Shambo Samrat Samajdar, Diabetes and Allergy-Asthma Specialty Clinic, Kolkata, West Bengal, India
Rohan Tripathi, Department of Device Development, Inovocare Healthsoft Solutions Pvt. Ltd., Kolkata, West Bengal, India
Shravan Venkatraman, Department of Clinical Pharmacology, JIPMER, Puducherry, India
Shatavisa Mukherjee, Department of Clinical and Experimental Pharmacology, School of Tropical Medicine, Kolkata, West Bengal, India
Jyotirmoy Pal, Department of Medicine, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India
Santanu Kumar Tripathi, Department of Clinical Pharmacology, Jagannath Gupta Institute of Medical Sciences and Hospital, Kolkata, West Bengal, India
Shashank R Joshi, Department of Endocrinology, Joshi Clinic, Mumbai, Maharashtra, India
Anuj Maheshwari, Department of Medicine, HIMS, Lucknow, Uttar Pradesh, India
Abstract
Medication adherence is critical for managing chronic diseases, especially among the elderly, who often face multiple comorbidities and polypharmacy. This review explores the multifaceted nature of medication adherence in the elderly, including definitions, the importance of adherence, factors affecting adherence, and strategies to improve it. The SIMPLE approach, which stands for Simplify regimen, Impart knowledge, Modify patient beliefs, Provide communication, Leave the bias, and Evaluate adherence, is highlighted as an effective strategy. In addition, the role of empathy and accessibility in enhancing adherence is discussed. Innovative solutions such as MedpeR®, a smart pillbox designed specifically for the Indian elderly, are also examined. This review aims to provide healthcare providers with comprehensive insights and practical approaches to improve medication adherence among elderly patients.
Introduction
Medication adherence is a crucial component in the treatment of chronic diseases, particularly in the elderly population. Defined by the World Health Organization (WHO) as “the degree to which the person’s behavior corresponds with the agreed recommendations from a healthcare provider,”[1] medication adherence encompasses several factors that influence a patient’s willingness and ability to follow a prescribed treatment regimen. This review aims to provide a detailed exploration of medication adherence in the elderly, including the importance of adherence, factors affecting adherence, and strategies to improve it, with a special focus on innovative solutions like MedpeR®.
Definitions
Medication adherence
According to the WHO, medication adherence is “the degree to which the person’s behavior corresponds with the agreed recommendations from a healthcare provider.”[1]
Elderly
Defined as a person aged 65 years or older.[2]
Importance of Medication Adherence
Crucial for treatment
Adherence[3] to medication is vital in the treatment of chronic diseases, particularly in the elderly, who often have multiple comorbidities[4] and are at higher risk of polypharmacy.[5] Proper medication adherence ensures that patients receive the full therapeutic benefits of their prescribed treatments.[6]
Consequences of nonadherence
Decreased therapeutic benefits
Poor adherence can lead to suboptimal drug levels, reducing the effectiveness of treatment. For example, inconsistent use of diabetic[7] medications can lead to poor glucose control.
Increased healthcare utilization
Nonadherence can result in frequent hospital and physician visits, increased healthcare costs, and the overtreatment of conditions.[8] This can strain healthcare resources and lead to unnecessary medical interventions.
Complications in chronic diseases
Nonadherence can exacerbate chronic diseases,[9] leading to complications such as hypoglycemia and hyperglycemia in diabetes patients. This can result in a deterioration of the patient’s medical condition and reduced quality of life.
Factors Affecting Medication Adherence in the Elderly
Patient factors
Mental state
Depression, lower cognitive function, memory issues, anxiety, sleep disturbances, and resisting care can all negatively impact medication adherence.[10] Cognitive decline and mental health issues are prevalent in the elderly and can significantly affect their ability to follow medication regimens.[11] This may result in the patient either taking the medication twice or completely forgetting to take it. The other factors can be drug automatism or bullying by the caretaker.[12]
Physical health
Poor dexterity, physical function impairments, impaired hearing, lower self-rated health, chronic conditions, and recent hospitalization can all pose challenges to adherence. Physical limitations can make it difficult for elderly patients to manage their medications effectively.
Demographics
Older age, male gender, low education level, being married, language and cultural barriers, and ethnicity can influence adherence. Sociodemographic factors can affect patients’ understanding of their treatment and their ability to access and manage medications.[13]
Behavior/attitudes/habits
Nonadherence to follow-ups, personality traits, use of complementary and alternative medicines, concurrent use of over-the-counter drugs, problem drinking, lower self-care, and lack of interpersonal relationships can all impact adherence.[14] Behavioral factors and habits can either support or hinder adherence to medication regimens.
Knowledge/beliefs
Beliefs about medication, perceived benefit of medications, knowledge about the condition, health literacy, misunderstanding of verbal instructions, lack of threatening view of illness, and perceived illness burden are critical factors.[15] Patients’ understanding and beliefs about their health and treatment play a significant role in their adherence behaviors.[16]
Medication factors
Formulation and packaging
Issues with drug formulation, packaging, and storage can affect adherence. Medications that are difficult to open or manage can deter patients from taking them as prescribed.[17]
Drug handling
Lack of use of medication boxes, necessity to cut tablets, and difficulty opening containers are common issues. Simplifying medication handling can improve adherence.
Drug regimen
Polypharmacy, frequent changes in medication regimen, and complex dosing schedules can overwhelm patients. Simplifying drug regimens and minimizing changes can help maintain adherence.
Other factors
Cost of medications, lack of insurance coverage, adverse drug reactions, drug–drug interactions, poor labeling instructions, short-term medications, and lack of immediate consequences of missed doses can all impact adherence. Financial barriers and side effects can discourage patients from following their prescribed regimens.
Healthcare provider factors
Communication
Poor communication, lack of patient involvement in decision-making, lack of confidence in healthcare providers, prescription by nonspecialists, lack of trust, lack of review of medications, and dissatisfaction with doctor visits are significant factors. Effective communication and a strong patient–provider relationship are crucial for adherence.
Healthcare system factors
Patient education
Lack of patient education, follow-up, medication schedule, short duration of prescriptions, and lack of community nursing services to pack medications can hinder adherence. Comprehensive education and support services are essential to ensure patients understand and can manage their medications.
Socioeconomic factors
Caregiver issues
Lack of caregivers and large caregiver burden can affect adherence. Adequate caregiver support is necessary for elderly patients who may be unable to manage their medications independently.
Measures to Improve Adherence
Patient factors
Assess mental status
Determine if the patient is capable of managing their medications. Cognitive assessments can help identify patients who may need additional support.[18]
Assess behavior, attitude, and habits
Evaluate willingness to take medications and adherence to follow-ups. Understanding patients’ behaviors and attitudes can inform tailored interventions.[19]
Assess knowledge and beliefs
Ensure accurate knowledge about medications and the disease. Providing clear and accessible information can improve patients’ understanding and adherence.
Assess physical status
Determine if physical limitations affect the ability to manage medications. Physical assessments can identify patients who may need assistive devices or caregiver support.
Address chronic conditions and recent hospitalization
Consider how these factors may impact adherence. Ensuring continuity of care and support during transitions can prevent lapses in adherence.[20]
Medication factors
Simplify drug and regimen
Use user-friendly packaging, provide appropriate storage instructions, and reduce the number of medications if possible. Simplifying regimens can make it easier for patients to adhere.
Address drug handling issues
Provide medications that do not require cutting and ensure easy-to-open containers. Making medications easier to handle can improve adherence.
Consider cost and insurance coverage
Ensure medications are affordable and covered by insurance. Financial support and insurance coverage can remove barriers to adherence.
Healthcare provider factors
Build trust
Foster a trusting relationship between healthcare providers and patients. Trust is essential for effective communication and adherence.
Improve communication and interaction
Understand the patient’s problems and provide clear instructions. Effective communication can help patients understand and follow their treatment plans. Unless the clinicians ensure adherence to the prescribed medications, it is not considered to treat the patient fully. This should be ensured for the patient to achieve maximum therapeutic benefits.[21]
Healthcare system factors
Provide sufficient patient education
Educate patients about the importance of adherence. Education programs can empower patients to manage their health and medications.
Offer support services
Provide services to help patients pack medications and manage polypharmacy. Support services can assist patients in managing complex regimens.
Socioeconomic factors
Address caregiver needs
Ensure the patient has adequate caregiver support if needed. Caregiver support is crucial for patients who cannot manage their medications independently.
The SIMPLE approach to improving medication adherence
The American College of Preventive Medicine recommends the mnemonic SIMPLE to help improve patient adherence to medication regimens.[22] This approach encapsulates six key strategies:
Simplify the regimen (S)
Complex treatment plans can hinder patient compliance, especially among the elderly. Simplifying the regimen to involve fewer medications, once-daily dosing, or aligning medication times with daily routines can enhance adherence.[23] Tools such as medication organizers and alarms can further aid in managing complex regimens.
Impart knowledge (I)
Educating patients about their conditions and the benefits of their treatments is crucial. Clear, written, and verbal instructions should be provided, avoiding medical jargon. Engaging family and friends, using written materials, and offering quality online resources can help reinforce understanding. Shared decision-making should be emphasized to ensure that patients are fully informed and involved in their treatment plans.
Modify patient beliefs and human behavior (M)
Addressing patient beliefs and behaviors is essential, as education alone may not suffice. Engaging patients in open dialogues about their expectations, fears, and concerns can help modify their attitudes toward medications. Empowering patients to self-manage their conditions and clearly communicating the risks of non-compliance are vital steps in fostering adherence.
Provide communication and trust (P)
Effective communication and trust between healthcare providers and patients are pivotal. Healthcare providers should hone their interviewing skills, practice active listening, and provide emotional support. Clear, direct, and thorough information should be given, encouraging patient input in decision-making and allowing ample time for questions. Building trust through these practices can significantly improve adherence.
Leave the bias (L)
Overcoming disparities requires that healthcare providers recognize and address their own biases. This involves learning about low health literacy and its impact on patient outcomes, adopting a patient-centered communication style, and tailoring education to the patient’s understanding level. Understanding the demographics of the patient population can help in providing more personalized care.
Evaluate adherence (E)
Regularly assessing adherence is crucial to identify and address noncompliance. This can be achieved through self-reports, directly asking patients about their adherence, and using tools like medication tracking apps. By continually monitoring adherence, healthcare providers can make necessary adjustments to treatment plans, thus improving patient outcomes.
Implementing the SIMPLE approach can lead to significant improvements in medication adherence among elderly patients, ultimately enhancing therapeutic outcomes and reducing healthcare costs. Text message reminders, electronic pill boxes, and smartphone applications play a vital role in improving adherence and this can increase the therapeutic benefits to the patients and improve the outcome.[24]
The Role of Empathy and Accessibility in Medication Adherence
Ensuring empathy in the patient–provider relationship can significantly increase medication adherence.[25] Empathy involves understanding and addressing the emotional and psychological needs of patients, which fosters a sense of trust and support. When patients feel that their healthcare providers genuinely care about their well-being, they are more likely to follow prescribed treatments. Empathetic communication should include active listening, validating patient concerns, and providing personalized care plans that consider individual circumstances and challenges. Alongside empathy, accessibility of medications is crucial. The two critical components of accessibility are the availability and affordability of drugs. Medications must be readily available at pharmacies or through delivery services to prevent delays in treatment. In addition, affordability ensures that patients can consistently purchase their medications without financial strain. Both availability and affordability directly contribute to accessibility, which is a key determinant of adherence. When patients can easily access their medications and feel supported by empathetic healthcare providers, they are more likely to adhere to their prescribed regimens, leading to better health outcomes and reduced healthcare costs.
Innovative Solutions: MedpeR®
MedpeR® - your personal Medicinal helpeR, developed by Inovocare Healthsoft Solutions Pvt. Ltd., is a unique smart pillbox designed to address the critical challenge of ensuring medication adherence among the elderly. This device, specifically created for the Indian elderly population, does not require a smartphone for day-to-day use and is equipped with various features to facilitate adherence. MedpeR® has nine compartments, numbered 1–8 for regular medicines and ∞ (infinity) for emergency medicines. Each compartment can have up to five alarms with two snoozes each, accompanied by an alarm buzzer and LEDs indicating the correct and wrong pills. Medication consumption records are saved for up to two weeks and push notifications are sent when Wi-Fi is available. The Assistive Refill feature uses visual cues to help avoid errors during refill, reducing the risk of placing medication in the wrong compartment. This comprehensive device, developed with support from the Department of Science and Technology, Government of India, and Texas Instruments, empowers patients and caregivers, reducing anxiety related to medication management. By integrating advanced technology and user-friendly features, MedpeR® represents a significant step forward in supporting medication adherence among the elderly.
Conclusion
Adherence to medications is essential for delivering therapeutic benefits, especially among the elderly. By considering patient, medication, healthcare provider, healthcare system, and socioeconomic factors, healthcare providers can develop individualized solutions to improve medication adherence. Ensuring adherence is critical for achieving better therapeutic outcomes and improving overall patient health. Strategies such as the SIMPLE approach and innovative solutions like MedpeR® can significantly enhance adherence, ultimately leading to improved health outcomes and reduced healthcare costs. Healthcare providers should focus on building empathetic relationships, ensuring accessibility, and leveraging technology to support their patients in adhering to their medication regimens.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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