Reference
Cross AJ, Elliott RA, Petrie K et al. (2020) Interventions for improving medication‐taking ability and adherence in older adults prescribed multiple medications, Cochrane Systematic Review, John Wiley & Sons, Ltd, 14651858, 10.1002/14651858.CD012419.pub2
At a glance
Older people, conventionally recognized as over 65 y.o., often experience multi-pathological conditions (Hilmer, et al., 2007) (WHO, 2000), involving multiple therapeutic interventions: among them the polypharmacy, defined as the use of 4 or more medications/die. World population aging makes this phenomenon increasing.
Medication-taking ability involves a careful adherence to medical prescriptions, such as knowing what medications to take, the correct administration, but these aspects can be quite complex for an older person.
The phenomenon of non-adherence, i.e. any deviation from the agreed prescription, can result in under-utilisation, over-utilisation, and incorrect use of medication. Advanced age, cognitive impairment, impaired vision, extreme complexity of the regimen can easily lead to unintentional non-adherence, very different from the voluntariness not to take the treatment as instructed.
This Cochrane Review highlights that the interventions described in the literature to improve adherence in elder (classified as educational, behavioural, and mixed) have low-level efficacy and require more accurate studies.
What is already known
Cochrane points out that the phenomenon of non-adherence can lead to a suboptimal response, recurrence of disease, increased reporting of adverse drug events (ADEs), avoidable hospitalisations, increased mortality, morbidity and, not least, increased healthcare costs (Cross, Elliott, Petrie, Kuruvilla, & George, 2020).
How widespread is the phenomenon? It seems that non-adherence is set at very high values, affecting up to 50% of older people, regardless of the geographical region they belong to.
There are many strategies put in place to encourage the elderly to properly take the prescribed therapy, including educational and behavioural interventions, alone or in combination. We can think, for example, of alarms, beepers, reminder charts/medication lists, calendar annotations, telephone reminders, simplifications of medication regimens (behavioural interventions) and group or individual educational attempts, provided by experienced staff, such as GPs, Nurses, Pharmacists.
From these considerations comes the interest of the authors and Cochrane, who intend to evaluate the different strategies aimed at enhancing medication-taking ability and/or medication adherence in older people (or their carers) in polypharmacy treatment, in order to evaluate their effectiveness, through a systematic review.
Characteristics of the study
An analysis of 50 studies (RCT, quasi-RCT), of which 30 were meta-analysed, investigated the results on more than 14,000 subjects over 65, spread over four Continents and in different settings of care: immediately before discharge, post discharge, to the General Medical Practitioner, the Territorial Pharmacy, and home healthcare services.
All studies have compared innovative intervention with traditional care.
Main results
Due to the heterogeneous nature of the interventions, Cochrane categorised them into three broad groups:
• educational interventions;
• behavioural interventions;
• mixed interventions (both educational and behavioural).
How to measure medication adherence?
The strategies adopted move from pill count, to the prescription claims/refills, up to the use of validated scales such as the Morisky Medication Adherence Scale (Bernsten, et al., 2001). In addition, knowledge was assessed most often by asking participants about appearance of the medication (colour, shape), indicated dose, possible interactions and consultation on any access to the Emergency Room for adverse events.
Educational interventions have yielded discordant results, attributable to the high heterogeneity of studies and the incompleteness of the final data. However, comforting results on adherence were obtained following individualised counselling sessions from Pharmacists and GPs.
Behavioural interventions appear to lead to an improvement in the adherence of the tested subjects, reporting fewer missed doses and an increase in the proportion of people who are adherent to medications.
Cochrane review highlights a significant gap in the literature regarding high-quality evidence on the effects of interventions for improving medication-taking ability, deserving of more rigorous investigations. For example, the effect of a regimen simplification to twice-daily dosing intervals and provided medications in unit of use packaging (translucent plastic cups with lids containing all medications for that dosing time) appeared to be positive.
Mixed interventions (educational and behavioural) had a variable impact on medication-taking ability, showing a slightly greater improvement in medication-taking ability compared to usual care,
result supported by a study that accompanied an educational approach with telephone follow-up. Other studies had fewer comforting results, using visual support strategies (tablets/capsules affixed).
The effect of mixed interventions on medication-taking ability was unable to be determined (low-quality evidence), although assuming an impact on the number of hospital readmissions and access to the Emergency Room (∼30% benefit in terms of decreased risk).
Limitations
There is concern about the extreme heterogeneity of studies and low methodological quality, highlighting the need for new systematic studies, testing ways to improve older people’s ability to use and adhere to multiple medications.
What’s new?
This is certainly an innovative review, focusing on an issue not recently systematically investigated.
It highlights the focal role played by health professionals, such as general practitioners, nurses and pharmacists, in direct daily contact with the elderly in poly-treatment.
Behavioural or mixed strategies may stimulate elder adherence, but literature needs to set high-quality study protocols to provide answers to clinical practice.
References
Bernsten C, Bjorkman I, Caramona M et al. Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical care: a multicentre study in seven European countries. Drugs & Aging 2001; 18(1): 63-77.
Cross A, Elliott R, Petrie K et al. (2020, May 8). Interventions for helping older adults prescribed multiple medications to use and take their medications. Cochrane Database of Systematic Reviews, 5, CD012419. doi:10.1002/14651858
Hilmer S, Mager D, Simonsick E et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007; 167(8): 781-7.
WHO (2000, Jun 26). Social Development and Ageing: Crisis or Opportunity? Special panel at Geneva 2000.