primary outcome:
Interventions for improving medication‐taking ability and adherence in older adults prescribed multiple medications
This review focused on two outcomes directly related to medication‐taking behaviour of older adults (or their carers): ability to manage medications and adherence to medication regimens. To be eligible for inclusion, studies had to have assessed at least one of these outcome measures for at least four regular prescribed medications (which could be the person’s own medications or, for assessment of ability to manage medication, a validated, simulated medication regimen instrument) (Elliott 2009). These two outcomes were evaluated separately.Medication‐taking ability was measured in five studies. Four studies used objective measures including a five‐item dexterity test that assessed skills such as ability to open child‐resistant closures on containers (Begley 1997), a medication‐taking behaviour score (Cargill 1992), the Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) (Lingler 2016), performance in an inpatient self‐administration of medications programme, and/or pharmacist assessment (with input from other team members) of ability to self‐administer medications (Pereles 1996). One study used a subjective measure ‐ a self‐reported assessment of safety in taking medication (Manning 2007). Medication‐taking ability was typically measured at short follow‐up points (e.g. 7 to 14 days; Manning 2007), except for one study, which had an extended measure at 12 months (Begley 1997).Medication adherence was measured in 48 studies (Table C). Twenty studies used an objective measure of adherence such as pill count (Begley 1997;Cargill 1992;Cohen 2011;Lee 2006;Lopez Cabezas 2006;Marusic 2013;Moral 2015;Murray 1993;Olesen 2014;Pereles 1996;Rich 1996;Williams 2012;Winland‐Brown 2000;Wood 1992), prescription claims/refills (Al‐Rashed 2002;Grymonpre 2001;Messerli 2016;Shimp 2012;Vinluan 2015), or machine‐recorded correct doses (Marek 2013). Twenty‐eight studies used a subjective measure of adherence; 16 of these used an original or modified version of the Morisky Medication Adherence Scale ‐ a validated measure of adherence (Bernsten 2001;Chrischilles 2014;Cossette 2015;George 2016;Haag 2016;Hale 2016;Khdour 2009;Morales Suarez‐Vurela 2009;Muth 2016;Nascimento 2016;Saez de la Fuente 2011;Volume 2001), the Medication Adherence Rating Scale (Bond 2007;Holland 2007;Muth 2016), the Brief Medication Questionnaire (Blalock 2010), and the Medical Outcome Study‐Specific Adherence Scale (Shively 2013). Four studies used structured interviews to enquire about adherence (Hanlon 1996;Lipton 1994;Nazareth 2001;Willeboordse 2017), and six studies asked participants a single question about forgotten or missed doses (Lim 2004;Naunton 2003;Taylor 2003;Truelove 2015;Wu 2006;Young 2016). One study used a patient‐completed daily log‐book of medication consumption (Pandey 2017), and one study included pharmacist review for pharmaceutical care issues including potential or actual adherence issues (Krska 2001). The longest follow‐up time points of post‐intervention adherence outcomes ranged from 1 month to 18 months, with the median time point of 6 months.Forty‐eight studies included a measure of adherence and were analysed based on the type of intervention provided: educational (n = 14 studies), behavioural (n = 7 studies), or mixed (n = 27 studies).Meta‐analyses were possible for 31 studies: 18 involving dichotomous measures (Analysis 1.1), and 13 involving continuous measures (Analysis 1.2). The 17 studies not included in meta‐analyses are briefly summarised in Table 2 and in the following subsections.Two studies included measures of medication‐taking ability.Cargill 1992 compared a mixed intervention versus an educational intervention. In this comparison, both groups received a 20‐minute nurse education session and review of medications (educational intervention); one of the groups also received follow‐up telephone calls (mixed intervention). No difference in medication‐taking behaviour between groups was reported at four to six weeks (score out of 100 read from a graph: mean 84 versus 86).Begley 1997 compared a mixed intervention involving pharmacist home interview with counselling versus a behavioural intervention of home interview only without counselling (modified usual care). This study reported no difference in dexterity between groups at 12 months (data were not reported).Six studies involved a measure of medication adherence.Two studies compared two behavioural interventions. In Murray 1993, pill count adherence was slightly higher in the group that received regimen simplification and unit of dose medication packaging than in the group given regimen simplification alone (92.6% versus 82.6%; P = 0.02). In Winland‐Brown 2000, nurse‐filled pillbox DAAs were associated with a higher number of missed pills as measured via pill count than via an automated dispenser with audible adherence reminders (mean 15.1 versus 1.7; P < 0.001); however the time interval is unclear.Cargill 1992 compared a mixed intervention versus an educational intervention and found no difference in pill count adherence between the group that received nurse teaching with additional telephone follow‐ups versus the group receiving a nurse teaching session without follow‐up (mean 76% versus 74%).Two studies compared mixed interventions versus behavioural interventions. Begley 1997 found that pharmacist home interview with counselling had slightly greater impact on pill count adherence than the home interview alone (mean ± SD percentage 86 ± 19 versus 75 ± 21). Olesen 2014 measured adherence using different methods in different groups, and thus data are not comparable.Marek 2013 compared two mixed interventions and found that pill count adherence was similar across both medication dispensing machine and simple medication box groups (98.8% versus 97.4%).