially with regards to the necessity-concern framework.

METHODS

414 Swedish patients using statins completed a questionnaire about their health, treatment, locus of control, perception of necessity-concern and adherence. The data were handled using a structural equation modeling approach.

RESULTS

Patients that reported high perceptions of necessity to treatment seemed to adhere well, and side effects appear to affect adherence negatively. Disease burden, cardiovascular disease experience and high locus of control seem to have mediating effects on adherence.

CONCLUSION

This study provides support for the hypothesis that health- and treatment-related factors, as well as locus of control factors, are indirectly associated with treatment adherence via their association with mediating factor necessity.

PRACTICE IMPLICATIONS

This study highlights the importance of considering patients' beliefs about medications, disease burden, experience of cardiovascular events and locus of control as these factors are associated with adherence behavior to statin treatment. This study also emphasizes more generally the importance of an approach targeting necessity and concern when communicating with and treating patients with lipid-lowering medication.

Serious adverse events after cataract surgery

PURPOSE OF REVIEW

Over the past several decades, there have been many advances in the equipment, instrumentation and techniques of performing cataract surgery. This review will address the impact of these advances on the safety profile of cataract surgery.

RECENT FINDINGS

Recent studies have demonstrated a decline in the risk of serious postoperative adverse events (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) following cataract surgery. Factors that increase the risk of serious complications from cataract surgery include patient-related factors (male sex, concomitant diabetic retinopathy, same day cataract surgery combined with another intraocular surgery, tamsulosin use) and surgeon-related factors (low surgical volume, limited experience, operating on patients who are most prone to adverse events).

SUMMARY

Cataract surgery continues to be a very well tolerated surgical procedure with few patients experiencing serious sight-threatening adverse events. Studies in the literature have helped surgeons identify patients who are at high risk for surgical complications and develop strategies to limit surgical complications when operating on these patients. As multifocal intraocular lenses, femtosecond laser technology, and other surgical innovations continue to gain popularity, it will be interesting in the coming years to determine whether there will be a continued reduction in complications of cataract surgery.

Using Daily Routines to Promote Medication Adherence in Older Adults

PURPOSE. To understand the medication routines used by older adults taking four or more medications daily.

METHOD. One hundred forty-nine community-dwelling older adults were interviewed about the individual routines, storage locations, equipment, and assistance that enabled their adherence to a medication regimen. A subsample of 84 older adults was observed completing one medication routine in their home environments.

FINDINGS. Medication habits were embedded in mealtime, wake-up, and sleep routines for 91% of the sample. Participants developed unique, individualized behaviors for taking medications that were choreographed within broader daily routines. The primary locations for storing medications were the kitchen and bathroom. Equipment used to promote adherence was primarily pillboxes or self-made adaptations. More than 50% of the entire sample required some type of assistance related to medication adherence.

IMPLICATIONS. Findings support the role of occupational therapists in collaborating with clients to develop individualized medication routines to promote medication adherence.

Geriatric gynecology: promoting health and avoiding harm

Age increases vulnerability, commonly accompanied by greater reliance on others and susceptibility to maltreatment. Physiologic processes become less resilient; the potential for harm from medical care increases. Awareness of frailty, functional, social, and potential maltreatment issues enables early referrals to help the patient maintain her independence. Health issues that may impede both gynecologic care and self-sufficiency include sensory deficits, physical disability, and cognitive impairment. Speaking slowly and providing contextual information enhance patient comprehension. Cancer screening depends on life expectancy. Osteoporosis treatment requires managing fall risk. Gynecologic symptoms more likely have multiple contributing factors than one etiology. Incontinence is a particularly complex issue, but invariably includes bladder diary assessment and pelvic floor muscle training. Function and frailty measures best predict perioperative morbidity. Communication with the patient, her family, other providers, and health care organizations is an important frontier in avoiding errors and adverse outcomes.

Frail elderly patients' experiences of information on medication. A qualitative study

Background

Older patients generally have only poor knowledge about their medicines. Knowledge is important for good adherence and for participating in decisions about treatment. Patients are entitled to be informed on an individual and adequate level. The aim of the study was to explore frail elderly patients’ experiences of receiving information about their medications and their views on how the information should best be given.

Methods

The study was qualitative in design and was carried out in 2011. Twelve frail elderly (aged 68–88) participants taking cardiovascular medications participated in semi-structured interviews covering issues related to receiving information about prescribed medicines. The interviews were recorded, transcribed and subjected to content analysis, in which the text was analysed in five steps, inspired by Graneheim and Lundman.

Results

The results revealed that the experiences which the elderly participants had regarding the receiving of medical information fell into two main categories: “Comfortable with information” or “Insecure with information”. The elderly felt comfortable when they trusted their physician or their medication, when they received enough information from the prescriber or when they knew how to find out sufficient information by themselves. They felt insecure if they were anxious, if the availability of medical care was poor or if they did not receive enough information.

Conclusions

Factors that frequently caused insecurity about information and anxiety were too short consultations, lack of availability of someone to answer questions or of the opportunity to contact the physician if adverse effects are suspected. These factors could easily be dealt with and there must be improvements in the clinics if the patients´ feelings of security are to be increased.

Users' experience of physical activity monitoring technology in rheumatoid arthritis

OBJECTIVES

The aim of the present study was to qualitatively explore users' experiences of home monitoring of health with specific regard to physical activity monitors.

METHODS

Fourteen participants were randomly selected from a larger sample of individuals with rheumatoid arthritis (RA) who had taken part in a physical activity monitoring study and had worn two physical activity monitors for seven days in their homes. These individuals were assigned to one of two focus groups. Each focus group lasted for between 40 minutes and an hour and was audio-recorded. A semi-structured questioning route was used, followed by subsequent theoretical thematic analysis.

RESULTS

No statistically significant differences were noted in the demographic factors between those who took part in the focus groups and the entire RA sample. Three distinct themes were identified: i) Experiences of having health monitored in the home, which was found to be largely positive; ii) Experiences of use of specific technology to monitor physical activity, which was generally reported as unobtrusive and not to impact significantly negatively on their daily life; iii) Perceptions and experiences of physical activity and exercise, which monitoring was reported to facilitate focusing on physical activity choices.

CONCLUSIONS

These focus groups were the first to highlight the perceptions held by individuals with RA regarding home monitoring and, in particular, physical activity monitoring. This has implications for those planning interventions for this group which involve home monitoring. Interesting findings were also highlighted regarding the perceptions and understanding of physical activity and exercise among people with RA.

Medication management among home-dwelling older patients with chronic diseases: possible roles for community pharmacists

OBJECTIVE

To describe medication management among home-dwelling older adults. These data should allow us to identify potential problems and to indicate target areas for community pharmacist intervention.

DESIGN

Cross-sectional observational study.

SETTING

Community pharmacies (n=86) in Belgium.

PARTICIPANTS

Home-dwelling older adults using at least one chronic medicine (n=338).

MEASUREMENTS

Data on drug use were taken from the electronic pharmacy databases, while drug adherence was measured by pill count, self-report and estimation by GP and pharmacist. Drug knowledge and practical drug management capacity were assessed by patient interview and questionnaire, respectively.

RESULTS

The study population (n=338) used a median of 5 chronic drugs per patient. Half of our sample (n=169) used psychotropic medication chronically, mainly benzodiazepines. In 100 patients (29.6%) at least one drug-drug interaction of potential clinical significance was observed. The overall mean adherence per patient was very high (98.1%), but 39.6% of individuals was underadherent with at least one medication. Seventy-six % of patients had an acceptable knowledge of the indication for at least 75% of their medication. In nearly 15 % of the study population cognitive impairment was suspected by the mini-cog test. The participants reported several practical problems with drug taking: difficulties with vision (32.0%), blister opening (12.1%), tablet swallowing (14.8%), tablet splitting (29.7% [represents % of patients who have to split tablets]) and distinction between different drug packages (23.4%).

CONCLUSION

This study identified the following aspects of medication management by home-dwelling older adults that could be improved by pharmaceutical care services: (i) assistance of cognitively impaired patients, (ii) management of practical drug taking problems, (iii) DDI screening, (iv) drug adherence, and (v) chronic benzodiazepine use.

The effects of Hartcoach, a life style intervention provided by telephone on the reduction of coronary risk factors: a randomised trial

Background

Cardiovascular disease (CVD) is the leading cause of death worldwide. Secondary prevention is essential, but participation rates for cardiac rehabilitation are low. Furthermore, current programmes do not accomplish that patients with CVD change their lifestyle in a way that their individual risk factors for recurrent events decrease, therefore more effective interventions are needed. In this study, the effectiveness of the Hartcoach-programme, a telephonic secondary prevention program focussing on self management, is studied.

Methods/design

A multicenter, randomised parallel-group study is being conducted. Participants are 400 patients with acute myocardial infarction (STEMI, NSTEMI,) and patients with chronic or unstable angina pectoris (IAP). Patients are recruited through the participating hospitals and randomly assigned to the experimental group (Hartcoach-programme plus usual care) or the control group (usual care).

The Hartcoach-programme consists of a period of six months during which the coach contacts the patient every four to six weeks by telephone. Coaches train patients to take responsibility for the achievement and maintenance of the defined target levels for their particular individual modifiable risk factors. Target levels and treatment goals are agreed by the nurse and patient together. Data collection is blinded and occurs at baseline and after 26 weeks (post-intervention). Primary outcome is change in cardiovascular risk factors (cholesterol, body mass index, waist circumference, blood pressure, physical activity and diet). Secondary outcomes include chances in glucose, HbA1c, medication adherence, self-management and quality of life.

Discussion

This study evaluates the effects of the Hartcoach-programme on the reduction of individual risk factors of patients with CVDs. Patients who are not invited to follow a hospital based rehabilitation programme or patients who are unable to adhere to such a programme, may be reached by this home based Hartcoach-programme. If positive results are found, the implementation of the Hartcoach-programme will be extended, having implications for the management of many people with CVD.

Trial registration

NTR2388

The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland

INTRODUCTION

Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum.

AIM

The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland.

METHODS

A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time.

RESULTS

Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication classes included anti-pyretics and non-opioid analgesics, psychoanaleptics, and psychleptic agents. Approximately 97% (n = 2279) of medication errors were as a result of drug administration errors (comprising a double dose [n = 1040], wrong dose [n = 395], wrong medication [n = 597], wrong route [n = 133], and wrong time [n = 110]). Prescribing and dispensing errors accounted for 0.68% (n = 16) and 2.26% (n = 53) of errors, respectively.

CONCLUSION

Empirical data from poisons information centres facilitate the characterisation of medication errors occurring in the community and across the healthcare spectrum. Poison centre data facilitate the detection of subtle trends in medication errors and can contribute to pharmacovigilance. Collaboration between pharmaceutical manufacturers, consumers, medical, and regulatory communities is needed to advance patient safety and reduce medication errors.

Severe adverse events after cataract surgery among medicare beneficiaries

PURPOSE

To determine rates and risk factors associated with severe postoperative complications after cataract surgery and whether they have been changing over the past decade.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

A total of 221 594 Medicare beneficiaries who underwent cataract surgery during 1994-2006.

METHODS

Beneficiaries were stratified into 3 cohorts: those who underwent initial cataract surgery during 1994-1995, 1999-2000, or 2005-2006. One-year rates of postoperative severe adverse events (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) were determined for each cohort. Cox regression analyses determined the hazard of developing severe adverse events for each cohort with adjustment for demographic factors, ocular and medical conditions, and surgeon case-mix.

MAIN OUTCOME MEASURES

Time period rates of development of severe postoperative adverse events.

RESULTS

Among the 221 594 individuals who underwent cataract surgery, 0.5% (1086) had at least 1 severe postoperative complication. After adjustment for confounders, individuals who underwent cataract surgery during 1994-1995 had a 21% increased hazard of being diagnosed with a severe postoperative complication (hazard ratio [HR] 1.21; 95% confidence interval [CI], 1.05-1.41) relative to individuals who underwent cataract surgery during 2005-2006. Those who underwent cataract surgery during 1999-2000 had a 20% increased hazard of experiencing a severe complication (HR 1.20; 95% CI, 1.04-1.39) relative to the 2005-2006 cohort. Risk factors associated with severe adverse events include a prior diagnosis of proliferative diabetic retinopathy (HR 1.62; 95% CI, 1.07-2.45) and cataract surgery combined with another intraocular surgical procedure on the same day (HR 2.51; 95% CI, 2.07-3.04). Individuals receiving surgery by surgeons with the case-mix least prone to developing a severe adverse event (HR 0.52; 95% CI, 0.44-0.62) had a 48% reduced hazard of a severe adverse event relative to recipients of cataract surgery performed by surgeons with the case-mix most prone to developing such outcomes.

CONCLUSIONS

Rates of sight-threatening adverse events after cataract surgery declined during 1994-2006. Future efforts should be directed to identifying ways to reduce severe adverse events in high-risk groups.