Medication non-adherence among older people : a review of interventions for improvement

Medication non-adherence among older people: a review of interventions for improvement Background Older people generally have more chronic conditions that often require complex pharmacological management involving several medicines. Adherence to medication in older people is influenced by cognitive and functional impairments and can vary from 26% to 59% but may be as low as 0%. The World Health Organization identified medication non adherence as one of the major causes of morbidity, mortality and health care costs. There are many factors that can contribute to non-adherence such as: frequent changes to drug regimen, misunderstanding prescribing instructions, limited education about the medication, and forgetfulness. Numerous interventions have been developed and tested to assess older people’s ability to manage and adhere to their medicines. Aims This review aimed to examine interventions both perceptual and practical that have been used to assess and improve adherence with medication in older people. Materials and Methods An extensive review of the literature was lead on main biomedical databases (PubMed, Cinahl, Cochrane) with MeSH controlled language research, when possible, or free-text research. The review started in May 2013 and was repeated to update retrieved data with newest document and add citation from Psychinfo database. Only publication after 2003 were included. At the end of the selection 32 research papers were find both relevant and appropriate. The focus of each article was summarize in a table, and built the conceptual structure of the study. Results Four systematic reviews with data for 133 RCTs and other 24 narrative reviews and original articles were included and analyzed in the literature research. The main themes identified were: patient behavioral approaches, formation giving, health professional involvement, health related outcomes, perceptions and attitudes to medication adherence and non-adherence, patients acceptance of their illness and shared decision making. 19 interventions resulted in a significant positive effect on enhancing of knowledge and adherence to therapy [ P=0.115 – P < 0.0001]. Interventions approaches used are complex, multifaceted and heterogeneous in the effects and they did not seem to work consistently across all studies. The methods to assess “adherence” were different between studies, resulting in an hard comparison. However an improvement in medication adherence is demonstrated in some intervention [+ 0.32% - +25,9%], but none of them obtained significant results on clinical outcomes. Educational intervention to improve adherence is mostly associated with the nurses role, who can express his contribution in a multidisciplinary team. Multiple and complex intervention, led on by different professionals, seems to get the best outcomes in term of adherence to therapy and reducing inappropriate medication use. Conclusions The findings of this review imply that there is no clear definition of non adherent behavior. Quantitative interventions fail to assess patient choice in relation to medication taking. Qualitative interventions show how important is to take into account patient’s perspective, beliefs and preferences but improvements are needed with regard to the quality of studies and the use of quality indicators. Polytherapy is shown to be a predictor of many complication and have to be considered especially providing health care to older people. Both adherence and appropriate prescribing need more research to develop an appropriate instrument for assessment. For interventions to be successful, they need to be both perceptual and practical related to factors that underpin intentional and unintentional non-adherence such as motivation and cognitive capacity. Future research needs to be more patient centered to elucidate the patient’s perspective and possible impact of a shared approach to clinical decision making. Nurses shares great responsibility with other professionals about enhancing adherence to medication, and should be taken in consideration as education providers, as they are aware of patient’s specific weaknesses.