Regimen complexity and medication nonadherence in elderly patients

Istituto Nazionale di Ricovero e Cura per Anziani (INRCA), Cosenza
Therapeutics and Clinical Risk Management (Impact Factor: 1.47). 03/2009; 5(1):209-16.
Source: PubMed


To assess whether the number of daily administrations of individual drugs, as a measure of regimen complexity, contributes to the profile of an elderly patient who adheres poorly to the prescribed therapy.
Six hundred ninety patients over 64 years who were consecutively admitted to 11 acute medical care and three long term/rehabilitation wards in Italy.
Self-reported adherence to drugs taken at home before admission was measured by a single question assessment for each listed drug supplemented with a latter question about the circumstances of the missed administration. For cognitively impaired patients the question was put to patients' relatives or caregivers.
A structured multidimensional assessment was performed to identify nonadherence and its potential correlates. Correlates of nonadherence were identified by multivariable logistic regression.
We recorded 44 cases (6.4%) of nonadherence to at least one drug. Being assisted by foreign caregivers (OR 2.17; 95% CI 1.02-4.63) and the use of at least one multiple daily dosing drug (OR 2.99; 95% CI 1.24-7.17) were significant independent correlates of medication nonadherence, while age, selected indexes of frailty and the cumulative number of prescribed drugs were not.
Regimen complexity and type of assistance are independent correlates of medication nonadherence.

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    • "Moreover, also movement disorders such as extrapyramidal diseases might cause further difficulty in coordination and properly sequencing the puffing and the breath holding in affected patients [113]. Furthermore, the number of daily dosings has been shown to be inversely associated with adherence in both a Parkinson population [114] and in a broad elderly population [115]. Finally, COPD-related and age-related lung volume and inhaled flows decrease may result in ineffective effort and poor drug inhalation [116]. "
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    ABSTRACT: The treatment of older and oldest old patients with COPD poses several problems and should be tailored to specific outcomes, such as physical functioning. Indeed, impaired homeostatic mechanisms, deteriorated physiological systems, and limited functional reserve mainly contribute to this complex scenario. Therefore, we reviewed the main difficulties in managing therapy for these patients and possible remedies. Inhaled long acting beta-agonists (LABA) and anticholinergics (LAMA) are the mainstay of therapy in stable COPD, but it should be considered that pharmacological response and safety profile may vary significantly in older patients with multimorbidity. Their association with inhaled corticosteroids is recommended only for patients with severe or very severe airflow limitation or with frequent exacerbations despite bronchodilator treatment. In hypoxemic patients, long-term oxygen therapy (LTOT) may improve not only general comfort and exercise tolerance, but also cognitive functions and sleep. Non-pharmacological interventions, including education, physical exercise, nutritional support, pulmonary rehabilitation and telemonitoring can importantly contribute to improve outcomes. Older patients with COPD should be systematically evaluated for the presence of risk factors for non-adherence, and the inhaler device should be chosen very carefully. Comorbidities, such as cardiovascular diseases, chronic kidney disease, osteoporosis, obesity, cognitive, visual and auditory impairment, may significantly affect treatment choices and should be scrutinized. Palliative care is of paramount importance in end-stage COPD. Finally, treatment of COPD exacerbations has been also reviewed. Therapeutic decisions should be founded on a careful assessment of cognitive and functional status, comorbidity, polypharmacy, and age-related changes in pharmacokinetics and pharmacodynamics in order to minimize adverse drug events, drug-drug or drug-disease interactions, and non-adherence to treatment.
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    • "In general, an increase in the number of daily doses of a drug may increase complexity, consistent with previous measures [14] [15] [16] [17] [18]. This is not guaranteed, however, as adding a second dose that is to be taken with another medication already in the regimen would not increase complexity as defined here. "
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    ABSTRACT: As the population in developed countries ages, patients with multiple chronic conditions are becoming more common. These patients are increasingly being managed with multiple concurrent medications and their medication regimens are frequently described as complex. Despite the significant challenges that complexity poses for clinical decision-making, the adherence of patients to their medication regimens and patient health and wellbeing, a robust understanding of this term in the context of medication regimens, is lacking. Here, it is shown that the essential feature of complex medication regimens is the multiplicity of rules that constitute their basic structure, rather than their intrinsic comprehensibility. Medication regimen complexity is a measure of the size of the consolidated medication script, or the shortest possible list of rules, for that medication regimen. A protocol is suggested for the consolidation of a medication regimen and the measurement and reduction of regimen complexity. This involves simplifying dosing instructions, consolidating the rules for taking medications, determining the number of rules in the consolidated medication script and eliminating or modifying rules towards a more parsimonious treatment plan. Following this protocol may reduce the burden on the patient associated with adhering to the treatment regimen and thus promote patient-centred outcomes, such as improved health and quality of life, key components of the general move towards person-centered medicine.
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