Journal of Community Health Nursing
ISSN: 0737-0016 (Print) 1532-7655 (Online) Journal homepage: http://www.tandfonline.com/loi/hchn20
Medication Management by Recently Hospitalized Older Adults Vicki Conn , Susan G. Taylor & Anita Stineman To cite this article: Vicki Conn , Susan G. Taylor & Anita Stineman (1992) Medication Management by Recently Hospitalized Older Adults, Journal of Community Health Nursing, 9:1, 1-11, DOI: 10.1207/s15327655jchn0901_1 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0901_1
Published online: 07 Jun 2010.
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Citing articles: 6 View citing articles
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Date: 08 November 2015, At: 17:57
JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(1), 1-1 1 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Medication Management by Recently Hospitalized Older Adults Vicki Conn, PhD, RN, and Susan G. Taylor, PhD, RN, FAAN
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University of Missouri-Columbia
Anita Stineman, RN, MS Southeastern Community College Keokuk, IA
Community-dwelling older adults often manage numerous prescriptive medications. The purpose of this study was to describe prescriptive medication management by older adults recently discharged from hospitals. The sample (N = 179) included adults, 65 t~ 101 years old, who managed a total of 950 prescriptive medications. Overall, subjects reported high confidence in their ability to manage medications. The lowest confidence levels were reported for recognizing unwanted side effects of medications. Although "forgetting" was the most commonly given reason for missed doses, one fourth of the reasons for missed doses indicated deliberate omission. Almost half of the slubjects received assistance from others with their medications; most of the assistance served to counteract the tendency to forget medication doses. The results of this study provide a research-based foundation for community health nursing efforts to strengthen the effectiveness of older adults' medication self-care behaviors.
Historically, community health nurses (CHNs) have been concerned with the health and well-being of high-risk populations. Older adults with chronic health problems are a rapidly growing high-risk population. Most older adults have at least one chronic: illness and many of these chronic illnesses are life threatening (e.g.,' heart disease, hypertension, diabetes). Most of the chronic illnesses common among older adults require continuous self-management of prescriptive medications. Because prescriptive medications potentially have both beneficial and harmful effects (Anderson, 1990; Fox & Auestad, 1990), considerable research and professional practice attention has focused on prescriptive medications and older adults. Most of the research examining older adults and prescriptive medications has focused on adherence or compliance to prescribed medication regimens. However, the adherence literature provides useful information about only one component of medication management: Whether medications are taken as directed. Adherence to prescrilbtive medication regimes does not always prevent adverse consequences. AdRequests for reprints should be sent to Vicki Conn, PhD, RN, S321 School of Nursing, University of Missouri-Columbia, Columbia, MO 6521 1.
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Conn, Taylor, and Stineman
verse drug reactions are estimated to be twice as likely in persons aged 60 to 70 and three times as likely in persons over 80 as for young adults (Durgin, 1982; Melmon, 1971; Wade & Bowling, 1986). The risk of adverse drug interaction increases dramatically with advanced age and with larger total numbers of different medications (Fox & Auestad, 1990). Self-management of prescriptive medications requires diverse knowledge, behaviors, judgments, and decisions ranging from those associated with obtaining medications to monitoring for medication side effects. Although most research on prescription medication use by older adults has focused on adherence, some findings indicate prescriptive medication use is often the result of deliberate decision making rather than automatically following the directives of health-care providers (Cooper, Love, & Raffoul, 1982; Segall, 1990). Although little is known about medication management other than adherence, it is clear that poor prescriptive medication management can have negative outcomes for older adults. Older adults consuming medications are at risk for negative outcomes, including hospitalization related to medication problems. One study (Col, Fanale, & Kronholm, 1990) found that 28% of hospital admissions for older adults were medication related (nonadherence and adverse drug reactions). Older adults with poorer knowledge of their medication regimen were found to be more likely to be admitted to the hospital for drug-related problems (Col, et al., 1990). Older adults consuming prescriptive medications are a group at risk for negative health outcomes. Demographic trends of increasing numbers of older adults, increasing health-care costs for older adults, and fragmentation of care for older adults are factors stimulating efforts to identify effective alternative care systems. Although only one in five older adults will be admitted to a hospital during a given year (Matteson & McConnell, 1988), those who have been hospitalized are at increased risk for rehospitalization. Recently hospitalized older adults are especially vulnerable to problems with medications because they are likely to be on more prescriptive medications and are in poorer health than the general population. CHNs are in a position to provide case management services to assist in meeting the needs of at-risk older adults in the community (Bremer, 1989), such as recently hospitalized older adults managing multiple prescriptive medications. Community health nursing services for older adults at risk for institutionalization or hospitalization have been found to be a cost-effective alternative (Bremer, 1987; Currie et al., 1980). Despite the potential benefits of nursing interventions for community-dwelling older adults, important information is lacking. There is an absence of research literature about how at-risk older adults manage their prescriptive medications. The published adherence literature provides insufficient detail about medication management. Knowledge about medication management would provide valuable information for CHNs providing primary care to individual older persons as well as in the planning of services for groups of older adults. The purpose of this descriptive study was to examine prescriptive medication management by older adults recently discharged from hospitals.
Medication Management
3
METHOD
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Sample
The sample included 179 adults who were at least 65 years old. Potential subjects were identified from the discharge records of two teaching hospitals and seven small- and medium-sized private hospitals in two midwestern states. Subjects were includ$d if they had been discharged from an acute care hospital within the last 10 to 20 days. Potential subjects were excluded if they were institutionalized, were unable to participate in a verbal interview, had daily supervision of a paid health-care provider, or had their medication prepared or administered by a paid health-care provider. Data Collection Measures
A structured interview format was developed for this study. Interviewers obtained general descriptive information about the subjects, including the number and type of chronic illnesses, the number of hospitalizations during the previous 12 months, and the presence or absence of communication with health-care providers (physicians, nurses, pharmacists) since the most recent hospital discharge. Subjects were asked to rate their confidence in their ability to perform specified compohents of medication management. For example, one question was "How certain are you that you know who to contact if you have questions or problems with your medications?" Subjects rated their confidence on a scale ranging from not at all certain (0)to very certain (10) for each of 14 dimensions of medication management (listed in Table 1). Inteiviewers asked subjects several questions for each prescribed medication. Subjects were asked to name each medication, describe the dosage of the medicaTABLE l Subjects' Perceived Confidence in Their Ability to Manage Medication Regimens.
Medicatidn Management Component You know how to store your medications properly You can iqentify your medications, either by name or by description You know what dose of medication to take You know when to take your medication You can remember to take your medications You are able to open the medication containers by yourself You can overcome any problems (like travel or sickness) you meet in taking your meqkications You know how to get further supplies of your medications You know1 how your medications are supposed to help You know if the medications are helping You can recognize unwanted side effects You know what to do if you experience unwanted side effects You know who to contact if you have questions or problems You know when to stop taking the medications, if ever
M
(SD)
Range
4
Conn, Taylor, and Stineman
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tion, and explain the purpose of the medication. For each medication, subjects were asked to give the reasons medication doses were not taken, describe any strategies they used to help them remember to take the medication, report if anyone helped them with the medication, and, if so, what kind of help others provided with medication. Medication containers were reviewed to determine the number of prescribing physicians and the numbers of pharmacies where medications were obtained. Hospital records were reviewed to determine the length of hospitalization and the medications prescribed for the subject at hospital discharge. Procedures
All procedures were approved by the Institutional Review Board for the protection of human subjects prior to initiation of the project. Interviewer training included strategies useful with older adults and with persons recovering from illness. Potential subject names and telephone numbers were obtained from hospital discharge records. Potential subjects were contacted by phone for consent to participate. Consenting subjects were interviewed in their homes and their hospital records were reviewed.
RESULTS The sample included 94 men (53%) and 85 women (47%). The average age was 75 years (SD = 6.96, range 65 to 101 years). Most subjects were White (n = 162, 91%); the remainder were Black (n = 17, 9%). Only 31% of the sample (n = 56) lived alone. The average household income was $14,735 (SD = $8,889, range $2,517 to $5O,ooo). The most common chronic disease among the sample was heart disease (n = 90) followed by arthritic joint problems (n = 56), hypertension (n = 43), pulmonary disease (n = 43), diabetes (n = 37), peripheral vascular disease (n = 23), and cancer (n = 21). Multiple chronic diseases were common among the sample (M = 2.27, SD = 1.12, range 0 to 5). The mean duration of the recent hospitalization was 9.53 days (SD = 9.45, range 1 to 74 days). Subjects had spent an average of 17.64 days in the hospital during the previous year (SD = 13.17, range 2 to 240 days). Forty percent (n = 72) of the subjects had been hospitalized more than once during the previous year. Slightly more than half of these older adults (n = 95, 53%) had communicated with a physician since their hospital discharge. Thirty-six percent (n = 64) had been visited by a nurse since their hospital discharge. Few (n = 14, 8%) had communicated with a pharmacist since their recent hospitalization. Information provided by subjects about how confident they were that they could accomplish certain behaviors related to medication management is presented in Table 1. Overall high levels of confidence in ability to manage medications was re-
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ported. Subjects were least confident that they could recognize unwanted side effects. The highest levels of confidence were reported for knowing how to obtain more medication, knowing who to contact for medication problems, and knowing when to take medications. Inf~rmationwas collected about a total of 950 medications managed by the 179 subjeots. Subjects managed regimens of 1 to 14 different prescribed medications (M = 5.3 1). The most common drug categories were cardiac/antianginal/coronary vasodilator (n = 150, 16%), diuretic (n = 99, lo%), anticoagulant (n = 63, 7%), potassiub (n = 57, 6%), antihypertensive (n = 55, 6%), antiarrhythmic (n = 53, 6%), and aotimicrobial (n = 49, 5Vo). The medications were prescribed by one to five different physicians (M = 1.42). Subjects obtained medications from one to three different pharmacies (M = 1.20). Subjects correctly named most medications (n = 821, 86%), using generic, trade, physidal appearance, and intended drug function as labels for medications (Mahdy & Seymour, 1990). Subjects reported they did not know the dosage of 67 medications (7%). Subjects correctly described the general function or intended target organ (Mahdy & Seymour, 1990) of most medications (n = 764, 80%). El&en subjects (6%) reported they did not use any strategy to help them remember ta take their medications. The remaining subjects reported 11 different strategies (a = 301) used to remember to take medications. The reported strategies are preseqted in Table 2. The most commonly mentioned strategy to assist subjects to remeaber to take medications was placing medication containers in particular locations, such as by the sink or on the kitchen table. The next most common strategy was libking medication administration with the routine activities of eating meals and g@ingto bed at night. Using timed pill boxes and having others remind them to take the medication were reported less often. The strategy of placing all medications in one container is a variation of a timed pill container arrangement in which the subjeats removed all medications needed for one 24-hr period from their containers and placed them together in one receptacle from which medications were administered during the 24-hr period. The responses of subjects when asked to describe the reasons for missed doses of TABLE 2 Reported Strategies Used to Remember to Take Medicationsa
Stmtegy Used to Remember Medication Place cohtainers in particular location Take in qssociation with meals/bedtime Timed pol box Other w o n reminds them Written +rections/checkoff list Places a# medications in one container Writes dqse number on container lids Routinehabit Carries &edication on person (inhalers) Sets alar@ clock Places patch on chest so visible an = 301. Subjects (N= 179) reported from 0 to 3 strategies.
6
Conn, Taylor, and Stineman TABLE 3 Subject Reasons for Missing Medication Dosesa
Reason for Missed Medication Dose
n (%)
Forget to take medication Uses the amount subject believes is needed; thus misses some doses Difficult to fit medication taking into life pattern Medication causes unwanted side effects or otherwise makes subject feel "bad" Medication too expensive Unable to self-administer medication Don't think they need the medication
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an = 246. Subjects (N = 179) reported reasons for missing any dose of each of 950 medications.
medications are summarized in Table 3. Forgetting to take medications (n = 148, 60%) was the most common reason mentioned for missed doses. lbenty-eight percent (n = 68) of the reasons given for missing medication could be described as intentional missed doses: (a) using the amount of medication that the subjects believed was appropriate, (b) not using medication due to undesirable effects of medications, (c) judging the medication too expensive, or (d) not taking the medication because the subjects believed they did not need the medication. About half of the subjects (n = 91, 5 1%) reported that no one assisted them with their medications. Persons assisting with medication management are shown in Figure 1. Spouses and adult children accounted for 79% of the persons reported as assisting with medications. The type of medication management assistance provided by others are shown in Figure 2. The most common types of assistance, preparing medications without a prompt from the subject and reminding subject to take medication, provided support to minimize the likelihood of forgetting to take medications. Only 15% (n = 18) of the types of assistance reported pertained to someone else administering medication to the subject.
DISCUSSION
Overall, subjects displayed a high level of confidence in their ability to manage medications and possessed adequate knowledge about most of the medications. Subjects managed an average of five different prescribed medications. Managing medications takes time and energy. The high levels of confidence and knowledge found in this study may be in part due to managing chronic illnesses having become the "work" of these older adults. Corbin and Strauss (1988) observed that for persons with chronic illness, managing the chronic illness and associated therapeutic regimens becomes the work of their life. The recent hospitalization probably emphasized the need for attention to self-care, including medication management. Most older adults are not hospitalized in a given year. Because 40% of these subjects had been hospitalized more than once during the previous year, this sample was not representative of older adults in general. The lowest level of confidence was reported by subjects for recognizing unwanted side effects of medications. Given the evidence that older adults are more likely than
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Persons assisting with medications Spouse Adult child
Nurse visiting home Unrelated cohaMtant Employed in-home assistant
FIGURE 1 Persons assisting subjects with medication management (n = 94). (Ninety-four persons were reported by the 88 subjects who said others helped them with medications.)
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9
younger persons to experience adverse drug reactions both because of age-related physiological changes and because of the numbers of medications they consume, the ability to recognize side effects of medications is especially important for older adults. Also, over one fourth of the medications in this study were new prescriptions for the subjects. Side effects of many medications appear only after drug levels accumullate in the body. Information about potential side effects of medications is needed for adequate self-management of medication regimens (Mahdy & Seymour, 1990). CHNs can aim interventions at individuals as well as at groups of older adults to enhance awareness of potential side effects of medications. Although older adults do manage many of the same medications for long periods of timie, over one fourth of the medications used by these older adults were new prescriptions; that is, they had not been on that particular medication prior to hospitalization. Most of these subjects had had contact with a physician or nurse in the period since their recent hospital discharge, which provided an opportunity to receive information about medications. These subjects were probably more likely than other community-dwelling older adults to have contact with health-care providers and bie on new prescriptions because they had illnesses necessitating the recent hospitblization. Tha results of this study document that missed doses of medications can be intentional or nonintentional. Although nonintentional missed doses (due to forgetting) were @ore common, over one fourth of the reasons given for missed doses could be categokized as intentional, in that subjects made decisions to not administer the medic+tions. The reasons subjects gave for intentional missed doses are congruent with dther reported research findings that deliberate decisions are made regarding prescriptive medication use (Segall, 1990). The intentional missed doses are particularly irhteresting in this group of recently discharged older adults because adherence (taking medications exactly as directed) is generally thought to be highest soon after a major health event. Thus intentional missed doses would not be expected so soon after hospital discharge. Intentional missed doses may be even more common amon4 older adults not recently hospitalized. These findings suggest health-care providers need to re-evaluate the rationale for the medication and the dosage. If the medic$tion and dosage are appropriate, the provider needs to communicate with older idults to attempt to achieve consensus regarding the appropriateness of the medications. The provider must maintain adequate communication with older clients tcu ensure accurate medication use information is available for diagnostic and therapeutic purposes. Providers who are unaware that clients are not taking medications as prescribed may inappropriately increase dosages, change medications, or otherwise alter treatment. The most commonly mentioned method used to assist in remembering medications, placing the containers in a particular location, functioned as a cue to action. For exmple, when subjects saw the containers by the sink when preparing meals they were reminded of the medications and decided whether the medications should be adqinistered. Although placing the containers in a particular location is a cue to action, it does not provide any means of validating whether medications have been
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Conn, Taylor, and Stineman
consumed. An older adult could see the medication container by the sink after a meal and be unsure if the dose were consumed prior to the meal or not at all. The use of timed pill boxes would provide information about which doses have been consumed, but these devices were infrequently used by this sample of older adults. Previous research has shown similar devices associated with increased adherence among older adults (Martin & Mead, 1982; Wong & Norman, 1987). Because most older adults do consume some prescription medications, CHN-taught programs regarding effective management techniques (e.g., timed pill box arrangement) might benefit many older adults, including those who eventually face increased numbers of medications. The assistance of spouses and adult children with medications is not surprising for a group of recently hospitalized older adults. The types of assistance most commonly provided (cue to take medication or preparing medication without a prompt from the subject) were especially appropriate, given the most common reason for missed doses of medication (forgetting). Although the caregiving research has documented family members' involvement, there is a lack of information about how caregivers assist older adults with medication management. This study demonstrated a congruence between older adults' most commonly reported reason for missing medications and their caregivers method of assisting them. To date, no published research reports describe how caregivers and older adults determine that caregiving assistance is needed for medication management. Further work with detailed study of medication management by caregivers and older adults is needed. Educational programs designed to maximize medication management skills need to be targeted to caregivers of older adults as well as to older adults managing prescriptive medications. The tradition of CHNs to focus on effective self-care among high-risk groups in the community (Paunonen & Haggman-Laitila, 1990) can be applied to at-risk older adults managing medications. This study provided information about selfmanagement of medication by older adults recently hospitalized. Subjects expressed the least amount of confidence in their ability to manage medication side effects. Subjects infrequently used medication assistive devices such as timed pill boxes to monitor the administration of medications. Although less common than forgetting medications, deliberate decisions accounted for one fourth of the reasons for missed medication doses. Further detailed studies of other aspects of medication management are needed. REFERENCES Anderson, E. (1990). Keeping an eye on older patients and their drugs. Geriatrics, 45(5), 81-82. Bremer, A. (1987). Revitalizing the district model for the delivery of prevention focused community health nursing services. Family and Community Health, 10(2), 1-10. Bremer, A. (1989). A description of community health nursing practice with the community-based elderly. Journal of Community Health Nursing, 6, 173- 184. Col, N., Fanale, J., & Kronholm, P. (1990). The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Archives of Internal Medicine, 150, 841-845.
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Cooper, J., Love, D., & Raffoul, P. (1982). Intentional prescription nonadherence (noncompliance) by the elderly. Journal of the American Geriatrics Society, 30, 329-333. Corbin, J., & Strauss, A. (1988). Unending work and care. San Francisco: Jossey-Bass. Currie, C., Burley, L., Doull, C., Ravetz, C., Smith, R., & Williamson, J. (1980). A scheme of augmented home care for acutely and sub-acutely ill elderly patients: Report on pilot study. Age and Aging, 9, 173-180. Durgin, J. (1982). The pharmacists' evaluation. Geriatric Nursing, 3, 31-33. Fox, E, & Auestad, A. (1990). Geriatric emergency clinical pharmacology. Emergency Medicine Clinics of North America, 8, 221-239. Mahdy, H., & Seymour, D. (1990). How much can elderly patients tell us about their medications? Postgmduate Medical Journal, 66, 1 16- 121 . Martin, D., & Mead, K. (1982). Reducing medication errors in a geriatric population. Journal of the Amepican Geriatrics Society, 30, 258-260. Mattesan, M., & McConnell, E. (1988). Gerontological nursing: Concepts andpractice. Philadelphia: Saunders. Melmod, K. (1971). Preventable drug reactions-Causes and cures. New England Journal of Medicine, 284, 1361-1368. Paunonien, M., & Haggman-Laitila, A. (1990). Life situation of aged home-nursing clients. Journal of Community Health Nursing, 7, 167-178. Segall, A. (1990). A community survey of self-medication activities. Medical Care, 28, 301-310. Wade, B., & Bowling, A. (1986). Appropriate use of drugs by elderly people. Journal of Advanced Nursdng, 11, 47-55. Wong, B., & Norman, D. (1987). Evaluation of a novel medication aid, the calendar blister-pak, and its effect on drug compliance in a geriatric outpatient clinic. Journal of the American Geriatrics Society, 35, 21-26.
ISSN: 0737-0016 (Print) 1532-7655 (Online) Journal homepage: http://www.tandfonline.com/loi/hchn20
Medication Management by Recently Hospitalized Older Adults Vicki Conn , Susan G. Taylor & Anita Stineman To cite this article: Vicki Conn , Susan G. Taylor & Anita Stineman (1992) Medication Management by Recently Hospitalized Older Adults, Journal of Community Health Nursing, 9:1, 1-11, DOI: 10.1207/s15327655jchn0901_1 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0901_1
Published online: 07 Jun 2010.
Submit your article to this journal
Article views: 7
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hchn20 Download by: [University of Cambridge]
Date: 08 November 2015, At: 17:57
JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(1), 1-1 1 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Medication Management by Recently Hospitalized Older Adults Vicki Conn, PhD, RN, and Susan G. Taylor, PhD, RN, FAAN
Downloaded by [University of Cambridge] at 17:57 08 November 2015
University of Missouri-Columbia
Anita Stineman, RN, MS Southeastern Community College Keokuk, IA
Community-dwelling older adults often manage numerous prescriptive medications. The purpose of this study was to describe prescriptive medication management by older adults recently discharged from hospitals. The sample (N = 179) included adults, 65 t~ 101 years old, who managed a total of 950 prescriptive medications. Overall, subjects reported high confidence in their ability to manage medications. The lowest confidence levels were reported for recognizing unwanted side effects of medications. Although "forgetting" was the most commonly given reason for missed doses, one fourth of the reasons for missed doses indicated deliberate omission. Almost half of the slubjects received assistance from others with their medications; most of the assistance served to counteract the tendency to forget medication doses. The results of this study provide a research-based foundation for community health nursing efforts to strengthen the effectiveness of older adults' medication self-care behaviors.
Historically, community health nurses (CHNs) have been concerned with the health and well-being of high-risk populations. Older adults with chronic health problems are a rapidly growing high-risk population. Most older adults have at least one chronic: illness and many of these chronic illnesses are life threatening (e.g.,' heart disease, hypertension, diabetes). Most of the chronic illnesses common among older adults require continuous self-management of prescriptive medications. Because prescriptive medications potentially have both beneficial and harmful effects (Anderson, 1990; Fox & Auestad, 1990), considerable research and professional practice attention has focused on prescriptive medications and older adults. Most of the research examining older adults and prescriptive medications has focused on adherence or compliance to prescribed medication regimens. However, the adherence literature provides useful information about only one component of medication management: Whether medications are taken as directed. Adherence to prescrilbtive medication regimes does not always prevent adverse consequences. AdRequests for reprints should be sent to Vicki Conn, PhD, RN, S321 School of Nursing, University of Missouri-Columbia, Columbia, MO 6521 1.
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2
Conn, Taylor, and Stineman
verse drug reactions are estimated to be twice as likely in persons aged 60 to 70 and three times as likely in persons over 80 as for young adults (Durgin, 1982; Melmon, 1971; Wade & Bowling, 1986). The risk of adverse drug interaction increases dramatically with advanced age and with larger total numbers of different medications (Fox & Auestad, 1990). Self-management of prescriptive medications requires diverse knowledge, behaviors, judgments, and decisions ranging from those associated with obtaining medications to monitoring for medication side effects. Although most research on prescription medication use by older adults has focused on adherence, some findings indicate prescriptive medication use is often the result of deliberate decision making rather than automatically following the directives of health-care providers (Cooper, Love, & Raffoul, 1982; Segall, 1990). Although little is known about medication management other than adherence, it is clear that poor prescriptive medication management can have negative outcomes for older adults. Older adults consuming medications are at risk for negative outcomes, including hospitalization related to medication problems. One study (Col, Fanale, & Kronholm, 1990) found that 28% of hospital admissions for older adults were medication related (nonadherence and adverse drug reactions). Older adults with poorer knowledge of their medication regimen were found to be more likely to be admitted to the hospital for drug-related problems (Col, et al., 1990). Older adults consuming prescriptive medications are a group at risk for negative health outcomes. Demographic trends of increasing numbers of older adults, increasing health-care costs for older adults, and fragmentation of care for older adults are factors stimulating efforts to identify effective alternative care systems. Although only one in five older adults will be admitted to a hospital during a given year (Matteson & McConnell, 1988), those who have been hospitalized are at increased risk for rehospitalization. Recently hospitalized older adults are especially vulnerable to problems with medications because they are likely to be on more prescriptive medications and are in poorer health than the general population. CHNs are in a position to provide case management services to assist in meeting the needs of at-risk older adults in the community (Bremer, 1989), such as recently hospitalized older adults managing multiple prescriptive medications. Community health nursing services for older adults at risk for institutionalization or hospitalization have been found to be a cost-effective alternative (Bremer, 1987; Currie et al., 1980). Despite the potential benefits of nursing interventions for community-dwelling older adults, important information is lacking. There is an absence of research literature about how at-risk older adults manage their prescriptive medications. The published adherence literature provides insufficient detail about medication management. Knowledge about medication management would provide valuable information for CHNs providing primary care to individual older persons as well as in the planning of services for groups of older adults. The purpose of this descriptive study was to examine prescriptive medication management by older adults recently discharged from hospitals.
Medication Management
3
METHOD
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Sample
The sample included 179 adults who were at least 65 years old. Potential subjects were identified from the discharge records of two teaching hospitals and seven small- and medium-sized private hospitals in two midwestern states. Subjects were includ$d if they had been discharged from an acute care hospital within the last 10 to 20 days. Potential subjects were excluded if they were institutionalized, were unable to participate in a verbal interview, had daily supervision of a paid health-care provider, or had their medication prepared or administered by a paid health-care provider. Data Collection Measures
A structured interview format was developed for this study. Interviewers obtained general descriptive information about the subjects, including the number and type of chronic illnesses, the number of hospitalizations during the previous 12 months, and the presence or absence of communication with health-care providers (physicians, nurses, pharmacists) since the most recent hospital discharge. Subjects were asked to rate their confidence in their ability to perform specified compohents of medication management. For example, one question was "How certain are you that you know who to contact if you have questions or problems with your medications?" Subjects rated their confidence on a scale ranging from not at all certain (0)to very certain (10) for each of 14 dimensions of medication management (listed in Table 1). Inteiviewers asked subjects several questions for each prescribed medication. Subjects were asked to name each medication, describe the dosage of the medicaTABLE l Subjects' Perceived Confidence in Their Ability to Manage Medication Regimens.
Medicatidn Management Component You know how to store your medications properly You can iqentify your medications, either by name or by description You know what dose of medication to take You know when to take your medication You can remember to take your medications You are able to open the medication containers by yourself You can overcome any problems (like travel or sickness) you meet in taking your meqkications You know how to get further supplies of your medications You know1 how your medications are supposed to help You know if the medications are helping You can recognize unwanted side effects You know what to do if you experience unwanted side effects You know who to contact if you have questions or problems You know when to stop taking the medications, if ever
M
(SD)
Range
4
Conn, Taylor, and Stineman
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tion, and explain the purpose of the medication. For each medication, subjects were asked to give the reasons medication doses were not taken, describe any strategies they used to help them remember to take the medication, report if anyone helped them with the medication, and, if so, what kind of help others provided with medication. Medication containers were reviewed to determine the number of prescribing physicians and the numbers of pharmacies where medications were obtained. Hospital records were reviewed to determine the length of hospitalization and the medications prescribed for the subject at hospital discharge. Procedures
All procedures were approved by the Institutional Review Board for the protection of human subjects prior to initiation of the project. Interviewer training included strategies useful with older adults and with persons recovering from illness. Potential subject names and telephone numbers were obtained from hospital discharge records. Potential subjects were contacted by phone for consent to participate. Consenting subjects were interviewed in their homes and their hospital records were reviewed.
RESULTS The sample included 94 men (53%) and 85 women (47%). The average age was 75 years (SD = 6.96, range 65 to 101 years). Most subjects were White (n = 162, 91%); the remainder were Black (n = 17, 9%). Only 31% of the sample (n = 56) lived alone. The average household income was $14,735 (SD = $8,889, range $2,517 to $5O,ooo). The most common chronic disease among the sample was heart disease (n = 90) followed by arthritic joint problems (n = 56), hypertension (n = 43), pulmonary disease (n = 43), diabetes (n = 37), peripheral vascular disease (n = 23), and cancer (n = 21). Multiple chronic diseases were common among the sample (M = 2.27, SD = 1.12, range 0 to 5). The mean duration of the recent hospitalization was 9.53 days (SD = 9.45, range 1 to 74 days). Subjects had spent an average of 17.64 days in the hospital during the previous year (SD = 13.17, range 2 to 240 days). Forty percent (n = 72) of the subjects had been hospitalized more than once during the previous year. Slightly more than half of these older adults (n = 95, 53%) had communicated with a physician since their hospital discharge. Thirty-six percent (n = 64) had been visited by a nurse since their hospital discharge. Few (n = 14, 8%) had communicated with a pharmacist since their recent hospitalization. Information provided by subjects about how confident they were that they could accomplish certain behaviors related to medication management is presented in Table 1. Overall high levels of confidence in ability to manage medications was re-
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5
ported. Subjects were least confident that they could recognize unwanted side effects. The highest levels of confidence were reported for knowing how to obtain more medication, knowing who to contact for medication problems, and knowing when to take medications. Inf~rmationwas collected about a total of 950 medications managed by the 179 subjeots. Subjects managed regimens of 1 to 14 different prescribed medications (M = 5.3 1). The most common drug categories were cardiac/antianginal/coronary vasodilator (n = 150, 16%), diuretic (n = 99, lo%), anticoagulant (n = 63, 7%), potassiub (n = 57, 6%), antihypertensive (n = 55, 6%), antiarrhythmic (n = 53, 6%), and aotimicrobial (n = 49, 5Vo). The medications were prescribed by one to five different physicians (M = 1.42). Subjects obtained medications from one to three different pharmacies (M = 1.20). Subjects correctly named most medications (n = 821, 86%), using generic, trade, physidal appearance, and intended drug function as labels for medications (Mahdy & Seymour, 1990). Subjects reported they did not know the dosage of 67 medications (7%). Subjects correctly described the general function or intended target organ (Mahdy & Seymour, 1990) of most medications (n = 764, 80%). El&en subjects (6%) reported they did not use any strategy to help them remember ta take their medications. The remaining subjects reported 11 different strategies (a = 301) used to remember to take medications. The reported strategies are preseqted in Table 2. The most commonly mentioned strategy to assist subjects to remeaber to take medications was placing medication containers in particular locations, such as by the sink or on the kitchen table. The next most common strategy was libking medication administration with the routine activities of eating meals and g@ingto bed at night. Using timed pill boxes and having others remind them to take the medication were reported less often. The strategy of placing all medications in one container is a variation of a timed pill container arrangement in which the subjeats removed all medications needed for one 24-hr period from their containers and placed them together in one receptacle from which medications were administered during the 24-hr period. The responses of subjects when asked to describe the reasons for missed doses of TABLE 2 Reported Strategies Used to Remember to Take Medicationsa
Stmtegy Used to Remember Medication Place cohtainers in particular location Take in qssociation with meals/bedtime Timed pol box Other w o n reminds them Written +rections/checkoff list Places a# medications in one container Writes dqse number on container lids Routinehabit Carries &edication on person (inhalers) Sets alar@ clock Places patch on chest so visible an = 301. Subjects (N= 179) reported from 0 to 3 strategies.
6
Conn, Taylor, and Stineman TABLE 3 Subject Reasons for Missing Medication Dosesa
Reason for Missed Medication Dose
n (%)
Forget to take medication Uses the amount subject believes is needed; thus misses some doses Difficult to fit medication taking into life pattern Medication causes unwanted side effects or otherwise makes subject feel "bad" Medication too expensive Unable to self-administer medication Don't think they need the medication
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an = 246. Subjects (N = 179) reported reasons for missing any dose of each of 950 medications.
medications are summarized in Table 3. Forgetting to take medications (n = 148, 60%) was the most common reason mentioned for missed doses. lbenty-eight percent (n = 68) of the reasons given for missing medication could be described as intentional missed doses: (a) using the amount of medication that the subjects believed was appropriate, (b) not using medication due to undesirable effects of medications, (c) judging the medication too expensive, or (d) not taking the medication because the subjects believed they did not need the medication. About half of the subjects (n = 91, 5 1%) reported that no one assisted them with their medications. Persons assisting with medication management are shown in Figure 1. Spouses and adult children accounted for 79% of the persons reported as assisting with medications. The type of medication management assistance provided by others are shown in Figure 2. The most common types of assistance, preparing medications without a prompt from the subject and reminding subject to take medication, provided support to minimize the likelihood of forgetting to take medications. Only 15% (n = 18) of the types of assistance reported pertained to someone else administering medication to the subject.
DISCUSSION
Overall, subjects displayed a high level of confidence in their ability to manage medications and possessed adequate knowledge about most of the medications. Subjects managed an average of five different prescribed medications. Managing medications takes time and energy. The high levels of confidence and knowledge found in this study may be in part due to managing chronic illnesses having become the "work" of these older adults. Corbin and Strauss (1988) observed that for persons with chronic illness, managing the chronic illness and associated therapeutic regimens becomes the work of their life. The recent hospitalization probably emphasized the need for attention to self-care, including medication management. Most older adults are not hospitalized in a given year. Because 40% of these subjects had been hospitalized more than once during the previous year, this sample was not representative of older adults in general. The lowest level of confidence was reported by subjects for recognizing unwanted side effects of medications. Given the evidence that older adults are more likely than
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Persons assisting with medications Spouse Adult child
Nurse visiting home Unrelated cohaMtant Employed in-home assistant
FIGURE 1 Persons assisting subjects with medication management (n = 94). (Ninety-four persons were reported by the 88 subjects who said others helped them with medications.)
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9
younger persons to experience adverse drug reactions both because of age-related physiological changes and because of the numbers of medications they consume, the ability to recognize side effects of medications is especially important for older adults. Also, over one fourth of the medications in this study were new prescriptions for the subjects. Side effects of many medications appear only after drug levels accumullate in the body. Information about potential side effects of medications is needed for adequate self-management of medication regimens (Mahdy & Seymour, 1990). CHNs can aim interventions at individuals as well as at groups of older adults to enhance awareness of potential side effects of medications. Although older adults do manage many of the same medications for long periods of timie, over one fourth of the medications used by these older adults were new prescriptions; that is, they had not been on that particular medication prior to hospitalization. Most of these subjects had had contact with a physician or nurse in the period since their recent hospital discharge, which provided an opportunity to receive information about medications. These subjects were probably more likely than other community-dwelling older adults to have contact with health-care providers and bie on new prescriptions because they had illnesses necessitating the recent hospitblization. Tha results of this study document that missed doses of medications can be intentional or nonintentional. Although nonintentional missed doses (due to forgetting) were @ore common, over one fourth of the reasons given for missed doses could be categokized as intentional, in that subjects made decisions to not administer the medic+tions. The reasons subjects gave for intentional missed doses are congruent with dther reported research findings that deliberate decisions are made regarding prescriptive medication use (Segall, 1990). The intentional missed doses are particularly irhteresting in this group of recently discharged older adults because adherence (taking medications exactly as directed) is generally thought to be highest soon after a major health event. Thus intentional missed doses would not be expected so soon after hospital discharge. Intentional missed doses may be even more common amon4 older adults not recently hospitalized. These findings suggest health-care providers need to re-evaluate the rationale for the medication and the dosage. If the medic$tion and dosage are appropriate, the provider needs to communicate with older idults to attempt to achieve consensus regarding the appropriateness of the medications. The provider must maintain adequate communication with older clients tcu ensure accurate medication use information is available for diagnostic and therapeutic purposes. Providers who are unaware that clients are not taking medications as prescribed may inappropriately increase dosages, change medications, or otherwise alter treatment. The most commonly mentioned method used to assist in remembering medications, placing the containers in a particular location, functioned as a cue to action. For exmple, when subjects saw the containers by the sink when preparing meals they were reminded of the medications and decided whether the medications should be adqinistered. Although placing the containers in a particular location is a cue to action, it does not provide any means of validating whether medications have been
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Conn, Taylor, and Stineman
consumed. An older adult could see the medication container by the sink after a meal and be unsure if the dose were consumed prior to the meal or not at all. The use of timed pill boxes would provide information about which doses have been consumed, but these devices were infrequently used by this sample of older adults. Previous research has shown similar devices associated with increased adherence among older adults (Martin & Mead, 1982; Wong & Norman, 1987). Because most older adults do consume some prescription medications, CHN-taught programs regarding effective management techniques (e.g., timed pill box arrangement) might benefit many older adults, including those who eventually face increased numbers of medications. The assistance of spouses and adult children with medications is not surprising for a group of recently hospitalized older adults. The types of assistance most commonly provided (cue to take medication or preparing medication without a prompt from the subject) were especially appropriate, given the most common reason for missed doses of medication (forgetting). Although the caregiving research has documented family members' involvement, there is a lack of information about how caregivers assist older adults with medication management. This study demonstrated a congruence between older adults' most commonly reported reason for missing medications and their caregivers method of assisting them. To date, no published research reports describe how caregivers and older adults determine that caregiving assistance is needed for medication management. Further work with detailed study of medication management by caregivers and older adults is needed. Educational programs designed to maximize medication management skills need to be targeted to caregivers of older adults as well as to older adults managing prescriptive medications. The tradition of CHNs to focus on effective self-care among high-risk groups in the community (Paunonen & Haggman-Laitila, 1990) can be applied to at-risk older adults managing medications. This study provided information about selfmanagement of medication by older adults recently hospitalized. Subjects expressed the least amount of confidence in their ability to manage medication side effects. Subjects infrequently used medication assistive devices such as timed pill boxes to monitor the administration of medications. Although less common than forgetting medications, deliberate decisions accounted for one fourth of the reasons for missed medication doses. Further detailed studies of other aspects of medication management are needed. REFERENCES Anderson, E. (1990). Keeping an eye on older patients and their drugs. Geriatrics, 45(5), 81-82. Bremer, A. (1987). Revitalizing the district model for the delivery of prevention focused community health nursing services. Family and Community Health, 10(2), 1-10. Bremer, A. (1989). A description of community health nursing practice with the community-based elderly. Journal of Community Health Nursing, 6, 173- 184. Col, N., Fanale, J., & Kronholm, P. (1990). The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Archives of Internal Medicine, 150, 841-845.
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Cooper, J., Love, D., & Raffoul, P. (1982). Intentional prescription nonadherence (noncompliance) by the elderly. Journal of the American Geriatrics Society, 30, 329-333. Corbin, J., & Strauss, A. (1988). Unending work and care. San Francisco: Jossey-Bass. Currie, C., Burley, L., Doull, C., Ravetz, C., Smith, R., & Williamson, J. (1980). A scheme of augmented home care for acutely and sub-acutely ill elderly patients: Report on pilot study. Age and Aging, 9, 173-180. Durgin, J. (1982). The pharmacists' evaluation. Geriatric Nursing, 3, 31-33. Fox, E, & Auestad, A. (1990). Geriatric emergency clinical pharmacology. Emergency Medicine Clinics of North America, 8, 221-239. Mahdy, H., & Seymour, D. (1990). How much can elderly patients tell us about their medications? Postgmduate Medical Journal, 66, 1 16- 121 . Martin, D., & Mead, K. (1982). Reducing medication errors in a geriatric population. Journal of the Amepican Geriatrics Society, 30, 258-260. Mattesan, M., & McConnell, E. (1988). Gerontological nursing: Concepts andpractice. Philadelphia: Saunders. Melmod, K. (1971). Preventable drug reactions-Causes and cures. New England Journal of Medicine, 284, 1361-1368. Paunonien, M., & Haggman-Laitila, A. (1990). Life situation of aged home-nursing clients. Journal of Community Health Nursing, 7, 167-178. Segall, A. (1990). A community survey of self-medication activities. Medical Care, 28, 301-310. Wade, B., & Bowling, A. (1986). Appropriate use of drugs by elderly people. Journal of Advanced Nursdng, 11, 47-55. Wong, B., & Norman, D. (1987). Evaluation of a novel medication aid, the calendar blister-pak, and its effect on drug compliance in a geriatric outpatient clinic. Journal of the American Geriatrics Society, 35, 21-26.
