Can palliative care improve therapeutically adherence in elderly patients?Îngrijirile paliative iniţiate precoce la pacienţii vârstnici pot creşte complianţa terapeutică

Ass Prof Ioana Dana Alexa, MD, PhD, senior specialist internal medicine and geriatrics (a), Adina Carmen Ilie, MD, geriatrics (b), Ramona Onuţu, MD, geriatrics (c)

(a), (b): Department of Geriatrics and Gerontology, University of Medicine and Pharmacy „Gr.T. Popa” Iaşi, Romania
(c): Department of Clinical Geriatrics, “Dr. C.I. Parhon” Hospital, Iaşi, Romania

Corresponding author: Ioana Dana Alexa: e-mail: ioana.b.alexa@gmail.com

Abstract

Objectives:
Therapeutic adherence represents the extent to which the patient’s behaviour follows medical recommendations. It is a complex, multifactorial process that strongly influences quality of life.

Material and method:
We performed a retrospective study that included 256 old patients ( 75 years) admitted in the Geriatric Department in the last year. Patients’ data were recorded in a database that contained demographic and clinical data, the presence of palliative care and information about patient’s current medication. Information about therapeutical adherence was collected for each person by a questionnaire, which consisted in verifying their knowledge about their diet and medication and comparing it with information from past medical records or family members.

Results and discussions:
We found several factors that influenced adherence to treatment: the residential area, the number of tablets prescribed by the physician, a strong familial and financial support, and last but not least, the presence of palliative care in the general management of the patient.

Conclusions:
Fighting non-adherence should rely upon three complementary directions: a multidisciplinary medical approach, telemonitoring (e-health), and geriatric palliative care.

Key words: therapeutic adherence, palliative care, elderly

Introduction

Therapeutic adherence is a complex behavioral process strongly influenced by the environment in which patients live and the healthcare providers’ practice. Furthermore, non-adherence or “non-compliance” represents the extent to which the patient’s behavior does not follow medical recommendations.

„Non-adherence is not a new phenomenon. The first recorded case took place in the Garden of Eden with dire consequences” (1). Scientific interest into non-adherence started in 1943 (1), but it was only 30 years ago when the seriousness of the problem was fully recognized and research began in earnest. It was noted that the elderly population is particularly vulnerable to non-adherence due to several reasons: physical barriers (sarcopenia, arthritis, tremors), cognitive barriers (memory loss, confusion), polimedicine, polipharmacy and iatrogeny, insufficient income, familial and social circumstances, and last but not least the nature of the patient–doctor relationship (2, 3).

We are unable to predict patients’ non-adherence at rates better than chance. When any member of the medical team asks about adherence, patients tend to exaggerate (“white coat” effects); therefore, patients’ self-reports usually overestimate compliance by a significant amount.

Recent studies (4, 5) report that up to 60% of all medication prescribed is taken incorrectly, or not at all. 90% of elderly patients make some medication errors, and 35% make potentially serious errors. 40% of all admissions are due to medication-related problems. Non-adherence can lead to treatment failure, further physical or mental health problems, service costs and carrier burden (1, 5)

Non-adherence as a phenomenon spans medical disciplines but research by its nature tends to be discipline specific in outlook, often limited to a specific diagnosis or medication. Recent reviews (5, 6, 7) consider that effective interventions on non-adherence should be complex, combining approaches such as counselling, information, reminders and family therapy; statistically significant positive findings did not however lead to worthwhile improvements in clinical outcome. Most meta-analyses include only papers that are methodologically robust; however, as most research in this area is small scale, adherence is often a secondary outcome measure nested within a larger study, and the quality of papers tends to be poor.

Materials and methods

We performed a retrospective study that included 256 old patients ( 75 years old) admitted to the Geriatrics Department of C. I. Parhon Hospital in 2012. Patients’ data were recorded in a secured database that contained demographic informations (age, gender, address, income, whether the patient has any family or is living alone), symptoms (musculoskeletal pain, depression, fatigue, balance disorders, anxiety, muscle cramps, dysphagia), clinical data (elements of frailty and/or sarcopenia, compliance to treatment) and data about current medication. Information about therapeutical adherence was collected for each person by an interview with the patient. The questionnaire consisted in verifying their knowledge about their diet and medication and comparing it with information from past medical records or from family members.
The data were analyzed using 20 SPSS. Patients were divided into two groups according to their therapeutical adherence as rated by the physician (compliant = group A vs non-compliant = group B); a correlation test was performed in order to identify factors that influence adherence to treatment. Those factors were then assessed by means of both parametric and non-parametric tests, according to data type. When possible, Fischer Exact test was employed, for detecting correlations between non-parametric dichotomous data. The statistical significance was defined as p

Results

There were no statistically significant differences between groups A and B regarding gender (42,3% males and 57,7% females in the compliant group vs 35,4% males and 64,6% females in the non-compliant group) and age (mean age in group A = 77,9 ± 2,9 years, whereas in group B it was 78,5 ± 2,8 years). There was an important difference between the groups regarding income, but it did not reach statistical significancy (1058,1±902,1 RON in group A vs 680,4±318,3 RON in group 2), with p = 0,1.
Symptoms that correlate well with non-adherence were: musculoskeletal pain, depression, balance disorders, anxiety; in group A these symptoms were noted in an increased number of patients than group B, but it did not reach statistical significance.

Clinical data was similar in the two groups, with fatigue present in 96 patients (59%) in group A and in 74 patients (52,1%) in group B (p=0,4); a decrease in mobility was noted in 109 patients (62,8%) in group A and 62 patients (66,7%) in group B (p=0,7) and a decrease in muscular force was present in 39 patients (11,5%) in group A and 23 patients (6,2%) in group B (p=0,5).

Among the tested parameters, one of the most important factor that influence adherence to treatment was the area were the patient had residence – living in a rural area seems to increase the probability that the patient will be non-compliant, with p = 0,04 as assessed by Fischer exact test. Of the patients that lived in a rural area, 53,6% were compliant and 46,4% were not as compared to patients from urban area, where 71,9% were compliant and 28,1% were not.

A second factor that influenced adherence to treatment was the number of pills that the patient was taking prior to admission, with an average of 4,79 pills/day in group A and 3,54 pills/day in group B (p=0,02).

Living with family had a statistically significant influence on adherence. In group A, 83 patients (42,3%) lived alone, as compared to 81 patients (64,5%) in group B (p = 0,01).

Discussion

Poor adherence to drug therapies still represents an unsolved problem and is much more severe in elderly. This contingent of population often has numerous co-morbidities that need numerous medical services, aggressive investigations and polimedication, usually prescribed by different specialists. Polimedication means difficult therapeutical schemes, usually with inappropriate drug posology, recommended to patients with cognitive disorders, sensory and motor deficiencies and lack of familial or social support for the possible handicap (8)

The number of seniors increases as an absolute value and as a percentage of the whole population; in USA, elderly population increased from 3 million in 1900 to 35 million in 2000 and the expectancy for 2030 is 40 million (9). Several studies (10, 11) reported that more than 40% of elderly patients takes 5 or more different types of drugs/day and 10% takes 10 or more different drugs/day. It is widely agreed that the use of many different drugs/day is highly associated with therapeutical non-adherence, iatrogeny, and risk for inducing geriatric syndromes such as: falls (orthostatic hypotension) and fractures, urinary incontinence (abuse of diuretics), cognitive impairment (abuse of sedatives, anti-depressants).

Therapeutical non-adherence may take many forms, e.g., not following dietary or exercise recommendations, not taking the prescribed number of pills or taking them at irregular or otherwise nontherapeutic intervals, not refilling prescriptions, and not showing up at follow-up clinic visits.

We believe that the real number of cases of non-compliance might be higher as patients were not entirely truthful in interviews, mostly because they became ashamed of not having followed medical recommendations.
There were no statistically significant differences between groups A and B regarding gender and age. We expected to find an important difference between the two groups regarding monthly income, because we considered that financial support should be a leading factor for non-adherence. We were surprised that there were no statistically significant differences, possibly due to the study design, that allowed patients to state whether or not they agree to including their income in the database. As a consequence, the number of patients for which income information was available was small (23 patients), which definitely influenced the results. However, our results were consistent with other studies (12), where side effects and forgetfulness were quoted as the most important causes for non-compliance .

An important factor for non-adherence was living in a rural area. This observation is in agreement with other studies (7, 12) and have several explanations: longer distances from any medical institution and/or pharmacy, lower degree of education and lower understanding of the importance of following medical recommendations, lower income and impossibility to fulfil elaborate prescriptions, unsatisfactory relationship with the local general practitioner and distrust versus his/her medical advice.

We were surprised to find a statistically significant correlation between a larger number of pills and therapeutical adherence (4,79 pills/day in group A and 3,54 pills/day in group B, p=0,02) and not other way around. It is probably due to the fact that patients that were considered compliant had a better recollection of the drugs they were currently taking, whereas non-compliant patients did not remember what medication they were under, no matter the number of pills/day. This was a limitation of our study as we were not able to find out if all the patients in Group A really followed medical prescriptions, even if they remembered the drugs they were on. Patients with a partial recall of their medication regimen are usually at higher risk for adverse effects than those with no recall at all, possibly because patients with no recall seek assistance more readily due to rapid worsening of symptoms; patients with partial recall are more prone to experience negative side effects due to overdosing the drugs they could remember, such as digoxin toxicity, oral anticoagulants or beta-blockers overdose.

An important factor for non-adherence was living alone status (p = 0,01), which was consistent to other studies (13, 14, 15). We believe that loneliness in elderly people is associated with poor health outcome because lonely people do not or cannot perform healthy behaviours, such as medical adherence, physical exercise, good diet and adequate sleep. It appears that people who are lonely have a tendency to see their life circumstances as more stressful, unpredictable, and overwhelming when compared to those who are less lonely (16, 17).

Symptoms that were not necessary linked to the main pathology but were affecting the quality of life and induce non-adherence (musculoskeletal pain, depression, balance disorders, anxiety) required palliative care measures. After we provided palliative care especially for these specific symptoms, the patients developed a new and improved relation with their physicians. They became more opened to doctor’s advice and more adherent to treatment. This observation may open a new research for non-adherent elderly patients with a higher need for palliative care (18, 19).

There are numerous studies (20, 21, 22) that have proposed several methods to fight non-adherence. We consider that there are two different, yet complementary approaches to this problem: the first direction should be the medical approach and the second should be telemonitoring and e-health services.

The first line is the multidisciplinary medical approach, due to the complex psycho-social context of the elderly patients themselves. The medical team (geriatrician and general practitioner, psychologist, dietetician, kynetotherapeut, nurses, social services, caregivers) should encourage treatment adherence by clearly communicate with their patients about therapeutic goals and methods to achieve them and by giving legible written instructions after considering the complexity of dosing schedules, expense, and potential adverse effects. Moreover, the patient should be continuously supervised, controlled and encouraged in respecting medical recommendations, and also should be permanently chequed for side effects and/or adverse events that can occur from the medication itself.

Given the importance of the growing need to improve medication adherence, choosing the best intervention represents a challenge for healthcare providers, and we consider that telemonitoring and e-health systems are the most interesting approaches to the elderly patient of XXIst century. There are many programs that encompass this domain (20,22) but one of the most interesting for our study is the polymedication electronic monitoring system (POEMS), developed by the Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Switzerland (22). This system allows reliable and precise measurement of patient adherence to medications by incorporating a micro circuitry into dose-dispensing drug packages of various designs, such that the manoeuvres needed to remove a dose of drug are detected, time-stamped, and stored. The personalized dose-dispensing aid organizes individual oral doses according to their prescribed intake schedule throughout the day and the week. The electronic monitoring of the entire therapy would reveal an intake pattern that would have remained undiscovered with any other device and would allow a personalized intervention to correct an inadequate medication intake behaviour. POEMS may guide health professionals when they need to optimize a pharmacotherapy because of suspected insufficient adherence. Further, knowing the intake pattern of the entire pharmacotherapy can elucidate unreached clinical outcome, drug-drug interactions, and drug resistance (22). In the near future, one could imagine that medication adherence data over the entire therapy plan would be available as soon as the electronic wires are activated, so that a failure to take medication could be detected immediately and intervention could be taken if appropriate.

The results of our study confirm several factors involved in therapeutical non-adherence. These included patients from rural areas, with low income and expensive medical prescriptions, patients with low educational level and sophisticated medical regimens, patients who receive too many drugs, patients with cognitive dysfunction and who live alone, patients who have only partial recall of their medical regimens, smokers and/or alcohol abusers and the symptoms that were not related to the main diseases but were affecting the quality of life. Fighting non-adherence should rely upon three complementary directions: the multidisciplinary medical approach and telemonitoring, in order to assist very old patients in taking their prescribed medical schedule and geriatric palliative care throughout the rest of their life. Geriatric palliative care is becoming an important link in assuring a good quality of life, a good treatment and a dignify ending for elderly patients and we should be able to provide it whenever is necessary, including the cases with non-adherence.

References

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Conflict of interest: none
Received: 13 September 2013
Accepted: 22 October 2013Conferenţiar dr Ioana Dana Alexa, medic primar de medicină internă şi geriatrie-gerontologie, doctor în ştiinţe medicale (a), Dr Adina Carmen Ilie, medic specialist de geriatrie-gerontologie, asistent universitar drd (b), Dr Ramona Onuţu, medic rezident de geriatrie-gerontologie (c)

(a), (b): Disciplina de Geriatrie-Gerontologie, Facultatea de Medicină, Universitatea de Medicină şi Farmacie „Gr.T. Popa” Iaşi, România
(c): Clinica de Geriatrie, Spitalul Clinic „Dr. C.I. Parhon”, Iaşi, România

Autorul corespondent: Ioana Dana Alexa: e-mail: ioana.b.alexa@gmail.com

Rezumat

Obiective:
Aderenţa la tratament este dată de modul în care pacientul respectă recomandările medicale. Este un proces complex, multifactorial, care influentează semnificativ calitatea vieţii fiecăruia.

Material şi metodă:
Am efectuat un studiu retrospectiv care a inclus un număr de 256 pacienţi vârstnici şi foarte vârstnici (>= 75 ani) internaţi în ultimul an în Clinica de Geriatrie a Spitalului Clinic „Dr. C.I. Parhon”. Informaţiile colectate au fost incluse într-o bază de date ce conţine: date demografice, date clinice, prezenţa măsurilor de îngrijire paliativă şi informaţii despre aderenţa la tratament. Informaţiile despre aderenţa la tratament au fost obţinute cu ajutorul unui chestionar ce constă în întrebări prin care se verifică cunoştinţele lor în ceea ce priveşte dieta şi medicaţia, iar aceste informaţii au fost comparate cu informaţiile din documentele medicale anterioare sau cu cele primite de la membrii familiei.

Rezultate şi discuţii:
Rezultatele studiului identifică o multitudine de factori ce influenţează aderenţa la tratament: locul de provenienţă, numărul de tablete prescrise de medic, existenţa suportului familial şi financiar si nu în cele din urmă, prezenţa îngijirilor paliative precoce în abordarea multidisciplinară a vârstnicului cu scopul ameliorării simptomelor şi creşterii calităţii vieţii.

Concluzii:
Reducerea nonaderenţei terapeutice ar trebui să se bazeze nu numai pe abordarea individualizată a pacientului vârstnic, dar şi pe introducerea precoce a îngrijirilor paliative cu scopul ameliorării calităţii vieţii.

Cuvinte cheie: aderenţa la tratament, îngrijiri paliative, vârstnici

(Full text în engleză)