Noncompliance in older adults aspects of ageism, research tools and practical recommendations

1. Noncompliance in older adults aspects of ageism, research tools and practical recommendations Marcel Leppée, MD, PhD Andrija Stampar Institute of Public Health Zagreb, Croatia

2. www.stampar.hr

5. Individuals, Societies, Cultures and Health (ISCH) COST Action IS1402Ageisma multi-national, interdisciplinary perspective Ageism (i.e., the complex and often negative social construction of old age) is highly prevalent. There is unequivocal evidence concerning the negative consequences associated with ageism at the individual, familial, and societal levels. The long term goal of this Action is to challenge the practice of ageism and allow older people to realize their full potential. 

6. WG1) Healthcare system This WG will focus on various health care settings, and evaluate the healthcare provision and medication management of older adults. Potential areas of focus would be: the various stakeholders involved in this system: • physicians, • social workers, • nurses, • patients, • etc

7. NONCOMPLIANCE

8. Compliance with medication “…the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.” (WHO)

9. Difference between ADHERENCE and COMPLIANCE ADHERENCE TO…. partnership between doctor and patient The patient’s co nformance with the provider’s recommendation with respect to timing, dosage and frequency of medication taking COMPLIANCE WITH ….. you must, you have to take (one-way street) Patient’s passive following of provider’s orders

10. CONCORDANCE is a related term used to describe a shared agreement between a health professional and a patient about therapeutic goals. It’s less a measure, and more a philosophical approach to implementing treatment plans. PERSISTENCE refers to the duration of conformance to a particular treatment plan, and is usually defined by the interval between when therapy is started, and when it is discontinued.

11. Methods of Measuring Compliance

12. Osterberg L, Blaschke T. Adherence to Medication. N Engl J Med 2005;353:487-97

13. The most common indirect method Self-reported questionnaire

14. Noncompliance in older patients 1. aspects of ageism

15. Noncompliance in the elderly • can be termed as “epidemic” • more than 10% of older adult hospital admissions may be due to noncompliance with medication regimens • one-third(33%) of older persons admitted to the hospital had a history of noncompliance • Nearly one-fourth (25%) of nursing home admissions may be due to older person’s inability to self-administer medications • approximately 125 000 deaths occur annually in the US due to noncompliance with cardiovascular medications

16. approximately one half of the elders who take at least one medication find compliance challenging and average compliance decreases from approximately: • 80% in patients taking medication once daily to • 50% in those taking medications four times a day or taking polypharmacy.

17. For a number of chronic medical conditions • diabetes, • hypertension, • hypercholesterolemia, and • congestive heart failure • higher rates of medication compliance • were associated with: • lower rates of hospitalization, and • a reduction in total medical cost

18. Helping older patients to improve their compliance requires: • knowledge of their current medication use • reasons for noncompliance • knowledge of personal beliefs and • health goals.

19. By discussing concerns, patients can learn that 1. denial of their illness and 2. misconceptions about their treatment can lead to noncompliance, resulting in complications, side effects and adverse drug events.

20. While discussing medications with elders, physicaian and pharmacist should educate the patient and/or caregiver.

21. oral counselling is imperative, but insufficient, • the elders need also written information in a readable font and patient-friendly language, especially if changes are being made. • TIP ! • Asking the elder to describe the drug’s purpose, its use instructions, and its potential side effects (called “back teaching”) can help to identify knowledge gaps in the older patient.

22. Compliance is a multidimensional phenomenon determined by the interplay of five sets of factors, termed “dimensions” by the World Health Organization: • Social/economic factors • Provider-patient/health care system factors • Condition-related factors • Therapy-related factors • Patient-related factors

23. Social and Economic Factors • The most consistently reported factors to impact medication compliance: • low literacy • limited access to health care • lack of health insurance coverage • poor social support • family instability • homelessness

24. 2.Health Care System-Related Factors • The quality of the doctor-patient relationship is one of the most important health care system-related factors • Health care systems create barriers to compliance by limiting access to health care in the following ways: • making appointments difficult to schedule • lacking continuity of provider care • using restrictive formularies and changing formularies • through high drug costs, copayments, or both.

25. 3. Condition-Related Factors • Compliance with a treatment regimens often declines significantly over time; • especially true for chronic illnesses that have few or no symptoms: • high blood pressure, • diabetes • osteoporosis, • hyperlipidemia • Without symptoms, a person may not be motivated to compliance with a treatment regimen. • Important! • to understand the illness and • what will happen if it is not treated.

26. 4. Therapy-Related Factors • have been also associated with decreased compliance: • complexity of the medication regimen • number of medications • number of daily doses required • duration of therapy • therapies that are inconvenient or interfere with a person's lifestyle • medications with a social stigma attached to its use medications such as antidepressants, are slow to produce effects • administration of a medication requires the mastery of specific techniques (injections and inhalers) • medication side effects or adverse drug reaction

27. 5. Patient-Related Factors • Physical factors • Physical impairments and cognitive limitations may • increase the risk for noncompliance in older adults. • Visual Impairment • Hearing Impairment • Cognitive Impairment • Impaired Mobility • Dexterity • Swallowing Problems

28. 5. Patient-Related Factors • Psychological/behavioral factors • Knowledge • Motivation • Readiness to Change Assessment • Self Efficacy • Alcohol and substance abuse

29. Consequences of medication noncompliance • Increased use of medical resources: • physician visits, • laboratory tests, • unnecessary additional treatments, • emergency department visits, • hospital or nursing home admissions • Treatment failure

30. Prerequisities for Compliance with Medication • Berger and Felkey summarized the prerequisites for compliance with medication regimens. Compliance requires that a person: • Show interest in his or her health and understand the diagnosis • Believe that the prescribed treatment will help • Know exactly how to take the medication and the duration of therapy • Find ways to fit the medication regimen into his or her daily routine • Value the outcome of treatment more than the cost of treatment • Believe that he or she can carry out the treatment plan • Believe that the health care practitioners involved in the treatment process truly care • about him or her as a person rather than as a disease to be treated Berger BA, Felkey BG. Improving patient compliance. Bridgewater, NJ: U.S. Pharmacist. IMPACT U.S. Pharmacist Continuing Education Series. 2001; June:1-12.

31. Levine demonstrated that the following steps increase compliance: a. Assessing the person's understanding about the disease and the treatment regimen and then providing information where knowledge gaps exist b. Tying the medication-taking process to other daily routines c. Using adherence aids, such as medication organizers or charts d. Simplifying medication regimens e. Providing human support within the health care team f. Recognizing difficulty in coping and other socio-behavioral issues that may affect the person's ability to follow the treatment regimen Levine AM. Antiretroviral therapy: adherence. Clin Care Options HIV [journal online]. 1998;4:1-10.

32. Predictors of Medication Noncompliance • Predictors of medication noncompliance may be useful to identify older adults who are most in need of interventions to improve compliance. Noncompliance warning signs may include: • Not filling a new prescription • Not obtaining refills as often as expected for medications taken on a chronic basis • Not refilling prescriptions for chronic medications • Not completing the entire course of therapy for short-term treatment • Identification of older persons at risk for medication noncompliance is just the first step in addressing this potential problem.

33. Noncompliance in older patients 2. research tools

34. Adherence scales are identified mostly in the last few years (2005-2015). One of the main sources was article (Lavsa et. al) which evaluated literature describing medication adherence surveys/scales to gauge patient behaviours at the point of care.

35. 1 Medication Adherence Questionnaire (MAQ) MMAS – Morisky Medication Adherence Scale 4-item scale (MMAS-4) 8-item scale (MMAS-8) Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986 Jan;24(1):67-74.

36. 1 • Medication Adherence Questionnaire (MAQ) • the shortest • the easiest • the fastest • wide range of diseases

37. 1 4 -item scale MMAS-4

38. 1 8-item scale MMAS-8

39. 2 • Self-efficacy for Appropriate Medication Use Scale • SEAMS • ”self-efficacy” • 13-item scale had good internal consistency reliability • a reliable and valid instrument that may provide a valuable assessment of medication self-efficacy in chronic disease management • appropriate for use in patients with low literacy skills Source Risser J, Jacobson TA, Kripalani S. Development and psychometric evaluation of the Self-efficacy for Appropriate Medication Use Scale (SEAMS) in low-literacy patients with chronic disease. J Nurs Meas. 2007;15(3):203-19.

40. 3 • The Brief Medication Questionnaire • BMQ • a new self-report tool for screening adherence and barriers to adherence • BMQ tool is: • useful in identifying patients who need assistance with their medications, • assessing patient concerns, and • evaluating new programs. Svarstad BL, Chewning BA, Sleath BL, Claesson C. The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence. Patient Educ Couns. 1999;37(2):113-24.

41. 3 • The Brief Medication Questionnaire • BMQ • includes: • 5-item Regimen Screen that asks patients how they took • each medication in the past week, • 2-item Belief Screen that asks about drug effects and • bothersome features, and • 2-item Recall Screen about potential difficulties remembering • 2-item Access Screen about difficulties in buying and refilling

42. 3

43. 3 Regimen screen Belief screen Recall screen Access screen

44. 4 Hill-Bone Compliance to High Blood Pressure Therapy Scale • The Hill-Bone Compliance Scale assesses patient behaviors for three important behavioral domains of high blood pressure treatment: • reduced sodium intake; • appointment keeping, and • medication taking. Kim MT, Hill MN, Bone LR, Levine DM. Development and testing of the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Prog Cardiovasc Nurs. 2000 Summer;15(3):90-6.

45. 4

46. 4 • This brief instrument provides: • - a simple method for clinicians in various settings to use to assess patients' self reported compliance levels and • to plan appropriate interventions.

47. 5 • Medication Adherence Rating Scale • MARS • 10-item scale includes: • a valid and reliable measure of compliancy for psychoactive • medications • diagnosed with schizophrenia Thompson K, Kulkarni J, Sergejew AA. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophr Res. 2000 May 5;42(3):241-7.

48. 5 Compliant = ‘No’ response for questions 1-6, 9–10. ‘Yes’ response for questions 7 and 8.

49. 6 • Adherence to Refills and Medications Scale • ARMS • 14 and 12-item scale: • chronic disease. • low-literacy patients Kripalani S, Risser J, Gatti ME, Jacobson TA. Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease. 2009;12(1):118-23.