Student Forum Identifying Solutions to Medication Adherence in the Visually Impaired Elderly Miranda Smith, Trista Bailey Adults older than 65 years of age with vision impairment are more likely to have difficulty managing medications compared with people having normal vision. This patient population has difficulty reading medication information and may take the wrong medication or incorrect doses of medication, resulting in serious consequences, including overdose or inadequate treatment of health problems. Visually impaired patients report increased anxiety related to medication management and must rely on others to obtain necessary drug information. Pharmacists have a unique opportunity to pursue accurate medication adherence in this special population. This article reviews literature illustrating how severe medication mismanagement can occur in the visually impaired elderly and presents resources and solutions for pharmacists to take a larger role in adherence management in this population. Key Words: Aging, Elderly, Geriatric, Vision, Visual impairment. Abbreviations: AFB = American Foundation for the Blind, ASCP = American Society of Consultant Pharmacists, MARS = Medication Adherence Report Scale, VI = Visual impairment. Consult Pharm 2014;29:131-4.
Adults older than 80 years of age comprise approximately 8% of the U.S. population but account for 70% of the population with visual impairment (VI).1 As patients age, their eyes are susceptible to age-related changes, leading to an increased incidence of disorders that can impair vision, such as macular degeneration, cataracts, and glaucoma. Comorbid health problems also put the elderly at risk for eye disease. For example, patients with diabetes are at an increased risk for developing diabetic retinopathy. Age and disease affect the vision of older adults and thus have the potential to affect every facet of health management for these patients. Low vision affects multiple aspects of health care: • Decreased acuity and difficulty reading small fonts may affect the ability of the elderly to complete forms for Medicare, insurance companies, and doctors’ offices. This could result in dangerously inaccurate information being given, especially in the case of medical history forms, where doctors may base treatment plans on inaccurate information. • Reduced acuity may cause difficulty or even a total inability to read medicine labels or treatment directions. The elderly may set their own dosage or ignore treatment recommendations entirely. The geriatric population may find it difficult to read pharmacy information given with prescription drugs, resulting in misunderstanding of side effects, warnings, or interactions with other substances. These patients may encounter difficulties measuring liquids, using eye drops, and administering injections.1 • Poor color discrimination can make medication organization a challenge. Many tablets come in similar sizes, colors, and shapes. Tablet markings are usually etched, meaning there is no color contrast, or printed in fine print. When medications are slightly different colors, poor color discrimination can considerably decrease the ability to distinguish the tablets. • Low vision also limits driving activities. The geriatric population may ignore recommendations to see medical professionals because of difficulty driving to an appointment or pharmacy.
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Student Forum Seeing the Scope of the Problem Research has been conducted to assess the ability of patients with VI to practice medication adherence and to find ways to help this population in doing so. The details of all studies discussed are included in Table 1. The studies were included if they specifically assessed adherence of elderly patients with VI. Two notable community-based studies found VI contributed to impaired adherence. One study administered two different questionnaires (Morisky Scale; Medication Adherence Report Scale [MARS]) to assess medication adherence. Investigators concluded that older people with VI are more than twice as likely to need help in managing medication. These patients with VI had significant difficulty distinguishing medications, especially differentiating colors.2 Similarly, in the Women’s Health and Aging study, visual acuity, contrast sensitivity, and stereopsis (depth perception) were found to be potential risk factors for impaired ability to implement a medication regimen in older adults.3 The adherence of institutionalized elderly with VI has also been investigated. One such study observed patients admitted to a geriatric unit of a hospital. These patients were tested on opening and removing tablets from various medicine containers. Impaired vision was associated with an inability to perform this task, which led to decreased adherence. Study investigators stressed that patients’ ability to open and remove tablets from packages/containers should be tested routinely during a stay in the hospital, and management of medication should be taught and supervised within the first few days after discharge from the hospital.4 If a patient is visually impaired and needs help managing medications, a hospital visit is an opportune time for a pharmacist to identify and assess this need. Many elderly people may associate decreased vision with aging and not realize that VI may be affecting important aspects of life such as medication management. A German study of elderly nursing facility residents found that many patients were unable to read newspaper-size print with their own reading glasses.5 While the effect of VI may be less detrimental upon medication adherence in long-term care facilities where caretakers administer medications, there are opportunities for intervention by a pharmacist.
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Assessing and correcting VI may lead to a reduction of anxiety and an increased sense of self-reliance by the patient, leading to less stress during long-term care.
Solutions for Improvement: A Sight for Sore Eyes In 2008, the American Society of Consultant Pharmacists (ASCP) Foundation and the American Foundation for the Blind (AFB) jointly published the “Guidelines for Prescription Labeling and Consumer Medication Information for People with Vision Loss” to provide specific recommendations for making medication information accessible for patients with vision loss.6,7 The ASCP/AFB guidelines contain labeling recommendations, information on audible devices, including prescription labelers, voiced scanning devices, and audible blood glucose and blood pressure monitors. Insulin syringe filling aids are discussed, including magnifiers and automated fillers. Assistive reading technology is also available, spanning a variety of software and equipment that can assist patients with VI.7 Commercial support systems include “talking labels,” which are devices providing prerecorded messages attached to medication packaging, and “penfriends,” which are pen-like barcode scanners that convert information to audio. These guidelines are invaluable for a pharmacist who may encounter patients with VI, especially the elderly, who likely need more assistance in medication management. Pharmacists can assist patients with visual, tactile, or audible labeling to differentiate medication containers. Once the patient has established a personalized system to identify medications, the pharmacist can have the patient demonstrate its use to verify comprehension, memory, and accuracy. Several factors should be considered to determine the best method of identification. The most critical is the degree of vision loss, including acuity, contrast sensitivity, and color discrimination. Cognitive skills, auditory acuity, manual strength, motor coordination, the complexity of the medication regimen, and the availability and level of caregiver support should also be considered. It is also important to take into account availability, cost, and ease of use of labeling materials or devices.
The Consultant Pharmacist FEbruary 2014 Vol. 29, No. 2
Medication Adherence in the Visually Impaired Elderly
Table 1. Selected Studies on Visual Impairment and Adherence Author/Size
Population
Primary Outcome
Results
McCann RM et al. N = 314
Community-dwelling patients at least 65 years of age with VI (n = 156) compared with patients with no VI (n = 158)
Assessment of medication adherence based on Morisky Scale & MARS
• 52.6% of VI patients & 52.5% of non-VI patients reported perfect adherence on Morisky Scale • 41.7% & 44.9% reported perfect adherence on MARS • 97.4% had difficulty reading medication labels • 80.1% used optical aids • 24.4% vs. 0% had difficulty distinguishing tablets (especially differentiating colors) • 28.8% vs. 12.7% needed help managing medications • 10.3% vs. 2.5% received help managing medication from a pharmacist (OR = 4.4, 95% CI 1.4-13.5)
Windham BG et al. N = 335
Community-dwelling women between 73 and 82 years of age
Ability to receive written and verbal instructions for taking two medications and placing them in pillboxes
• 44% incorrectly placed one or both medications. Found to be a result of poor visual acuity, contrast sensitivity, and stereopsis
Nikolaus T et al. N = 119
Patients admitted from home to a geriatric hospital
Ability to open and remove tablets from various common medication containers
• 10.1% failed to open at least one container. Inability associated with impaired vision, cognitive function, manual dexterity. Inability affected adherence to medications
Sadowski B et al. N = 76
Elderly nursing facility residents
Ability to read newspapersize print using magnification
• 45% unable to read print with personal reading glasses • 91% regained reading ability by magnification • 77% required 1-3 times magnification • 14% required 10-25 times magnification • 9% required > 25 times magnification
Abbreviations: CI = Confidence interval, MARS = Medication Adherence Report Scale, OR = Odds ratio, VI = Visual impairment. Source: References 2-5.
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Student Forum In 1995, a study developed a pictorial labeling system to provide pharmaceutical care for visually impaired patients. Most participating pharmacists and students were satisfied with the labels and felt the system was easy to implement; patients receiving pictorial labels felt that the print size of the labels made them easier to read than traditional labels.8 Providing easy-to-understand pictorial labeling is less expensive than purchasing audible labelers and is a cost-effective option. Communication with patients suffering VI might comprise sending letters in large print with different font styles or background contrast or offering information in audio format, by telephone, or electronically. The primary focus of the pharmacist should be to ensure that health care information is offered in various formats, both visual and audio, including large print and computer or Web-based versions. Adults older than 65 years of age who lose their vision as a result of age-related eye disease may not be aware of services or devices that can help them cope with vision loss and make activities of daily living easier.7,9 In conclusion, pharmacists should remember to ask patients about their vision and check that they have sufficient ability or support in opening containers/packaging, distinguishing tablets, measuring liquids, or using eye drops or injections. Practical help may include providing more accessible information through large-print labels, different textures and shapes of containers, audible labels, syringe-filling aids, and medication organizers with tablets packed in daily quantities. Discussing VI with caregivers is also important. For patients who rely on home-delivery or a caregiver to pick up medications, an audible label is a good option. The pharmacist is able to record both instructions and information for the patient regarding his or her medications. Knowledge of possible improvements to medication management should encourage pharmacists to inform policymakers and pharmaceutical companies on means to improve the health care of visually impaired patients. Continued research exploring the best approaches to address this patient population’s needs is essential, both to avoid potential adverse health events from nonadherence and to cultivate strategies for cost-effective support programs.
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Miranda Smith is a 2014 PharmD candidate, Texas Tech University Health Sciences Center School of Pharmacy, Abilene, Texas. Trista Bailey, PharmD, BCPS, is assistant professor in geriatrics, Texas Tech University Health Sciences Center School of Pharmacy. For correspondence: Trista Bailey, PharmD, BCPS, Texas Tech University Health Sciences Center School of Pharmacy, 1718 Pine Street, Abilene, TX 79601; Phone: 325-696-0451; Fax: 325-676-3824; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.131.
References 1. Pelletier AL, Thomas J. Vision loss in older persons. Am Fam Physician 2009;79:963-70. 2. McCann RM, Jackson AJ, Stevenson M et al. Help needed in medication self-management for people with visual impairment: casecontrol study. Br J Gen Pract 2012;62:e530-7. 3. Windham BG, Griswold ME, Fried LP et al. Impaired vision and the ability to take medications. J Am Geriatr Soc 2005;53:1179-90. 4. Nikolaus T, Kruse W, Bach M et al. Elderly patients’ problems with medication. An in-hospital and follow-up study. Eur J Clin Pharmacol 1996;49:255-9. 5. Sadowski B, Grub A, Trauzettel-Klosinski S. Reading ability and need for reading aids, inadequate management of a nursing home population. Klin Monbl Augenheilkd 2000;217:278-83. 6. Zagar M, Baggarly S. Simulation-base learning about medication management difficulties of low-vision patients. Am J Pharm Educ 2010;74:1-7. 7. Guidelines for Prescription Labeling and Consumer Medication Information for People with Vision Loss. A Collaborative Project of American Society of Consultant Pharmacists Foundation and American Foundation for the Blind. Available at http://www.ascpfoundation.org/ downloads/Rx-CMI%20Guidelines%20vision%20loss-FINAL2.pdf. Accessed January 2, 2013. 8. Hanson EC. Evaluating cognitive services for non-literate and visually impaired patients in community pharmacy rotation sites. Am J Pharm Educ 1995;59:48-55. 9. Cupples ME, Hart PM, Johnston A et al. Improving healthcare access for people with visual impairment and blindness. BMJ 2012;344:e542.
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Adults older than 80 years of age comprise approximately 8% of the U.S. population but account for 70% of the population with visual impairment (VI).1 As patients age, their eyes are susceptible to age-related changes, leading to an increased incidence of disorders that can impair vision, such as macular degeneration, cataracts, and glaucoma. Comorbid health problems also put the elderly at risk for eye disease. For example, patients with diabetes are at an increased risk for developing diabetic retinopathy. Age and disease affect the vision of older adults and thus have the potential to affect every facet of health management for these patients. Low vision affects multiple aspects of health care: • Decreased acuity and difficulty reading small fonts may affect the ability of the elderly to complete forms for Medicare, insurance companies, and doctors’ offices. This could result in dangerously inaccurate information being given, especially in the case of medical history forms, where doctors may base treatment plans on inaccurate information. • Reduced acuity may cause difficulty or even a total inability to read medicine labels or treatment directions. The elderly may set their own dosage or ignore treatment recommendations entirely. The geriatric population may find it difficult to read pharmacy information given with prescription drugs, resulting in misunderstanding of side effects, warnings, or interactions with other substances. These patients may encounter difficulties measuring liquids, using eye drops, and administering injections.1 • Poor color discrimination can make medication organization a challenge. Many tablets come in similar sizes, colors, and shapes. Tablet markings are usually etched, meaning there is no color contrast, or printed in fine print. When medications are slightly different colors, poor color discrimination can considerably decrease the ability to distinguish the tablets. • Low vision also limits driving activities. The geriatric population may ignore recommendations to see medical professionals because of difficulty driving to an appointment or pharmacy.
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Student Forum Seeing the Scope of the Problem Research has been conducted to assess the ability of patients with VI to practice medication adherence and to find ways to help this population in doing so. The details of all studies discussed are included in Table 1. The studies were included if they specifically assessed adherence of elderly patients with VI. Two notable community-based studies found VI contributed to impaired adherence. One study administered two different questionnaires (Morisky Scale; Medication Adherence Report Scale [MARS]) to assess medication adherence. Investigators concluded that older people with VI are more than twice as likely to need help in managing medication. These patients with VI had significant difficulty distinguishing medications, especially differentiating colors.2 Similarly, in the Women’s Health and Aging study, visual acuity, contrast sensitivity, and stereopsis (depth perception) were found to be potential risk factors for impaired ability to implement a medication regimen in older adults.3 The adherence of institutionalized elderly with VI has also been investigated. One such study observed patients admitted to a geriatric unit of a hospital. These patients were tested on opening and removing tablets from various medicine containers. Impaired vision was associated with an inability to perform this task, which led to decreased adherence. Study investigators stressed that patients’ ability to open and remove tablets from packages/containers should be tested routinely during a stay in the hospital, and management of medication should be taught and supervised within the first few days after discharge from the hospital.4 If a patient is visually impaired and needs help managing medications, a hospital visit is an opportune time for a pharmacist to identify and assess this need. Many elderly people may associate decreased vision with aging and not realize that VI may be affecting important aspects of life such as medication management. A German study of elderly nursing facility residents found that many patients were unable to read newspaper-size print with their own reading glasses.5 While the effect of VI may be less detrimental upon medication adherence in long-term care facilities where caretakers administer medications, there are opportunities for intervention by a pharmacist.
132
Assessing and correcting VI may lead to a reduction of anxiety and an increased sense of self-reliance by the patient, leading to less stress during long-term care.
Solutions for Improvement: A Sight for Sore Eyes In 2008, the American Society of Consultant Pharmacists (ASCP) Foundation and the American Foundation for the Blind (AFB) jointly published the “Guidelines for Prescription Labeling and Consumer Medication Information for People with Vision Loss” to provide specific recommendations for making medication information accessible for patients with vision loss.6,7 The ASCP/AFB guidelines contain labeling recommendations, information on audible devices, including prescription labelers, voiced scanning devices, and audible blood glucose and blood pressure monitors. Insulin syringe filling aids are discussed, including magnifiers and automated fillers. Assistive reading technology is also available, spanning a variety of software and equipment that can assist patients with VI.7 Commercial support systems include “talking labels,” which are devices providing prerecorded messages attached to medication packaging, and “penfriends,” which are pen-like barcode scanners that convert information to audio. These guidelines are invaluable for a pharmacist who may encounter patients with VI, especially the elderly, who likely need more assistance in medication management. Pharmacists can assist patients with visual, tactile, or audible labeling to differentiate medication containers. Once the patient has established a personalized system to identify medications, the pharmacist can have the patient demonstrate its use to verify comprehension, memory, and accuracy. Several factors should be considered to determine the best method of identification. The most critical is the degree of vision loss, including acuity, contrast sensitivity, and color discrimination. Cognitive skills, auditory acuity, manual strength, motor coordination, the complexity of the medication regimen, and the availability and level of caregiver support should also be considered. It is also important to take into account availability, cost, and ease of use of labeling materials or devices.
The Consultant Pharmacist FEbruary 2014 Vol. 29, No. 2
Medication Adherence in the Visually Impaired Elderly
Table 1. Selected Studies on Visual Impairment and Adherence Author/Size
Population
Primary Outcome
Results
McCann RM et al. N = 314
Community-dwelling patients at least 65 years of age with VI (n = 156) compared with patients with no VI (n = 158)
Assessment of medication adherence based on Morisky Scale & MARS
• 52.6% of VI patients & 52.5% of non-VI patients reported perfect adherence on Morisky Scale • 41.7% & 44.9% reported perfect adherence on MARS • 97.4% had difficulty reading medication labels • 80.1% used optical aids • 24.4% vs. 0% had difficulty distinguishing tablets (especially differentiating colors) • 28.8% vs. 12.7% needed help managing medications • 10.3% vs. 2.5% received help managing medication from a pharmacist (OR = 4.4, 95% CI 1.4-13.5)
Windham BG et al. N = 335
Community-dwelling women between 73 and 82 years of age
Ability to receive written and verbal instructions for taking two medications and placing them in pillboxes
• 44% incorrectly placed one or both medications. Found to be a result of poor visual acuity, contrast sensitivity, and stereopsis
Nikolaus T et al. N = 119
Patients admitted from home to a geriatric hospital
Ability to open and remove tablets from various common medication containers
• 10.1% failed to open at least one container. Inability associated with impaired vision, cognitive function, manual dexterity. Inability affected adherence to medications
Sadowski B et al. N = 76
Elderly nursing facility residents
Ability to read newspapersize print using magnification
• 45% unable to read print with personal reading glasses • 91% regained reading ability by magnification • 77% required 1-3 times magnification • 14% required 10-25 times magnification • 9% required > 25 times magnification
Abbreviations: CI = Confidence interval, MARS = Medication Adherence Report Scale, OR = Odds ratio, VI = Visual impairment. Source: References 2-5.
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Student Forum In 1995, a study developed a pictorial labeling system to provide pharmaceutical care for visually impaired patients. Most participating pharmacists and students were satisfied with the labels and felt the system was easy to implement; patients receiving pictorial labels felt that the print size of the labels made them easier to read than traditional labels.8 Providing easy-to-understand pictorial labeling is less expensive than purchasing audible labelers and is a cost-effective option. Communication with patients suffering VI might comprise sending letters in large print with different font styles or background contrast or offering information in audio format, by telephone, or electronically. The primary focus of the pharmacist should be to ensure that health care information is offered in various formats, both visual and audio, including large print and computer or Web-based versions. Adults older than 65 years of age who lose their vision as a result of age-related eye disease may not be aware of services or devices that can help them cope with vision loss and make activities of daily living easier.7,9 In conclusion, pharmacists should remember to ask patients about their vision and check that they have sufficient ability or support in opening containers/packaging, distinguishing tablets, measuring liquids, or using eye drops or injections. Practical help may include providing more accessible information through large-print labels, different textures and shapes of containers, audible labels, syringe-filling aids, and medication organizers with tablets packed in daily quantities. Discussing VI with caregivers is also important. For patients who rely on home-delivery or a caregiver to pick up medications, an audible label is a good option. The pharmacist is able to record both instructions and information for the patient regarding his or her medications. Knowledge of possible improvements to medication management should encourage pharmacists to inform policymakers and pharmaceutical companies on means to improve the health care of visually impaired patients. Continued research exploring the best approaches to address this patient population’s needs is essential, both to avoid potential adverse health events from nonadherence and to cultivate strategies for cost-effective support programs.
134
Miranda Smith is a 2014 PharmD candidate, Texas Tech University Health Sciences Center School of Pharmacy, Abilene, Texas. Trista Bailey, PharmD, BCPS, is assistant professor in geriatrics, Texas Tech University Health Sciences Center School of Pharmacy. For correspondence: Trista Bailey, PharmD, BCPS, Texas Tech University Health Sciences Center School of Pharmacy, 1718 Pine Street, Abilene, TX 79601; Phone: 325-696-0451; Fax: 325-676-3824; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.131.
References 1. Pelletier AL, Thomas J. Vision loss in older persons. Am Fam Physician 2009;79:963-70. 2. McCann RM, Jackson AJ, Stevenson M et al. Help needed in medication self-management for people with visual impairment: casecontrol study. Br J Gen Pract 2012;62:e530-7. 3. Windham BG, Griswold ME, Fried LP et al. Impaired vision and the ability to take medications. J Am Geriatr Soc 2005;53:1179-90. 4. Nikolaus T, Kruse W, Bach M et al. Elderly patients’ problems with medication. An in-hospital and follow-up study. Eur J Clin Pharmacol 1996;49:255-9. 5. Sadowski B, Grub A, Trauzettel-Klosinski S. Reading ability and need for reading aids, inadequate management of a nursing home population. Klin Monbl Augenheilkd 2000;217:278-83. 6. Zagar M, Baggarly S. Simulation-base learning about medication management difficulties of low-vision patients. Am J Pharm Educ 2010;74:1-7. 7. Guidelines for Prescription Labeling and Consumer Medication Information for People with Vision Loss. A Collaborative Project of American Society of Consultant Pharmacists Foundation and American Foundation for the Blind. Available at http://www.ascpfoundation.org/ downloads/Rx-CMI%20Guidelines%20vision%20loss-FINAL2.pdf. Accessed January 2, 2013. 8. Hanson EC. Evaluating cognitive services for non-literate and visually impaired patients in community pharmacy rotation sites. Am J Pharm Educ 1995;59:48-55. 9. Cupples ME, Hart PM, Johnston A et al. Improving healthcare access for people with visual impairment and blindness. BMJ 2012;344:e542.
The Consultant Pharmacist FEbruary 2014 Vol. 29, No. 2
