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Adults sixty-five years of age and older are a growing population, and are the largest consumers of prescription and nonprescription medications in the United States with potentially increased medication interaction risks. Therefore, an investigation to determine if elderly populations at two minority serving, independent housing sites perceived any issues regarding their medication use, including any communication challenges with their providers. The data were collected using a survey in which participants had to recall information about their medication use and past provider interaction.
Participants (N=21; 90.5% female; using 5.1 ± 2.6 medications) completed a needs assessment. Results indicated that patients felt comfortable talking to their doctors. However, the communication that occurs may not have included education on polypharmacy. Many participants did not believe that they could describe details about their medications, such as the purpose (47.6%), instructions (42.9%), side effects (66.7%), and the possible risk of addiction (42.9%). This assessment indicates a need for an intervention that is focused on communication about polypharmacy and medication review education.
The term polypharmacy, literally meaning “many pharmacies,”, has various definitions in different medical literature. Baranzini, et al, defined polypharmacy as the use of four or more medications or up to seven or more medications.1 Michocki, Lamy, Hooper, and Richardson considered polypharmacy to be the condition in which patients receive too many medications, medications for too long, or medications in exceedingly high doses.2 Bushardt, et al, concludes that there is no consensus in the medical literature for the definition of polypharmacy.3 For the purposes of this study and for medical inclusivity, polypharmacy will be defined as the use of more than one medication.
Polypharmacy is escalating as a public health problem in the United States' health care system.3 Although, polypharmacy can be deemed appropriate when multiple drug regimens are necessary to treat more than one medical condition, it must be monitored carefully by clinicians to achieve a therapeutic goal.4 Polypharmacy has been shown to increase the risks of drug-drug interactions, drug-disease interactions, and inappropriate dosing.3 Due to co-morbidities associated with aging, the geriatric population is the most susceptible group of people to polypharmacy and its associated adverse health outcomes.3 Patients sixty-five years of age and older are the largest consumers of prescription and nonprescription medications in the United States.3 By 2050, the number of people 65 years of age and older is expected to nearly double from 38.7 million in 2008 to approximately 88.5 million.4 With the predicted growth of the geriatric population, the occurrence of multiple chronic diseases that require concomitant management will also increase.3 Furthermore, health care physicians will face the challenge of balancing the risks and benefits that result from multiple medication use.3
Interpersonal communication plays a key role in the health behavior change process.5 Good communication between a patient and their physician leads to an overall improvement in physical health, chronic disease management, and a better quality of life in regards to patient health.5 A key aspect of good communication is a detailed medication history. Medication histories are vital in preventing prescription errors and reducing consequent risks to geriatric patients.6 However, patients and physicians often omit asking or informing about over-the-counter (OTC) and herbal medications because they consider them unimportant.7–10 These nonprescription drugs may be involved in harmful drug to drug interactions and other adverse drug effects.7–9 Furthermore, a good medication history includes more details than the drug name and the dosage. It should also include adverse drug reactions, hypersensitivity reactions, start and stop date for certain medicines, all OTC medications, and herbal or natural supplements.6
In many previous interventions and studies that have reviewed polypharmacy and its effects on the geriatric population, results have shown that polypharmacy increases the risk of negative health effects.1,3,4,11 However, there has been little research focused on the issues of polypharmacy within elderly minority populations in Hawai‘i. The purpose of the Polypharmacy Reviews among Elderly Populations (PREP) Project: Assessing Needs in Patient-Provider communication was to determine if elderly populations at two housing sites had any issues regarding polypharmacy. The PREP project also assessed any communication challenges regarding polypharmacy in this minority, geriatric population. It was hypothesized that the results would indicate areas in need of intervention within this population.
The project was approved by the University of Hawai‘i (UH) at Manoa Committee on Human Studies (CHS). Permission was granted by the housing site manager to do data collection at the elderly housing sites in 2011.
Participants were recruited for the needs assessment via flyers that were posted throughout two independent housing sites. The housing sites are classified as Section 8 housing, and they are located in the ‘Ewa District of O‘ahu. These sites were selected based upon previous relationships established between the advising author and the complexes. Any interested resident was allowed to attend the event. At any given time there may be a maximum of 170 residents living at the housing complexes.
Flyers advertised a game of Medication BINGO that residents could take part in while learning about a new study being conducted at UH Manoa. The flyers also advertised snacks and juice. Residents who attended the meeting were first informed about the project, and then asked to sign a consent form if they were interested in completing a survey. Completion of the survey was not necessary to take part in the Medication BINGO game that followed. Prizes for the Medication BINGO included a bag filled with office supplies, a plastic bowl or cup, and an energy bar. All residents who attended the meeting, regardless of whether or not they filled out the survey, were given a snack bag filled with an instant noodle soup mix, two granola bars, and a bag of cookies at the end of the event.
Participants completed a self-administered, paper survey which included questions pertaining to multiple medication use involving any prescription or over-the-counter medicines, topical agents, herbal supplements, and vitamins. Other sections of the survey included questions pertaining to knowledge on medication reviews, and communication between residents and their primary care physician. Some of the questions were taken from the Hyperpharmacotherapy Assessment Tool (HAT).3 The HAT is a tool that was designed for physician assistants to use as a guide during a drug therapy evaluation process.3 The questions in the HAT did not fit our study's purposes, and many of the items were not used. However, the HAT was used as a content reference for developing survey questions regarding multiple medication use. Content addressing the total number of medications, the use of multiple pharmacies, and a patient/caregiver's ability to describe the purpose, side effects, and instructions for all medications was taken from the HAT. Survey questions were developed to fit the Theory of Planned Behavior (TPB) model that assesses an individual's behavioral, normative, and control beliefs.
The survey was primarily designed to be answered on a three-point (“no”, “not sure”, “yes”) and a five-point Likert scale (“Strongly Disagree” to “Strongly Agree”). Some questions were also tailored to be answered on a numerical value scale. Likert scales were utilized for questions that did not require a numerical value to allow for variance within participant responses. The data taken from the surveys were compiled and analyzed using Microsoft Excel. The data were analyzed to determine the percent of participants who responded positively to items in the survey by selecting “Strongly Agree” and “Agree”. Certain survey items were reverse coded to display the highest value as positive. The survey is provided in the Appendix.
Demographics of participants are presented in Table 1. Participants (N = 21) were mostly older females of various ethnicities.
Participants reported an average medications number of 5.1 ± 2.6, range of 10, and a median of 5.0. Figure 1 shows the percent of participants who responded “Strongly Agree” and “Agree” to questions about their medication use.
Participants strongly believed that it was not okay to take another person's medications (Figure 1). Most participants did not feel that they had difficulty keeping track of their medications or trouble taking them (Figure 1). However, Figure 1 also showcases that participants did not feel confident about their knowledge regarding their medication use. Many participants did not believe that they could describe details about their medications, such as the purpose (47.6%), instructions (42.9%), side effects (66.7%), and the possible risk of addiction (42.9%).
Figure 2 shows that most participants do not have someone helping them keep track of their medications. Most participants also responded that they do not have a printed schedule or any other tool they use to aid them in organizing their medication use. According to the data, 61.9% responded to never having had an adverse reaction from their medications. If the participant did have an adverse reaction, 9.5% said they asked their doctor about it.
Participants received their care from a range of one to five physicians. There was an equal distribution (28.6% of participants) between the number of participants who reported receiving care from one or two physicians, 19.1% from three physicians, 14.3% from four physicians, and 4.8% from five physicians. The majority (90.5%) of the participants stated that they use only one pharmacy.
Figure 3 shows the results obtained on physician-patient communication. Over 90% of participants reported positively (“Strongly Agree” or “Agree”) for survey items regarding physician-patient communication. The majority of the participants felt comfortable talking to their doctors, and asking questions when they needed clarification. Results show that the participants believe that their primary care physician knows all of the medications being prescribed to them (including those prescribed by other physicians), and are knowledgeable of all the medications the participants are currently taking. However, Figure 3 also shows that less than half of the participants believe they were knowledgeable about multiple medication use and medication reviews. The majority of participants did not believe that they had the ability to describe what a “drug-drug interaction” was (76.2%) or the purpose of a medication review (61.9%).
Figure 4 displays the percentage of those who responded positively regarding multiple medication use and medication reviews. About one-third of the participants reported receiving a medication review. Six participants (28.6%) reported receiving an annual medication review. Less than half (42.9%) of the participants, had asked their doctor for a medication review. However, more than half of the participants (61.9%) were interested in learning and talking to their doctors about a medication review.
There were four questions from the survey that the participant selection of the response “Not Sure” or “Neutral” was greater than 20-percent (Table 2). Five participants (23.8%) responded “Not Sure” when asked if they ever had an adverse reaction to their medication(s). Five out of 20 participants (25.0%) responded “Neutral” and “Not Sure” to whether they believed they had the ability to describe the purpose of a medication review and if they were currently receiving an annual medication review, respectively. Furthermore, 28.6% (six participants) were not sure if they had ever received a medication review.
A significant association was found for individuals who have someone (other than their physician) to help them with their medications and those who utilize tools for referencing their medications (Table 3). In this association, a participant who receives help with their medications from another individual was more likely to also use a printed medication schedule or tool to help them remember to take their medications. A significant association was also determined between the number of medications an individual took and the number of doctors or specialists they visit. In this association, the more providers a participant received care from, the more medications they were likely to be taking.
The results from this study suggest that while participants feel comfortable communicating with their doctor, the content of these conversations may not include polypharmacy issues and medication reviews. Many participants were uncertain about details concerning their medications. In addition, participants did not demonstrate confidence about understanding the adversities associated with multiple medication use and the importance of completing medication reviews. Furthermore, most of the participants responded that they had not received or were unsure about receiving medication reviews. This result serves to emphasize that while participants feel their physician is open to communication, there may be a lack of communication occurring where medication reviews are concerned. When asked if they were able to describe a “drug-drug interaction” or the purpose of a medication review, the responses ranged from disagree to neutral. Participants were either unsure about these questions or about the topics these questions were in reference to. However, it was encouraging that more than 60% of the population was interested in learning about medication reviews and talking to their doctor about a medication review.
The correlation analysis provided insight into associations between measures. The association found between the number of providers for a participant and the number of medications they are taking suggests that seeing multiple doctors may increase the likelihood of taking multiple medications. While causal relationships cannot be inferred, this association may indicate that each doctor is prescribing a medication, thereby increasing the overall number of medications for a patient. This finding exemplifies the importance of effective patient-physician communication as well as communication among physicians caring for the same patient to reduce adverse drug-drug interactions.
Another interesting finding is the association between individuals who have someone helping them with their medication regimen and those who utilize tools for referencing their medications. Further research is needed to understand why this association is occurring. Possible reasons may be that the individual assisting the participant is using the medication tools (pillboxes, printed charts) to care for the participant or the assisting individual is teaching the participant to use them. Another reason could be that some participants are more likely to seek help from any and all available sources, whether they be a person or tool. Thus, future studies could delve deeper into the associations found in this exploratory study.
In Hawai‘i, the effects of a medication review by geriatricians in a nursing home were analyzed.11 The study involved a review of a patient's medication list, consulting Beers' Criteria online, and recommending medication changes to the patient's primary physicians.11 Results showed that 46.2% of the patients were on nine or more medications.11 The ethnicities of the patients were not specified. After a physician intervention, the average total of medications declined, demonstrating that the application of a system of medication guidelines and tools can significantly reduce polypharmacy.11
Interventions that have targeted reducing polypharmacy among the elderly population have placed emphasis on the role and responsibility of the physician. Hanlon, et al, performed a trial in Durham, North Carolina, of a clinical pharmacist intervention in elderly outpatients with polypharmacy to improve inappropriate prescribing.12 Clinical pharmacists met with the intervention group to evaluate medications, give general drug information, and make recommendations that were sent to the patient's physician.12 After one year, there was a 23% difference between groups in the reduction of inappropriate prescribing.12 Thus, pharmacists can also make a significant contribution to improving prescription appropriateness for elderly adults.12
There is a movement within healthcare to improve communication and availability of patient information at the point of care through Health Information Exchange (HIE) and other Health Information Technology (HIT). As more providers adopt electronic health records and exchange patient information, the quality of communication between patients and among their providers in regards to multiple medication use is likely to improve. Communication among a patient's physicians is important, and it can be facilitated by technologies that allow physicians to readily identify all the medications taken by a patient to reduce the occurrence of adverse drug-drug interactions. HIT tools may also help patients access information about their medications and remind them how and when to take them. Interventions testing such applications among high risk populations in Hawai‘i are also needed.
The data from this needs assessment indicates a need for an intervention that is focused on multiple medication use and medication review awareness and education. An intervention should address important findings from the study such as the results indicating that most participants did not have another individual, a medication schedule, or another tool to aid them in keeping track of their medications. An intervention should especially target those individuals who feel they have difficulty following their medication regimen, but are not utilizing any tools to help themselves. In addition, further analysis should be done to assess the relationship between the measures, and to test causality of having an adverse reaction to medications. Geriatric individuals are more susceptible to adverse effects due to polypharmacy simply due to physiology and co-morbidities associated with aging. An intervention is needed to address these health issues to ensure that elderly patients are better equipped to manage their multiple medication use.
Due to limited resources and time constraints, only two local housing sites were selected for participation in this study. One of the limitations was the participation of the residents in the housing sites for the study. Between the two housing complexes, which serves a maximum of 170 individuals at any given time, only 21 people chose to participate. Only a small concentrated population was studied for multiple medication use and adversities associated with polypharmacy. This small sample size limited our ability to conduct sub-analyses, and may not be a representative sample of the study population. The number of individuals living at the housing sites, and their distribution by gender is unknown. Therefore, it is unknown if a majority of the residents are female since a greater proportion of females chose to participate in the study. In addition, this was a retrospective study which may have lead to a recall bias in answering the survey questions.
It is difficult to generalize the results of this exploratory study to broader populations in Hawai‘i. However, issues regarding polypharmacy and patient-physician communication among elderly individuals has not been studied extensively in Hawai‘i, and there is limited data in the literature that approaches polypharmacy from a patient perspective. Physician-patient communication is an important component to for reducing possible adversities due to polypharmacy. This is a serious issue that needs to be further assessed and addressed accordingly. A more representative island-wide or state-wide study should be completed in the future to further assess multiple medication use and adverse polypharmacy among at-risk populations like the elderly. Future studies and interventions should also include a focus on determining causes of adverse reactions due to medications. Polypharmacy has often been approached from the provider's side. It would take considerably more time and resources to engage and educate healthcare providers on issues regarding polypharmacy, especially within the fragmented structure of the system where physicians are not always in direct contact with one-another. This study has attempted to approach polypharmacy from a patient perspective and future studies could aim at improving patient awareness on polypharmacy, and empowering them with the knowledge and tools they need to successfully reduce chances of adversities due to polypharmacy.
** Some of the questions included in this survey were taken from the Hyperpharmacotherapy Assessment Tool (HAT), and modified to fit the needs of this study. The original questions can be found in the following journal article: Bushardt, R. L., Massey, E. B., Simpson, T. W., Ariail, J. C., & Simpson, K. N. (2008). Polypharmacy: Misleading, but manageable. Clinical Interventions in Aging, 3(2), 383–389.
None of the authors have any conflict of interest.