EVALUATION OF MEDICATION KNOWLEDGE IN ELDERLY PATIENTS Mary Beth O'Connell and June F. Johnson
OBJECTIVE: To identify problems with medication knowledge, selfestimated compliance, and recall of medication education in a group of elderly patients. DESIGN:
Survey.
SElTING:
Medicine and geriatric clinics at a county hospital.
PATIENTS: Patients medication.
~
years old and taking at least one prescription
MAIN omCOME MEASUREMENTS: Medication knowledge, selfestimated compliance, and recall of medication education. RK~ULTS: The percent of geriatric patients correctly stating 76-100 percent of their medication doses, uses, and frequencies was 30, 64, and 66 percent, respectively. Fifteen patients (34 percent) stated they never missed a medication dose and 27 (61 percent) remembered to take their medications by memory alone. Sixteen and 86 percent, respectively, of the patients from the medicine and geriatric clinics could not recall receiving verbal or written educational material. Only 27 percent of patients recalled having been told about possible adverse reactions. The most frequently cited providers of medication information were physicians.
CONCLVSIONS: Specially designed multidisciplinary medication education programs with repeated written and verbal reinforcement for elderly patients may improve patients' knowledge about their medications, recognition and management of adverse reactions, and compliance.
Ann Pharmacother 1992;26:919-21.
continues to be documented in the literature.!" Evidence suggests that lack of education by healthcare professionals may contribute to this problem. I .3,4.6-9 The purpose of this study was to identify problems with medication knowledge, self-estimated compliance, and medication education recall in a group of ambulatory, elderly patients. MEDICATION MISUSE BY THE ELDERLY
Methods Elderly patients (aged ;:«) y) being seen in the geriatric and medicine clinics at Hennepin County Medical Center and taking one or more medications were selected for participation in the study. All elderly patients
MARY BETH O'CONNELL, Phann.D., FACCP, FASHP, is an Associate Professor, College of Pharmacy, University of Minnesota. and a Clinical Pharmacy Specialist in Geriatrics, Pharmacy Depanment, Hennepin County Medical Center: and JUNE F. JOHNSON, Phann.D., at the time of this study was a Clinical Pharmacist, Hennepin County Medical Center, Minneapolis, MN: she is currently a Clinical Assistant Professor, College of Pharmacy, University of Buffalo, Buffalo, and a Clinical Pharmacy Specialist in Geriatrics, Rochester General Hospital, Rochester, NY. Reprints: Mary Beth O'Connell, Phann.D., FACCP, FASHP, College ofPhannacy, University of Minnesota, HSUF 7-115, 308 Harvard Sl. S.E., Minneapolis, MN 55455.
in clinic on the day pharmacy students were available were interviewed. Patients were excluded if they had a diagnosis of dementia or confusion and were judged by the clinic nurse and pharmacist to be unable to accurately relate information. Formal mental status assessments were not conducted. Most of the patients in the geriatric clinic had been referred from other clinics and tended to have more complicated problems. A clinical pharmacist did not practice in either of these clinics. Each patient's chart was reviewed to obtain demographic information and an accurate medication list. Only over-the-counter (OTC) medications listed in the medical record were included in the analysis. After an orientation to medication history-taking and a few practice patient interviews, one of two pharmacy students interviewed patients from both clinics, using a standard form, for 5-15 minutes prior to the physician visit. Each question was read directly from the questionnaire to minimize interpretive differences and prompting. Patients were asked to state (I) the name, dosage, administration frequency, and indication for each of their medications; (2) any adverse effects that they were wamed about and how these would be managed; (3) actions they would take following missed doses; (4) whether a compliance aid or another individual assisted them with medication management; and (5) whether a healthcare professional provided them with verbal or written medication information. We did not formally assess cognitive function nor were we able to verify self-estimated compliance or the accuracy of past education program recall. The data were analyzed using nonpaired Student's r-test, linear regression, and chi-square. Because of the small number of patients from each clinic, the respondents were combined for the medication knowledge analysis. A p value of g).05 was considered significant,
Results
Twenty patients from the geriatric clinic (mean age 78.9
± 7.9 y) and 24 from the medicine clinic (mean age 71.5 ± 8.5 y) were interviewed. All of the patients lived in the community except for 3 from the geriatric clinic who resided in a nursing home. The geriatric clinic patients took an average of 4.0 ± 2.7 medications daily (range 1-10); the medicine clinic patients took an average of 5.75 ± 2.47 (range 3-11) (p=O.029). A weak, yet significant, relationship was found to exist between age and the total number of medications used by each patient for the total group (y=O.1x + 12.4, r = 0.3291, p=0.028), but was not identified for the medicine and geriatric clinic subgroups. The patients were better able to accurately report the purpose of their medications and the frequency of administration than the doses of their medications (Table 1). For example, 64 percent of the patients were able to correctly recall the frequency of use for 76-100 percent of their medications; only 30 percent were able to correctly recall the doses of 76-1 ()() percent of their medications. The use of aids and coaching (i.e., hints or suggestions made by the
The Annals ofPharmacotherapy
•
1992 July/August, Volume 26 •
Downloaded from aop.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 29, 2016
919
interviewer if the patient was unable to recall information spontaneously) improved the recall of medication names. Prescription vials were the most commonly used aid followed by coaching, drug appearance, and medication lists. Thirty-two patients (73 percent) claimed that they could not remember being told about the potential adverse effects of their medications. Over half of the patients admitted that they would not contact a healthcare professional for further evaluation or information if they suspected an adverse reaction. There was no correlation between clinic type an.d the number of patients who recalled receiving information about adverse effects or appropriate behavior when confronted with an adverse effect. With respect to self-estimated compliance, 15 patients (34 percent) stated that they had never missed a medication dose. Most patients (61 percent) relied on memory al~ne t? ~ake their medications. Fifty percent of the geriat~c clinic and 71 percent of the medicine clinic patients relied totally on memory. Memory aids included pill boxes (16 percent), another person (II percent), and a written list (7 percent). Only 2 patients used more than one method to enhance their memory. The number of medications taken did not influence the use of memory aids. If a dose was omitted, 90 percent of the patients stated that they would continue the regimen as scheduled. None stated that they would double the next dose. Other behaviors such as taki?g the dose when remembered, were also 'listed as op-
nons. Eighty-~ou~ pe~cent of the patients recalled receiving so~e medication mformation. However, only 14 percent
claimed that they had received any written information. According to the patients, physicians were the most frequent providers of medication information (70 percent), followed by nurses (16 percent), and pharmacists (II percent). The type of medication education provided did not vary according to clinic.
Discussion O~r survey of elderly clinic patients suggests that sub~tan~Ial gaps exist in patients' understanding of proper medicanon u~e. Mean medication use among this population
(4.9 medications/d) falls within the range reported in the literature for ambulatory elderly patients (2-5.6/d).I,2,4,7,lo-13 Our study excluded patients not taking any medication and probably underestimated actual OTC use. Ellor and Kurz noted that one of every six elderly patients fails to include OTC agents when listing their medications." Most of the ~lderly patients we surveyed knew the purposes and dosmg frequencies of their medications, but fewer than half knew the prescribed doses. Only 66 percent of the patients reported 100 percent compliance with their medications. Self-reported compliance rates can be unreliable as evide~ced by the Systolic Hypertension Elderly Project in WhICh 74 percent of the patients with a low pill count reported 100 percent compliance.' Many factors may have contributed to decreased knowledge about and compliance with medications among the respondents. These include lack of individualized medication counseling, lack of written instructions to reinforce verbal instructions, inability to recall information previously presented, lack of compliance aids or assistants, as well as other causes. Only 14 percent of the patients reported 920
•
The Annals ofPharmacotherapy
•
Table 1. Accuracy of Recalling Specific Information About Medications By the Elderly" PERCENTAGE OF MEDICATIONS CORRECTLY RECALLED
0-25 26-50 51-75 76-100 Overall mean of medications correctly recalled
PERCENT OF ELDERL Y PATIENTS DOSE
39 16 16 29 47.2±38
FREQUENCY OF USE
PURPOSE
4
9
9
5
23 64 80.7±22.6
20 66 78.3±29
"n=44.
receiving any written information on their medications. Less than half used a compliance aid or had someone assist the~ with their medications. Missed doses were generally omitted. A number of other studies have previously addressed these issues.P" ~ area of particular concern is lack of knowledge regardmg adverse effects. Only 27 percent of the patients s~ted that they had been informed of and knew about posSIble adv~rse ett:ects. Thi~ statistic is similar to percentages reported in preVIOUS studies.P" None of the patients in our study reported experiencing any potential adverse effects. Adverse consequences may result from this lack of knowle~ge if p~tients.continue ~g their medications, inappropnat~ly discontinue essential medications, delay in seeking medical attention, or fail to obtain advice from a healthcare practitioner. Because the elderly may experience diminished recall of compl~x issues an~ decreased efficiency in processing information and solvmg problems, written material (in addition ~o t~e prescri~tion label) should be incorporated into f?ediCatiO~ educati~n progr~s.I4-16 Reliance on prescription label information alone IS of great concern as evide~ced by Murray et aI., who reported that 24 percent of patients they evaluated could not read the primary label and 39 percent could not read the auxiliary label because of impaired vision, inadequate legibility of type, or illiteracy.~3 In addit~on, an organized system for managing medicanons that mcorporates useful compliance aids, knowledge of what to do if doses are missed, and written information may improve compliance.v'
OBJECTIVE: To identify problems with medication knowledge, selfestimated compliance, and recall of medication education in a group of elderly patients. DESIGN:
Survey.
SElTING:
Medicine and geriatric clinics at a county hospital.
PATIENTS: Patients medication.
~
years old and taking at least one prescription
MAIN omCOME MEASUREMENTS: Medication knowledge, selfestimated compliance, and recall of medication education. RK~ULTS: The percent of geriatric patients correctly stating 76-100 percent of their medication doses, uses, and frequencies was 30, 64, and 66 percent, respectively. Fifteen patients (34 percent) stated they never missed a medication dose and 27 (61 percent) remembered to take their medications by memory alone. Sixteen and 86 percent, respectively, of the patients from the medicine and geriatric clinics could not recall receiving verbal or written educational material. Only 27 percent of patients recalled having been told about possible adverse reactions. The most frequently cited providers of medication information were physicians.
CONCLVSIONS: Specially designed multidisciplinary medication education programs with repeated written and verbal reinforcement for elderly patients may improve patients' knowledge about their medications, recognition and management of adverse reactions, and compliance.
Ann Pharmacother 1992;26:919-21.
continues to be documented in the literature.!" Evidence suggests that lack of education by healthcare professionals may contribute to this problem. I .3,4.6-9 The purpose of this study was to identify problems with medication knowledge, self-estimated compliance, and medication education recall in a group of ambulatory, elderly patients. MEDICATION MISUSE BY THE ELDERLY
Methods Elderly patients (aged ;:«) y) being seen in the geriatric and medicine clinics at Hennepin County Medical Center and taking one or more medications were selected for participation in the study. All elderly patients
MARY BETH O'CONNELL, Phann.D., FACCP, FASHP, is an Associate Professor, College of Pharmacy, University of Minnesota. and a Clinical Pharmacy Specialist in Geriatrics, Pharmacy Depanment, Hennepin County Medical Center: and JUNE F. JOHNSON, Phann.D., at the time of this study was a Clinical Pharmacist, Hennepin County Medical Center, Minneapolis, MN: she is currently a Clinical Assistant Professor, College of Pharmacy, University of Buffalo, Buffalo, and a Clinical Pharmacy Specialist in Geriatrics, Rochester General Hospital, Rochester, NY. Reprints: Mary Beth O'Connell, Phann.D., FACCP, FASHP, College ofPhannacy, University of Minnesota, HSUF 7-115, 308 Harvard Sl. S.E., Minneapolis, MN 55455.
in clinic on the day pharmacy students were available were interviewed. Patients were excluded if they had a diagnosis of dementia or confusion and were judged by the clinic nurse and pharmacist to be unable to accurately relate information. Formal mental status assessments were not conducted. Most of the patients in the geriatric clinic had been referred from other clinics and tended to have more complicated problems. A clinical pharmacist did not practice in either of these clinics. Each patient's chart was reviewed to obtain demographic information and an accurate medication list. Only over-the-counter (OTC) medications listed in the medical record were included in the analysis. After an orientation to medication history-taking and a few practice patient interviews, one of two pharmacy students interviewed patients from both clinics, using a standard form, for 5-15 minutes prior to the physician visit. Each question was read directly from the questionnaire to minimize interpretive differences and prompting. Patients were asked to state (I) the name, dosage, administration frequency, and indication for each of their medications; (2) any adverse effects that they were wamed about and how these would be managed; (3) actions they would take following missed doses; (4) whether a compliance aid or another individual assisted them with medication management; and (5) whether a healthcare professional provided them with verbal or written medication information. We did not formally assess cognitive function nor were we able to verify self-estimated compliance or the accuracy of past education program recall. The data were analyzed using nonpaired Student's r-test, linear regression, and chi-square. Because of the small number of patients from each clinic, the respondents were combined for the medication knowledge analysis. A p value of g).05 was considered significant,
Results
Twenty patients from the geriatric clinic (mean age 78.9
± 7.9 y) and 24 from the medicine clinic (mean age 71.5 ± 8.5 y) were interviewed. All of the patients lived in the community except for 3 from the geriatric clinic who resided in a nursing home. The geriatric clinic patients took an average of 4.0 ± 2.7 medications daily (range 1-10); the medicine clinic patients took an average of 5.75 ± 2.47 (range 3-11) (p=O.029). A weak, yet significant, relationship was found to exist between age and the total number of medications used by each patient for the total group (y=O.1x + 12.4, r = 0.3291, p=0.028), but was not identified for the medicine and geriatric clinic subgroups. The patients were better able to accurately report the purpose of their medications and the frequency of administration than the doses of their medications (Table 1). For example, 64 percent of the patients were able to correctly recall the frequency of use for 76-100 percent of their medications; only 30 percent were able to correctly recall the doses of 76-1 ()() percent of their medications. The use of aids and coaching (i.e., hints or suggestions made by the
The Annals ofPharmacotherapy
•
1992 July/August, Volume 26 •
Downloaded from aop.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 29, 2016
919
interviewer if the patient was unable to recall information spontaneously) improved the recall of medication names. Prescription vials were the most commonly used aid followed by coaching, drug appearance, and medication lists. Thirty-two patients (73 percent) claimed that they could not remember being told about the potential adverse effects of their medications. Over half of the patients admitted that they would not contact a healthcare professional for further evaluation or information if they suspected an adverse reaction. There was no correlation between clinic type an.d the number of patients who recalled receiving information about adverse effects or appropriate behavior when confronted with an adverse effect. With respect to self-estimated compliance, 15 patients (34 percent) stated that they had never missed a medication dose. Most patients (61 percent) relied on memory al~ne t? ~ake their medications. Fifty percent of the geriat~c clinic and 71 percent of the medicine clinic patients relied totally on memory. Memory aids included pill boxes (16 percent), another person (II percent), and a written list (7 percent). Only 2 patients used more than one method to enhance their memory. The number of medications taken did not influence the use of memory aids. If a dose was omitted, 90 percent of the patients stated that they would continue the regimen as scheduled. None stated that they would double the next dose. Other behaviors such as taki?g the dose when remembered, were also 'listed as op-
nons. Eighty-~ou~ pe~cent of the patients recalled receiving so~e medication mformation. However, only 14 percent
claimed that they had received any written information. According to the patients, physicians were the most frequent providers of medication information (70 percent), followed by nurses (16 percent), and pharmacists (II percent). The type of medication education provided did not vary according to clinic.
Discussion O~r survey of elderly clinic patients suggests that sub~tan~Ial gaps exist in patients' understanding of proper medicanon u~e. Mean medication use among this population
(4.9 medications/d) falls within the range reported in the literature for ambulatory elderly patients (2-5.6/d).I,2,4,7,lo-13 Our study excluded patients not taking any medication and probably underestimated actual OTC use. Ellor and Kurz noted that one of every six elderly patients fails to include OTC agents when listing their medications." Most of the ~lderly patients we surveyed knew the purposes and dosmg frequencies of their medications, but fewer than half knew the prescribed doses. Only 66 percent of the patients reported 100 percent compliance with their medications. Self-reported compliance rates can be unreliable as evide~ced by the Systolic Hypertension Elderly Project in WhICh 74 percent of the patients with a low pill count reported 100 percent compliance.' Many factors may have contributed to decreased knowledge about and compliance with medications among the respondents. These include lack of individualized medication counseling, lack of written instructions to reinforce verbal instructions, inability to recall information previously presented, lack of compliance aids or assistants, as well as other causes. Only 14 percent of the patients reported 920
•
The Annals ofPharmacotherapy
•
Table 1. Accuracy of Recalling Specific Information About Medications By the Elderly" PERCENTAGE OF MEDICATIONS CORRECTLY RECALLED
0-25 26-50 51-75 76-100 Overall mean of medications correctly recalled
PERCENT OF ELDERL Y PATIENTS DOSE
39 16 16 29 47.2±38
FREQUENCY OF USE
PURPOSE
4
9
9
5
23 64 80.7±22.6
20 66 78.3±29
"n=44.
receiving any written information on their medications. Less than half used a compliance aid or had someone assist the~ with their medications. Missed doses were generally omitted. A number of other studies have previously addressed these issues.P" ~ area of particular concern is lack of knowledge regardmg adverse effects. Only 27 percent of the patients s~ted that they had been informed of and knew about posSIble adv~rse ett:ects. Thi~ statistic is similar to percentages reported in preVIOUS studies.P" None of the patients in our study reported experiencing any potential adverse effects. Adverse consequences may result from this lack of knowle~ge if p~tients.continue ~g their medications, inappropnat~ly discontinue essential medications, delay in seeking medical attention, or fail to obtain advice from a healthcare practitioner. Because the elderly may experience diminished recall of compl~x issues an~ decreased efficiency in processing information and solvmg problems, written material (in addition ~o t~e prescri~tion label) should be incorporated into f?ediCatiO~ educati~n progr~s.I4-16 Reliance on prescription label information alone IS of great concern as evide~ced by Murray et aI., who reported that 24 percent of patients they evaluated could not read the primary label and 39 percent could not read the auxiliary label because of impaired vision, inadequate legibility of type, or illiteracy.~3 In addit~on, an organized system for managing medicanons that mcorporates useful compliance aids, knowledge of what to do if doses are missed, and written information may improve compliance.v'
