Multifaceted Prospective Memory Intervention to Improve Medication Adherence

Electronic Monitoring of Medication Adherence to Direct Oral Anticoagulants: A Systematic Review

Strict medication adherence, which reflects the process by which patients take their medication as prescribed, is crucial for the use of direct oral anticoagulants (DOACs). Therefore, technological devices may serve as promising tools for assessing adherence. We aimed to systematically review the literature focusing on electronically monitored adherence (EMA) to DOACs. All studies indexed in EMBASE, Cochrane Library, MEDLINE, Scopus, and Web of Science from inception until September 1, 2023, were searched. Original studies targeting the query topics were included, findings were categorized and narratively synthetized. Adherence data, including the quality of data reporting bias, were evaluated using the EMERGE guideline. The review protocol was registered in the PROSPERO database (ID CRD42023441161). Out of the 5911 potential hits, 19 articles, comprising 15 research studies, were identified. These studies enrolled 4163 patients (median 72.1 years; 57.9% males), usually chronically treated with DOACs for atrial fibrillation. EMA was measured in 3451 patients by seven different devices from eight manufacturers; the median population tracked with electronic monitoring was 56 patients over 5 months per study. Observational studies resulted in 88.6% and interventional studies resulted in 92.5% of EMA to DOACs, mostly monitoring regimen and taking adherence. Two studies reported high-quality adherence data, whereas 11 reported low-quality adherence data. The item described in the EMERGE guideline as affecting adherence by measurement method, as appropriate, has rarely been addressed. This review broadens the understanding of the overall high EMA to DOACs reported across various study populations and designs. Furthermore, due to the identified gaps in current literature, it highlights the pressing need for standardized methodologies and improved adherence reporting. This study was supported by the GAUK 328322 and SVV 220665.

Mobility-Based Smartphone Digital Phenotypes for Unobtrusively Capturing Everyday Cognition, Mood, and Community Life-Space in Older Adults: Feasibility, Acceptability, and Preliminary Validity Study

BACKGROUND

Current methods of monitoring cognition in older adults are insufficient to address the growing burden of Alzheimer disease and related dementias (AD/ADRD). New approaches that are sensitive, scalable, objective, and reflective of meaningful functional outcomes are direly needed. Mobility trajectories and geospatial life space patterns reflect many aspects of cognitive and functional integrity and may be useful proxies of age-related cognitive decline.

OBJECTIVE

We investigated the feasibility, acceptability, and preliminary validity of a 1-month smartphone digital phenotyping protocol to infer everyday cognition, function, and mood in older adults from passively obtained GPS data. We also sought to clarify intrinsic and extrinsic factors associated with mobility phenotypes for consideration in future studies.

METHODS

Overall, 37 adults aged between 63 and 85 years with healthy cognition (n=31, 84%), mild cognitive impairment (n=5, 13%), and mild dementia (n=1, 3%) used an open-source smartphone app (mindLAMP) to unobtrusively capture GPS trajectories for 4 weeks. GPS data were processed into interpretable features across categories of activity, inactivity, routine, and location diversity. Monthly average and day-to-day intraindividual variability (IIV) metrics were calculated for each feature to test a priori hypotheses from a neuropsychological framework. Validation measures collected at baseline were compared against monthly GPS features to examine construct validity. Feasibility and acceptability outcomes included retention, comprehension of study procedures, technical difficulties, and satisfaction ratings at debriefing.

RESULTS

All (37/37, 100%) participants completed the 4-week monitoring period without major technical adverse events, 100% (37/37) reported satisfaction with the explanation of study procedures, and 97% (36/37) reported no feelings of discomfort. Participants' scores on the comprehension of consent quiz were 97% on average and associated with education and race. Technical issues requiring troubleshooting were infrequent, though 41% (15/37) reported battery drain. Moderate to strong correlations (r≥0.3) were identified between GPS features and validators. Specifically, individuals with greater activity and more location diversity demonstrated better cognition, less functional impairment, less depression, more community participation, and more geospatial life space on objective and subjective validation measures. Contrary to predictions, greater IIV and less routine in mobility habits were also associated with positive outcomes. Many demographic and technology-related factors were not associated with GPS features; however, income, being a native English speaker, season of study participation, and occupational status were related to GPS features.

CONCLUSIONS

Theoretically informed digital phenotypes of mobility are feasibly captured from older adults' personal smartphones and relate to clinically meaningful measures including cognitive test performance, reported functional decline, mood, and community activity. Future studies should consider the impact of intrinsic and extrinsic factors when interpreting mobility phenotypes. Overall, smartphone digital phenotyping is a promising method to unobtrusively capture relevant risk and resilience factors in the context of aging and AD/ADRD and should continue to be investigated in large, diverse samples.

Developing feedback visualizations to support older adults' medication adherence

Background

Blood pressure control is critical for older adults because the prevalence of hypertension and resulting cardiovascular illness increases with age. Antihypertension medications are central to blood pressure treatment. However, nonadherence to antihypertension medications is high. Health technology such as smartphone apps provide an opportunity for users to manage their medication regimen and support processes related to medication-taking.

Objective

We implemented a user-centered evaluation approach to develop and refine adherence feedback visualizations for the MEDSReM© medication adherence app for older adults with hypertension.

Methods

We conducted a literature review and iterative usability testing to achieve this objective. We identified adherence goals, information needs, as well as design guidelines by reviewing theoretical frameworks and existing scientific evidence. We then used a two-phase iterative user-centered study and subject matter expert evaluation. Both quantitative and qualitative data were used to select and improve the current prototype and evolve to the next prototype.

Results

The need for daily, weekly, and monthly adherence performance information as well as visualization formats for conveying this information was identified from the literature review. Overall, the information shown in visualization prototypes was successfully interpreted by participants. Comprehension issues of visualizations were identified and addressed from visual prototype revisions. Insights from both user and subject matter expert groups were used to select and refine the prototypes for the MEDSReM app.

Conclusion

Evidence-based and user-centered approaches were effective for developing visualizations about adherence performance feedback in the MEDSReM app and provided insight into how the app can be made easy to understand and use by older adults with hypertension, which will be evaluated in future effectiveness testing.

Translation of a Successful Behavioral Intervention to a Digital Therapeutic Self-Management System for Older Adults

Feature at a Glance: Nonadherence to hypertension medications is associated with negative health outcomes, which is of particular importance for older adults because of the high prevalence of hypertension in this population. To promote medication adherence among this group, we translated a behavioral intervention that improved adherence by 36% into a digital therapeutic self-management system. Design strategies included interviewing older adults, conducting usability evaluations after each iteration, and engaging a team of experts from nursing, cognitive psychology, pharmacy, human factors in aging, and software development. We outline our design process that can guide translation of other behavioral interventions into digital therapeutic platforms.

It's complicated: Executive functioning moderates impacts of daily busyness on everyday functioning in community-dwelling older adults

OBJECTIVE

Research shows that cognitively healthy older adults with mild executive function (EF) weaknesses are vulnerable to the negative impacts of life complexity (or daily busyness) when performing instrumental activities of daily living (IADLs). However, past research assessed life complexity only at one timepoint, not capturing daily fluctuations. Importantly, fluctuations in busyness can themselves have deleterious impacts on functioning. This study extended past research by examining whether (1) variability in daily busyness would be more detrimental than level of busyness to performance of IADLs, and (2) EF assessed at home would moderate deleterious impact of busyness on IADLs.

METHOD

Fifty-two community-dwelling older adults aged 60 to 95 completed daily IADL tasks and daily measures of EF and busyness via ecological momentary assessment, independently at home for 18 days.

RESULTS

(1) In a subset of participants with mild EF weaknesses, high variability in busyness across days was associated with fewer tasks completed correctly; and (2) across all participants (regardless of EF), high levels of daily busyness were associated with fewer tasks completed on time.

CONCLUSIONS

Findings indicate that high variability in daily busyness, potentially reflecting a lack of daily routine, was associated with IADL errors among cognitively healthy older adults with mild EF weaknesses. Additionally, consistently high levels of busyness were associated with failures to complete tasks, or failures to complete them on time, regardless of EF. These results further support the Contextually Valid Executive Assessment (ConVExA) model, which posits that EF and contextual factors interact to predict functional outcomes.

A rapid review of interventions to improve medicine self-management for older people living at home

BACKGROUND

As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored.

AIM

This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address.

DESIGN

A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory.

RESULTS

Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty.

CONCLUSION

To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system.

PATIENT OR PUBLIC CONTRIBUTION

A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.

Designing Feedback Visualizations for Anti-Hypertensive Medication Adherence for Older Adults

Adhering to anti-hypertensive medications contributes to control of blood pressure and improved health outcomes. However, adherence rates among older adults are low. Patient monitoring of medication taking helps increase adherence and technology has great potential to support self-monitoring, in part by providing visual feedback about medication taking performance. However, little attention has been paid to designing feedback visualizations in medication-monitoring technology for older adults. In this research, we identified guidelines for designing understandable and effective adherence visualizations for older adults from existing theories and literature. With the guidelines in mind, we designed, refined, and evaluated visualizations that provided adherence feedback for a smartphone application with 17 older participants. Based on theory and evidence, we identified design guidelines for feedback visualizations. These guidelines can support design of useful feedback visualizations that may improve medication adherence among older adults.

A Participatory Sensing Study to Understand the Problems Older Adults Faced in Developing Medication-Taking Habits

Past research has demonstrated that older adults tend to use daily activities as cues to remember to take medications. However, they may still experience medication non-adherence because they did not select adequate contextual cues or face situations that interfere with their medication routines. This work addresses two research questions: (1) How does the association that older adults establish between their daily routines and their medication taking enable them to perform it consistently? (2) What problems do they face in associating daily routines with medication taking? For 30 days, using a mixed-methods approach, we collected quantitative and qualitative data from four participants aged 70–73 years old about their medication taking. We confirm that older adults who matched their medication regimens to their habitual routines obtained better results on time-based consistency measures. The main constraints for using daily routines as contextual cues were the insertion of medication taking into broad daily routines, the association of multiple daily routines with medication taking, the lack of strict daily routines, and the disruption of daily routines. We argue that the strategies proposed by the literature for forming medication-taking habits should support their formulation by measuring patients’ dosage patterns and generating logs of their daily activities.

Prospective Memory Training in Older Adults: A Systematic Review and Meta-Analysis

Prospective memory (PM), which enables one to remember to carry out delayed intentions, is crucial for everyday functioning. PM commonly deteriorates upon cognitive decline in older adults, but several studies have shown that PM in older adults can be improved by training. The current study aimed to summarise this evidence by conducting a qualitative systematic analysis and quantitative meta-analysis of the effects of PM training in older adults, for which systematic searches were conducted across seven databases (Cochrane Library, Embase, PubMed, PsycInfo, Web of Science, CINAHL and Scopus). Forty-eight studies were included in the qualitative analysis, and 43% of the assessed PM training interventions showed positive gains in enhancing PM. However, the methodological quality varied across the studies, with 41% of the non-randomised control trials (non-RCTs) rated as having either serious or critical risk of bias. Therefore, only 29 RCTs were included in the subsequent quantitative meta-analysis. We found a significant and moderate immediate efficacy (Hedges' g = 0.54) of PM training in enhancing PM performance in older adults, but no significant long-term efficacy (Hedges' g = 0.21). Two subgroup analyses also revealed a robust training efficacy across the study population (i.e., healthy and clinical population) and the number of training sessions (i.e., single session and programme-based). Overall, this study provided positive evidence to support PM training in older adults. Further studies are warranted to explore the mechanisms by which PM training exerts its effects, and better-quality RCTs are needed to provide more robust evidence supporting our findings.

A Systematic Review and Meta-analysis of Face-to-face Medication Adherence Interventions for Patients with Long Term Health Conditions

BACKGROUND

Although previous reviews demonstrated effectiveness related to medication adherence interventions, they incorporated various digital platforms and other multiple delivery modes, which makes difficult to distinguish what aspects of the interventions led to effectiveness.

PURPOSE

This review aimed to (i) estimate the efficacy of face-to-face medication adherence interventions on adherence outcomes, in adults with Long Term Health Conditions (LTHCs) and (ii) identify the Behaviour Change Techniques (BCTs) used in the interventions and examine their potential impact on efficacy.

METHODS

Cochrane Controlled Register of Trials, Embase, MEDLINE (Ovid), PsycINFO, Web of Science, PubMed, and Scopus databases were searched. Randomized controlled trials were included if they described an intervention to improve medication adherence, delivered via face-to-face only, and included patients with LTHCs. Studies were excluded if they used additional delivery modes, involved family members or used a group format. In addition, use of BCTs was coded.

RESULTS

20 studies were included (n = 3667). Statistically significant pooled effects were found favoring the intervention than control, for the following MEMS (electronic monitoring) measures: percentage of prescribed doses taken on time over a period of 3 weeks to 2 months (MD 9.34, 95% CI 4.36-14.33, p = .0002; I2 =0%); percentage of prescribed doses taken for a period of 1 week to 2 months (MD 5.63, 95% CI 1.62-9.64, p = .006; I2 = 51%) and for 1 month (OR = 2.51, 95% CI 1.37-4.57, p = .003; I2 = 0%); percentage of days correct doses taken for 1 month to 14 weeks (MD 6.59, 95% CI 0.74-13.15, p = .03; I2 = 68%). Studies using the Morisky scale showed a significant between group difference for 1-3 months (MD 0.86, 95% CI 0.59-1.13, p < .00001; I2 = 0%). Overall, more BCTs were identified in intervention conditions than in comparison conditions (22 vs. 10). The impact of BCTs on intervention effectiveness could not be established as the analyses were underpowered.

CONCLUSIONS

Face-to-face interventions increased adherence to medication among adult patients with LTHCs. Although we were able to identify BCTs among interventions, data were insufficient to determine the impact of particular BCTs on intervention effectiveness.

The Chinese version of the Memory for Intentions Test (MIST): development and evaluation of its reliability and concurrent validity

This study aims to develop a simplified Chinese version of the "Memory for Intentions Test" (MIST), evaluate its reliability and concurrent validity, explore the inter-relationships among the MIST variables and the relationships between the MIST variables and socio-demographic factors.

Two hundred healthy, Chinese-speaking adults of the Han community participated in this study. Form A of the Chinese MIST and two prospective items of the Rivermead Behavioural Memory Test, Second Edition (RBMT-II, Chinese version) were administered to all participants to evaluate internal consistency, split-half reliability, and concurrent validity. Twenty of these participants were assessed twice on Form A with a two-week interval to examine test-retest reliability. They were also assessed on both Form A and Form B to examine alternate-form reliability.

The findings of the study indicated good internal consistency (Cronbach's α = .833) and excellent split-half reliability (r = .924-.930) among the six subscales of the Chinese MIST, although the internal consistency was low (Cronbach's α = .129) for individual PM trials. We also found adequate concurrent validity (ρ = .722, p< .001), test-retest reliability (ρ = .716, p < .001), and alternate-form reliability (ρ= .828, p < .001).

The Chinese MIST demonstrated suitable reliability and concurrent validity in the Chinese-speaking population. The present study provides a new standardized prospective memory test for the Chinese population, which would enhance future clinical research in this field on the Chinese mainland.

Stimulating the Involvement of Family Members in the Medication Management Activities of Older Adults Through Ambient Displays: Qualitative Study

Little attention has been paid to how medication management technologies, designed for older adults, modify the participation of family caregivers. We developed a tablet-based ambient display that provides external cues to remind and motivate older adults to take their medications. This study aimed to understand the effect of ambient displays on the involvement of family members in the elderly's medication management. We conducted a 10-week study consisting of interviews administered weekly to nine elderly-caregivers. We identify that new involvement patterns of the family caregivers were provoked through external cues, which made them aware of older adults' medication adherence and encouraged younger relatives to help older adults.

Enhancing cue salience improves aspects of naturalistic time-based prospective memory in older adults with HIV disease

OBJECTIVE

Older persons living with HIV (PLWH) disease commonly experience failures of time-based prospective memory (PM) in their daily lives. This study examined the benefits of providing strategic supports at encoding, monitoring, and cue detection for naturalistic time-based PM among older PLWH.

METHOD

Participants included 116 older PLWH and 48 seronegatives who completed a baseline neuropsychological evaluation (see Woods et al., 2020), including a laboratory PM experiment that paralleled the design of the current naturalistic study. The naturalistic time-based PM task required participants to press a button on a portable PM response box 4 times per day for 1 month. PLWH were randomly assigned to an unsupported control condition or to an experimental group in which strategic processing was supported at encoding (implementation intentions and visualization), monitoring (content-free cuing), and/or cue detection (auditory alarm). The seronegative participants were all assigned to the unsupported control group.

RESULTS

In a model adjusting for age and affective disorders, PLWH who received all three supports in combination demonstrated moderately better naturalistic time-based PM accuracy as compared with PLWH controls. Both the cue detection and combination conditions were associated with markedly more precise response timing on the naturalistic time-based PM task. Supported PM accuracy as measured in the laboratory was positively associated with naturalistic PM accuracy among PLWH in the experimental groups.

CONCLUSIONS

Providing strategic supports to enhance the cue salience of naturalistic time-based PM tasks may improve both the accuracy and timing with which older PLWH remember to perform time-based intentions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Improving Prospective Memory Performance in Community-dwelling Older Adults: Goal Management Training and Implementation Intentions

Aim: The present study tested a compensatory executive intervention for prospective memory (goal management training) for the first time in older adults. Prospective memory (the ability to remember and execute a task in the future) declines with age, with significant implications for older adults' activities of daily living and quality of life. Prospective memory interventions have focused primarily on the retrospective component of prospective memory (e.g., implementation intentions). However, executive dysfunction is also implicated in age-related prospective memory decline.Methods: Community-dwelling older adults were randomly allocated to receive goal management training, implementation intentions or no intervention. Prospective memory was assessed before and after the intervention with a well-validated laboratory-based prospective memory measure. Results: Contrary to predictions, neither goal management training nor implementation intentions were successful at improving prospective memory in healthy older adults. Participants who received goal management training were more likely to have difficulty comprehending the intervention. Post-hoc analyses suggested implementation intentions improved prospective memory specifically for participants with poorer baseline prospective memory. Conclusions: These results represent important cautionary findings about the possible limitations of goal management training to improve prospective memory in older adults. Future research should also consider the role of baseline prospective memory ability in affecting response to compensatory intervention.

Home Care Patients' Experiences with Home Care Nurses' Support in Medication Adherence

PURPOSE

To describe nurses' support interventions for medication adherence, and patients' experiences and desired improvements with this care.

PATIENTS AND METHODS

A two-phase study was performed, including an analysis of questionnaire data and conducted interviews with members of the care panel of the Netherlands Patients Federation. The questionnaire assessed 14 types of interventions, satisfaction (score 0-10) with received interventions, needs, experiences, and desired improvements in nurses' support. Interviews further explored experiences and improvements. Data were analyzed using descriptive statistics and a thematic analysis approach.

RESULTS

Fifty-nine participants completed the questionnaire, and 14 of the 59 participants were interviewed. The satisfaction score for interventions was 7.9 (IQR 7-9). The most common interventions were: "noticing when I don't take medication as prescribed" (n = 35), "helping me to find solutions to overcome problems with using medications" (n = 32), "helping me with taking medication" (n = 32), and "explaining the importance of taking medication at the right moment" (n = 32). Fifteen participants missed ≥1 of the 14 interventions. Most mentioned the following: "regularly asking about potential problems with medication use" (33%), "regularly discussing whether using medication is going well" (29%), and "explaining the importance of taking medication at the right moment" (27%). Twenty-two participants experienced the following as positive: improved self-management of adequate medication taking, a professional patient-nurse relationship to discuss adherence problems, and nurses' proactive attitude to arrange practical support for medication use. Thirteen patients experienced the following as negative: insufficient timing of home visits, rushed appearance of nurses, and insufficient expertise about side effects and taking medication. Suggested improvements included performing home visits on time, more time for providing support in medication use, and more expertise about side effects and administering medication.

CONCLUSION

Overall, participants were satisfied, and few participants wanted more interventions. Nurses' support improved participants' self-management of medication taking and enabled patients to discuss their adherence problems. Adequately timed home visits, more time for support, and accurate medication-related knowledge are desired.

Methodological features of quantitative studies on medication adherence in older patients with chronic morbidity: A systematic review

OBJECTIVES

The growing number of chronic, multimorbid older adults encourages healthcare systems to cope with polypharmacy and non-adherence. However, methodology on how to provide effective interventions to enhance medication adherence is still object of debate.

METHODS

To describe methodological features of quantitative studies concerning older adults' medication adherence, by means of a PRISMA systematic review (Scopus, PubMed, Medline). A specific focus was devoted to theoretical models and to the ABC Taxonomy model, as stated by the EMERGE guidelines.

RESULTS

55 papers were included. Most of the studies were conducted using randomized control trials (63.6%) and focused on a single disease only (72.7%). Most of the interventions were provided by a single professional figure (70.9%). Medication adherence was mainly evaluated by means of questionnaires (61.8%) and by clinical records (30.9%). Sixteen studies considered a theoretical model in the intervention framework. The Initiation phase (ABC Taxonomy) was the most neglected.

CONCLUSIONS

Future studies upon medication adherence should account real-life challenges such as multimorbidity, polypharmacy and interdisciplinarity, analyzing adherence as a complex, holistic process.

PRACTICE IMPLICATIONS

Theoretical models may be useful to enhance the soundness of the results, to ease their comparability, to calibrate tailored strategies and to plan patient-centered interventions.

A Pantheoretical Framework to Optimize Adherence to Healthy Lifestyle Behaviors and Medication Adherence: The Use of Personalized Approaches to Overcome Barriers and Optimize Facilitators to Achieve Adherence

Patient nonadherence to healthy lifestyle behaviors and medical treatments (like medication adherence) accounts for a significant portion of chronic disease burden. Despite the plethora of behavioral interventions to overcome key modifiable/nonmodifiable barriers and enable facilitators to adherence, short- and long-term adherence to healthy lifestyle behaviors and medical treatments is still poor. To optimize adherence, we aimed to provide a novel mobile health solution steeped in precision and personalized population health and a pantheoretical approach that increases the likelihood of adherence. We have described the stages of a pantheoretical approach utilizing tailoring, clustering/profiling, personalizing, and optimizing interventions/strategies to obtain adherence and highlight the minimal engineering needed to build such a solution.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Supporting the Medication Adherence of Older Mexican Adults Through External Cues Provided With Ambient Displays: Feasibility Randomized Controlled Trial

BACKGROUND

Problems with prospective memory, which refers to the ability to remember future intentions, cause deficits in basic and instrumental activities of daily living, such as taking medications. Older adults show minimal deficits when they rely on mostly preserved and relatively automatic associative retrieval processes. On the basis of this, we propose to provide external cues to support the automatic retrieval of an intended action, that is, to take medicines. To reach this end, we developed the Medication Ambient Display (MAD), a system that unobtrusively presents relevant information (unless it requires the users' attention) and uses different abstract modalities to provide external cues that enable older adults to easily take their medications on time and be aware of their medication adherence.

OBJECTIVE

This study aimed to assess the adoption and effect of external cues provided through ambient displays on medication adherence in older adults.

METHODS

A total of 16 older adults, who took at least three medications and had mild cognitive impairment, participated in the study. We conducted a 12-week feasibility study in which we used a mixed methods approach to collect qualitative and quantitative evidence. The study included baseline, intervention, and postintervention phases. Half of the participants were randomly allocated to the treatment group (n=8), and the other half was assigned to the control group (n=8). During the study phases, research assistants measured medication adherence weekly through the pill counting technique.

RESULTS

The treatment group improved their adherence behavior from 80.9% at baseline to 95.97% using the MAD in the intervention phase. This decreased to 76.71% in the postintervention phase when the MAD was no longer being used. Using a one-way repeated measures analysis of variance and a post hoc analysis using the Tukey honestly significant difference test, we identified a significant statistical difference between the preintervention and intervention phases (P=.02) and between the intervention and postintervention phases (P=.002). In addition, the medication adherence rate of the treatment group (95.97%) was greater than that of the control group (88.18%) during the intervention phase. Our qualitative results showed that the most useful cues were the auditory reminders, followed by the stylized representations of medication adherence. We also found that the MAD's external cues not only improved older adults' medication adherence but also mediated family caregivers' involvement.

CONCLUSIONS

The findings of this study demonstrate that using ambient modalities for implementing external cues is useful for drawing the attention of older adults to remind them to take medications and to provide immediate awareness on adherence behavior.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04289246; https://tinyurl.com/ufjcz97.

Text message reminders as an adjunct to a substance use intervention for adolescents and young adults: Pilot feasibility and acceptability findings

OBJECTIVE

Text messaging has been proposed as a method for increasing the reach of interventions for harmful alcohol and other drug use. This paper describes the design of an automated text messaging adjunct to a substance use intervention intended to support adolescents and young adults attempting to change their alcohol and other drug use behavior. Feasibility and acceptability testing was conducted as part of this pilot study.

METHOD

Five focus groups were conducted to refine text message content and finalize pilot intervention design. Automated, daily, substance use-related reminder text messages were sent to pilot intervention participants (n = 39), who were recruited from outpatient treatment.

RESULTS

Of those who were invited, 63% enrolled in the study and 89.7% remained enrolled in the study as measured by completing at least one assessment after baseline. Participants reported a positive experience with the messages, particularly supportive/empowering messages and commitment reminder messages.

CONCLUSIONS

These findings suggest that text messaging is a feasible and acceptable method for delivery of substance use-related reminder content as an adjunct to substance use intervention.

Impact of multimodal interventions on medication nonadherence among elderly hypertensives: a randomized controlled study

Purpose: The study was conducted to investigate the effects of multimodal interventions on medication nonadherence, quality of life (QoL), hypertension (HTN), self-efficacy, and clinical outcome in terms of blood pressure (BP) among elderly people with HTN. Methods: An experimental design using a randomized controlled trial was adopted (N=80+80). The experimental group received multimodal interventions and the control group received routine care. Both groups were followed up at baseline and at 3 and 6 months. The data collection tools of demographic and clinical proforma, structured knowledge questionnaire on HTN (r=0.84), Revised Medication Adherence Self-Efficacy Scale (r=0.94), Morisky Medication Adherence Scale (r=0.83), World Health Organization Quality of Life-BREF scale (r=0.87), and digital BP apparatus were used. Necessary administrative permission was obtained for the study. Results: The study results proved that nurse-led multimodal interventions led to an improvement in medication adherence [F(1.75,214.30)=774.18, p<0.001], knowledge on HTN [F(2,244)=43.83, p<0.001], and self-efficacy [F(1,122)=3.99, p=0.04] of elderly people on antihypertensives over a period of 6 months. Overall QoL did not exhibit any statistically significant improvement, and no statistically significant reductions in the systolic BP (SBP) and diastolic BP (DBP) scores were obtained (p>0.05) in the experimental group over a period of 6 months. However, the clinical significance of multimodal interventions for improvements in medication adherence, QoL, knowledge on HTN, and self-efficacy was more favorable compared with the reduction in SBP and DBP scores. Conclusion: Nurses play a crucial role in improving medication adherence among elderly people with HTN. Trial details: Ethical clearance was obtained (IEC no. KH IEC 253/2012) from the Institutional Ethical Committee of Manipal University, Manipal, and the study was conducted in accordance with the Declaration of Helsinki. The study is registered under Clinical Trials Registry of India (CTRI/2017/04/008405). Informed consent was obtained from participants, and the confidentiality of information was assured.

Interventions to Improve Medication Adherence: A Review

IMPORTANCE

Among adults with chronic illness, 30% to 50% of medications are not taken as prescribed. In the United States, it is estimated that medication nonadherence is associated with 125 000 deaths, 10% of hospitalizations, and $100 billion in health care services annually.

OBSERVATIONS

PubMed was searched from January 1, 2000, to September 6, 2018, for English-language randomized clinical trials of interventions to improve medication adherence. Trials of patients younger than 18 years, trials that used self-report as the primary adherence outcome, and trials with follow-up periods less than 6 months were excluded; 49 trials were included. The most common methods of identifying patients at risk for nonadherence were patient self-report, electronic drug monitors (pill bottles), or pharmacy claims data to measure gaps in supply. Patient self-report is the most practical method of identifying nonadherent patients in the context of clinical care but may overestimate adherence compared with objective methods such as electronic drug monitors and pharmacy claims data. Six categories of interventions, and characteristics of successful interventions within each category, were identified: patient education (eg, recurrent and personalized telephone counseling sessions with health educators); medication regimen management (using combination pills to reduce the number of pills patients take daily); clinical pharmacist consultation for chronic disease co-management (including education, increased frequency of disease monitoring via telephone or in-person follow-up visits, and refill reminders); cognitive behavioral therapies (such as motivational interviewing by trained counselors); medication-taking reminders (such as refill reminder calls or use of electronic drug monitors for real-time monitoring and reminding); and incentives to promote adherence (such as reducing co-payments and paying patients and clinicians for achieving disease management goals). The choice of intervention to promote adherence will depend on feasibility and availability within a practice or health system. Successful interventions that are also clinically practical include using combination pills to reduce daily pill burden, clinical pharmacist consultation for disease co-management, and medication-taking reminders such as telephone calls to prompt refills (maximum observed absolute improvements in adherence of 10%, 15%, and 33%, respectively).

CONCLUSIONS AND RELEVANCE

Adherence can be assessed and improved within the context of usual clinical care, but more intensive and costly interventions that have demonstrated success will require additional investments by health systems.

User Insights for Design of an Antihypertensive Medication Management Application

Hypertension is the most common chronic disease affecting older adults (65+) in the United States. Unfortunately, many struggle to adhere to their antihypertensive medications as only about half diagnosed with the disease have it controlled. Therefore, there is a need for designing supportive medication management systems to aid this population with their antihypertensive medications, especially using increasingly adopted technologies such as smartphones. The preferences of older adults with hypertension must be considered when designing such systems for this population. Six older adults participated in structured interviews to inform the design of the Medication Education, Decision Support, Reminding and Monitoring System (MEDSReM). Results revealed management needs, design insights, and reminder preferences, as well as mostly positive opinions regarding technology use for medication management. These findings informed the development of MEDSReM with the goal of supporting older adults in successfully managing their antihypertensive medications.

Neurocognitive Function in Children with Primary Hypertension after Initiation of Antihypertensive Therapy

OBJECTIVE

To determine the change in neurocognitive test performance in children with primary hypertension after initiation of antihypertensive therapy.

STUDY DESIGN

Subjects with hypertension and normotensive control subjects had neurocognitive testing at baseline and again after 1 year, during which time the subjects with hypertension received antihypertensive therapy. Subjects completed tests of general intelligence, attention, memory, executive function, and processing speed, and parents completed rating scales of executive function.

RESULTS

Fifty-five subjects with hypertension and 66 normotensive control subjects underwent both baseline and 1-year assessments. Overall, the blood pressure (BP) of subjects with hypertension improved (24-hour systolic BP load: mean baseline vs 1 year, 58% vs 38%, P < .001). Primary multivariable analyses showed that the hypertension group improved in scores of subtests of the Rey Auditory Verbal Learning Test, Grooved Pegboard, and Delis-Kaplan Executive Function System Tower Test (P < .05). However, the control group also improved in the same measures with similar effects sizes. Secondary analyses by effectiveness of antihypertensive therapy showed that subjects with persistent ambulatory hypertension at 1 year (n = 17) did not improve in subtests of Rey Auditory Verbal Learning Test and had limited improvement in Grooved Pegboard.

CONCLUSIONS

Overall, children with hypertension did not improve in neurocognitive test performance after 1 year of antihypertensive therapy, beyond that also seen in normotensive controls, suggesting improvements with age or practice effects because of repeated neurocognitive testing. However, the degree to which antihypertensive therapy improves BP may affect its impact upon neurocognitive function.

Using Smart City Technology to Make Healthcare Smarter

Smart cities use information and communication technologies (ICT) to scale services include utilities and transportation to a growing population. In this article we discuss how smart city ICT can also improve healthcare effectiveness and lower healthcare cost for smart city residents. We survey current literature and introduce original research to offer an overview of how smart city infrastructure supports strategic healthcare using both mobile and ambient sensors combined with machine learning. Finally, we consider challenges that will be faced as healthcare providers make use of these opportunities.

Sensitivity of the Mini-Mental State Examination, Montreal Cognitive Assessment and the Addenbrooke's Cognitive Examination III to everyday activity impairments in dementia: an exploratory study

OBJECTIVE

The Mini-Mental State Examination (MMSE) is one of the most frequently used cognitive measures for dementia severity and linked to deficits in everyday functioning. Recently, the Montreal Cognitive Assessment (MoCA) and the Addenbrooke's Cognitive Examination III (ACE-III) increasingly substitute for the MMSE. However, there are no specific cutoffs in the ACE-III for mild dementia. The objectives of this exploratory study were to assess the sensitivity of each scale to everyday functioning and to examine the cutoffs between mild and moderate dementia on the ACE-III.

METHODS

People with mild dementia completed the MMSE, MoCA and ACE-III, whilst informal carers completed the Revised Interview for Deteriorations in Daily Living Activities for Dementia to rate their relative's initiative and performance of instrumental activities of daily living and the Katz activities of daily living scale. Data were analysed using correlation analysis, raw score comparisons, Cohen's kappa and receiver operating characteristics analysis.

RESULTS

Thirty-three dyads completed the measures. The ACE-III was the most sensitive tool for everyday functioning performance, whilst its language subscale was specifically related to initiation of activities. The most suitable cutoff on the ACE-III between mild and moderate dementia was 61.

CONCLUSIONS

Findings suggest the ACE-III more efficiently identifies everyday functional impairments. Further research is required to confirm these exploratory analyses of the cutoff between mild and moderate dementia on the ACE-III. Both functional impairment and stage of dementia are needed in the diagnostic process and in the clinical assessment of people with dementia. Copyright © 2016 John Wiley & Sons, Ltd.

Understanding the Medication Adherence Strategies of Older Adults with Hypertension

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