- Email: [email protected]
Adherence and Oral Agents With Older Patients
154
Seminars in Oncology Nursing, Vol 27, No 2 (May), 2011: pp 154-160
ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS KRISTEN W. MALONEY AND SARAH H. KAGAN OBJECTIVE: Oral antineoplastic agents offer multiple advantages in cancer therapies. Thus, understanding issues of adherence to these agents for older adults becomes critical to successful comprehensive care of the older cancer patient. DATA SOURCES: This analysis of adherence to oral agents among older cancer patients draws on interdisciplinary geriatric and oncologic research reports and clinical reviews. CONCLUSION: Older adults are at increased risk for poor adherence to oral agents. Barriers to adherence are diverse. Problems emerge from age-related physical changes, comorbid conditions, polypharmacy, and drug interactions. Psychosocial barriers include limited insurance coverage and transportation problems to social isolation and inadequate social support.
IMPLICATION FOR NURSING PRACTICE: Nurses should lead interdisciplinary, individualized plans of care to mitigate barriers and support adherence to cancer therapy. KEY WORDS: Elderly, aged, adherence, oral medications, chemotherapy, patient education
DHERENCE to antineoplastic oral agents by older adults presents intertwined challenges of oncologic considerations and geriatric concerns.1 Older adults, especially those who are over 75 years of age who live alone, face many barriers to oral agent adherence.2 Among these barriers are adequate
A
access to these antineoplastic agents, sufficient knowledge of their cancer treatment and pharmacotherapy of comorbid condition to support adherence, the physical and cognitive capacity for self-administration, and risk of drug interactions and adverse events within the context of comorbid diseases and polypharmacy.1,3,4 Importantly,
Kristen W. Maloney MSN, RN: Clinical Nurse Specialist, Rhoads Three Inpatient Oncology Unit, Hospital of the University of Pennsylvania, Philadelphia, PA. Sarah H. Kagan, PhD, APRN-BC, AOCNÒ, FAAN: The Lucy Walker Honorary Term Professor of Gerontological Nursing, School of Nursing, Clinical Nurse Specialist, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA.
Address correspondence to Sarah H. Kagan, PhD, APRN-BC, AOCNÒ, FAAN, The Lucy Walker Honorary Term Professor of Gerontological Nursing, School of Nursing, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104-4217. e-mail: [email protected] Ó 2011 Elsevier Inc. All rights reserved. 0749-2081/2702-$36.00/0. doi:10.1016/j.soncn.2011.02.007
ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS
people over the age of 65 are users of the greatest proportion of all prescription drugs, including antineoplastic agents. Lichtman2 notes that older adults account for approximately 30% of drug costs annually and that about half of all medications are marketed for the geriatric population. Further barriers are specifically experienced by older adults who have limited financial resources and restricted transportation options, as well as limited fine motor capacity, and impaired memory and other cognitive capacities.5-7 Such barriers result in generalized risk of limited adherence and need for individualized plans of care to support oral agent adherence and prevention of adverse events and complications. Oral agents offer convenience and safety and are desirable for patients, their families, and clinicians alike.1,8 Irshad and Maisey8 note that patients and clinicians commonly prefer oral agents for convenience and comfort given equivalent efficacy to intravenous regimens and favorable safety records. As a result, a large proportion of antineoplastic agents in development are oral.2,4,9 Irshad and Maisey as well as Moore8,9 further point out the ability to avoid invasive treatments and attendant complications that may occur more often in older adults and the attractiveness of cost containment with oral regimens. Older adults, who may find transportation and coordination of complex ambulatory infusion regimens overwhelmingly burdensome, favor the advantages of oral agents.1 Thus, older cancer patients, who collectively account for the majority of people diagnosed with cancer, are increasingly likely to be prescribed oral antineoplastic regimens. This article integrates oncologic and geriatric concerns to adherence to oral agents for older adults. It presents implications for practice, education, research, and policy. Issues of access, knowledge, administration, and problem-solving are detailed to direct nursing and interdisciplinary care and to highlight education for older adults and their family caregivers.
ADHERENCE TO ORAL AGENTS FOR OLDER ADULTS Access Financial concerns are foremost among barriers to adherence with any oral medication prescribed to older adults. Like medications for many other chronic diseases, oral antineoplastic regimens
155
are expensive. They can often be extremely costly when the newest chemotherapeutic or targeted agents are prescribed.10,11 While the therapeutic gains of such agents are important, financially mediated poor adherence to prescribed care may negate potential therapeutic advantages. Older adults commonly live within fixed, limited incomes. As a result, they may have insufficient funds for copayments mandated for medications under insurance coverage or may have to prioritize spending on essentials such as food or utility costs.3,12 Hence, poor adherence is often the unintended consequence of combining oral agents with limited personal finances. Medicare beneficiaries now enjoy the most recent major change in benefits, called Medicare Part D. Medicare Part D was enacted in January 2006, providing prescription drug coverage through a variety of plans. Beneficiaries elect to enroll in a plan that best suits their prescription drug needs, and can alter enrollment should their needs change, though such alterations in enrollment are limited to once each year. Despite obvious advantages over no prescription drug coverage, most patients being treated for cancer, like other chronic diseases requiring often new and expensive medications, find they face gaps in the Medicare Part D because of costs for annualized treatment regimens that exceed coverage.13 Within Medicare Part D, there is a monetary limit to prescription coverage for each calendar year that varies by the available plan selected by an older patient. Those on fixed, limited incomes face a gap in coverage, better known as the ‘‘donut hole,’’ which requires them to pay out of pocket after the annual limit in coverage is met. Depending on prescription needs, this gap can occur weeks or even months before the end of the calendar year and initiation of renewed coverage with the first of the next year. Surprisingly, Madden and colleagues13 found that cost-related nonadherence to medications actually rose slightly after introduction of Medicare Part D. Hence, Medicare Part D requires careful scrutiny and must not be viewed as a panacea against financial mediated problems in adhering to oral antineoplastic agents. For some individuals, small grants offered by the American Cancer Society or other community agencies serving people with cancer or older adults and their families may bridge gaps in coverage. Additionally, pharmaceutical company prescription grants offer a useful resource for covered drugs and for eligible older patients.
156
K.W. MALONEY AND S.H. KAGAN
Transportation to obtain medications, like transportation to medical appointments and other care, also limits access and consequently impairs adherence to oral agents for some older adults.14 Older adults are less likely than younger counterparts to be independently able to navigate their communities. They may lack physical and mental capacities to safely use an automobile or lack the license and confidence to drive. Older adults may not have family and friends who can provide transportation or even obtain medications for them. Urban elders may rely on public transportation, but use of public services may be logistically difficult or unsafe for frail or fatigued individuals.6,15 Rural elders face equally complicated transportation challenges that include long distances and absent services. Additionally, while subsidized medical transportation services may be available to impoverished elders, these services almost never provide adequate flexibility and accessibility to insure medications will be obtained in a timely manner from specialized pharmacies that stock oral antineoplastic agents. Social services assessments gauge eligibility for community-based short- and long-term transportation systems often accessible through the local Area Agency on Aging or similar social services. Even those services intended for well elders may be invaluable to supporting adherence and overall outcomes of and satisfaction with care. Knowledge Knowledge to adequately schedule, ingest, and monitor response to oral agents is often exceedingly complex. Understanding oral antineoplastic regimens presents a challenge even for well-educated individuals who have no functional limitations.16 Thus, older adults who have functional limitations face the additional trial of understanding the agents prescribed, the cancer these agents treat, and the interactions with treatments taken for other chronic and acute conditions within the context of circumscribed capacity. Requisite knowledge is, however, foundational to comprehending complex matters of scheduling administration through the day and week, in addition to following prescriptions around timing vis- a-vis ingestion of food and other medications. Knowing expected response patterns and priority side effects to report, in contrast to side effects of other medications and effects of drug interaction, completes the knowledge foundation required for self-administration of oral agents. Acquiring and using this knowledge mandates
literacy, numeracy, and cognition, including executive function and memory. However, literacy, numeracy, and cognition are often limited among the current generations of older adults.17,18 Use of technologies to promote adherence further requires computer literacy. Computer literacy, while increasing in recent years, is limited among older adults.19 Patient and family education anchors adherence and cancer treatment when oral regimens are used. Assessment of health literacy and numeracy, as well as applicable issues in computer literacy and anxiety, is often the essential step overlooked in patient and family education.17 Baker and colleagues17 found significant associations between inadequate literacy and mortality among older adults, and noted that educational level is a poor indicator of literacy. They suggest fluency better assesses literacy. Weiss and colleague’s20 assessment of health literacy as the ‘‘new vital sign’’ offers a clinically useful and efficient assessment technique.20 Ideally, literacy and numeracy assessment should be combined with routine assessment of mental status, using a tool such as the Folstein Mini-Mental Status Examination at baseline.6,14 Alterations in adherence can then be understood in context of global mental function. Additionally, global assessment of hearing and vision with referral to specialists, as appropriate, are important. Marked changes from baseline or complaints about changes warrant referral and the potential need for compensatory aides.21,22 Baseline assessments of literacy, numeracy, learning style preferences, and computer literacy and access provide a strong foundation to create an individualized teaching plan. Each member of the team, including the patient, selected family or friends, and every clinician, play critical roles in successful education for self-administration of and adherence to oral agents.9 Moore9 underscores that, to promote adherence, patients prescribed oral agents must fundamentally understand how each medication works, how to take the medication, what side effects to expect and report, how to manage these side effects, and how to contact their health care provider for any follow-up questions. She further underscores the need for a full hour for education when initiating or changing therapies.9 Banna and colleagues23 extend these recommendations, suggesting that take-home information, medication diaries, and guidelines for dose reduction in
ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS
the event of side effects can augment successful patient education. A variety of teaching methods and materials targeted to the older person’s capacity, needs, and preferences must support and reinforce patient education (see Table 1).9,22,24-27 Teaching methods that match the patient’s and family or caregiver’s literacy and learning needs require evaluation of the available educational materials. Written materials that use approximately fifthgrade literacy skills and are formatted using a black, san serif font in 14-point or larger type accommodate most older adults’ visual capacity and literacy skills.22 Use of illustrations or cartoons can improve comprehension and retention, both for those older adults with low literacy skills as well as for those with adequate skills.28 Pharmaceutical companies, large hospitals and health systems, and patient advocacy organizations may have materials in video or other media format for patients with low literacy.24,25 Use of video, computer-based, or web-based materials may be less successful among older adults who are unfamiliar with computers or who do not
157
have home access to computers, CD or DVD players.19 Educating friends or family caregivers secures an additional means to support adherence to oral agents for older adults. DiMatteo5 found that social variables significantly influence adherence. For example, married individuals are more likely to adhere to medication regimens. Unmarried individuals were 1.13 times more likely to report nonadherence that married individuals. Older adults are also more likely to be socially isolated by widowhood and other losses, and, as a result, may have more factors contributing to poor adherence. Educating designated caregivers may then modify factors related to social isolation to support adherence. However, as with patients, assessing literacy, numeracy, and preferred learning styles is critical to successful engagement and education of these individuals.29 Administration Administration of oral agents, is the crux of adherence to oral treatment. Without the physical and mental capacity to ingest and metabolize oral
TABLE 1. Strategies to Improve Adherence to Oral Antineoplastic Agents Educational strategies Assess numeracy and computer literacy, as well as general literacy, for all older patients Match educational strategies to older patient’s and family caregiver’s literacy and learning preferences Insure that all educational materials are written at fifth-grade reading level or below for all older patients Include a glossary of medical terms in written educational materials to increase comprehension Write all educational materials in black using 14-point or larger sans serif font, like Arial or Calibri Use illustrated materials to help to improve information retention among all older adults Use illustrated written materials, video, and other media to support those older patients and family caregivers with low literacy skills Behavioral strategies Use a written medication schedule for all older patients who have sufficient literacy and cognitive capacity to remember and use them Try an alarmed medication box for older patients with complex regimens or for those with low literacy and numeracy Use telephone reminders provided by family members or caregivers, especially for isolated or shut-in older patients Suggest an electronic programmed telephone service in areas where available for dose and refill reminders Offer electronic, alarmed schedules for computer-literate older patients who have access to a computer Suggest using the alarm function on smart phones for older patients who use them Refer eligible older patients to a social workers who can help access Medicare home health services and services supplied through the local Area Agency on Aging (http://www.n4a.org/) Combining strategies Combine educational and behavioral strategies for optimal support of adherence Select strategies based on assessment of older patient and family caregiver capacities, skills, and preferences Ask for periodic return demonstration of behaviors and devices used to support adherence Review and revise adherence strategies used when the older patient’s status changes Data from Hartigan,16 Baker et al,17 Kinnane et al,24 George et al,26 and van Vuuren et al.27
158
K.W. MALONEY AND S.H. KAGAN
medications, older adults are at risk of not being able to adhere to and benefit from therapy before it begins. Candidates for oral therapy should be carefully selected from among all older adult patients. Lonardi and colleagues1 and Lichtman2,30 offer compelling analyses of chemotherapy use among older patients, highlighting that both biological and functional changes with age, as well as a paucity of clinical trials data with research involving older adults, may disadvantage older adults who are prescribed oral antineoplastic agents. Altered pharmacokinetics in older adults, along with a propensity for polypharmacy within this group of cancer patients, further contributes to the risk of problems in administration, absorption, and response.1,2,30,31 In fact, Jorgensen and colleagues3 suggest that polypharmacy may be associated with a decreased survival rate among older cancer patients. Older patients should be screened for adequate organ, physical, and mental function. Concerns about frailty, organ function, and capacity should trigger further specialized evaluation as well as decision-making conversations.6,14 Nurses who conduct intake interviews or other initial assessments have a critical opportunity to ascertain need for further screening and specialized assessment.7 Most ambulatory oncology care settings can conduct or refer patients for mental status examination, including recent recall, short- and long-term memory, as well as executive function. Ideally, occupational therapy and speech language pathology referrals complete specific assessment of fine motor skills and swallowing, respectively. Deficits in executive function and memory and in fine motor skills, such as those used to sort tablets or capsules for dose administration, that influence administration are often remediated with targeted interventions. Carefully planned use of devices and other technologies, in addition to available support services, may bridge gaps in older adults’ particular functional capacities (Table 1). At a very basic level, a written medication administration schedule and the written instruction that Moore9 and Banna and colleagues23 outline are essential to every older person’s oral agent adherence plans. Medication administration boxes, sometimes called pill boxes or ‘‘medi-sets,’’ can provide alarmed, timed dispensing of multiple doses per day. More elaborately, family and friends can offer telephone reminders and can visit daily when older adults are scheduled to take oral agents. Medicare home
care services and regionally specific telehealth and other services may be useful for some older adults. Social workers offer knowledge of available services and connections to those agencies, like the Area Agencies on Aging, that provide and coordinate a variety of programs. However, these services are commonly limited to those who are at least temporarily home bound. Alternatively, for those elders with independent financial means, privately paid staff or use of commercially available services may offer feasible support for adherence. Investigation of medication reminder interventions and adherence technologies is growing.26,32,33 Yet this research, systematically reviewed, shows limited evidence to select one intervention over others.26 Consequently, George and colleagues26 recommend combining an individualized set of educational and behavioral interventions to suit a specific patient’s needs to adherence and concordance. Additionally, referral to and collaboration with social workers and home service providers can establish eligibility and coverage for home, telehealth, and other electronic services including robotic aids and computerized reminder systems.26 Problem Solving Self-administration of oral antineoplastic agents requires a capacity for problem solving and judgment. Older patients must use their knowledge of the oral agents, expected response, potential side effects, and possible interactions with other medications, as well as foods, to monitor themselves, record events, and make choices about changing therapy within guidelines or contacting their treating clinicians. While clinically feasible, problem-solving assessment is not available, alterations in problem solving are associated with depression and thus, depression can serve as a proxy for some aspects of problem solving.34,35 Thus, assessment for depression to support adherence and achieve comprehensive care should be performed at baseline and on a periodic basis to insure adequacy of care and to support optimal adherence.35,36 Brief instruments along with more extensive assessments, such as the Geriatric Depression Scale, offer an array of options for screening, referral, and full assessment.36-38 However, additional support is necessary, even with adequate problem-solving skills. Older adults of the generation that experienced the Great Depression and World War II, as well as those older people who have surmounted imposing personal obstacles such as immigration, poverty,
ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS
and cumulative loss, may resort natively to selfreliance, resisting encouragement to contact clinicians with explanations of ‘‘not wanting to be a bother.’’ Problem solving and judgment may be augmented by well-timed telephone follow-up and triage of problems to members of the team, such as social workers, who can support development of new behavioral responses.9,23,39,40 Creating partnerships among physicians, advanced practice nurses, nurses, pharmacists, and social workers provides a collaborative basis for supporting problem solving and adherence among older patients. Boparai and Lichtman41 describe a multidisciplinary geriatric medication clinic, relying on the expertise of a pharmacist, to avoid potentially inappropriate medication use in patients over the age of 65 who were being treated at a tertiary cancer center. This sort of model is resource-intensive but offers a model that other facilities may adapt based on available resources. Lynch and colleagues40 describe a different model, based on the use of a geriatric social worker as the hub of the team approach, to limit threats to adherence and intervene to promote adherence and concordance. Appraisal of extant resources and patient needs may help facilities with varying needs and infrastructure to design locally relevant models to support older adult patient adherence in the setting of comprehensive cancer care.
CONCLUSION Achieving adherence to oral antineoplastic agents for older adults presents challenges to older patients and their family and other caregivers, as well as to their nurses, physicians, and other members of the interdisciplinary team. Older adults currently comprise the largest group of people diagnosed with cancer; this trend will grow as our society ages. Psychosocial barriers to adherence range from limited financial resources and gaps in prescription coverage, to low literacy and numeracy, and limited access to multi-media devices for education. Older patients also confront threats to adherence that
159
encompass biological and functional changes with age, as well as age-related comorbid conditions. Careful and detailed individualized assessment of intrapersonal and social resources grounds an interdisciplinary plan of care that targets each older patient’s particular needs. Use of assessment tools and other elements of comprehensive geriatric assessment allow for baseline data collection and comparison with repeated assessment.6,7,14,20 Engaging family and friends who are committed to supporting the older patient and who can be educated to provide support overcomes the threat of limited social support to adherence. Assessment of function and resources will direct interventions that can vary from medication schedules to use of more elaborate timed, alarmed medication administration sets and telephone follow-up. Assessing patient’s problem-solving capacity and judgment is also critical to success. Enhancing problem solving may range from one-on-one intervention to building skills through programmatic innovations such as interdisciplinary teams with targeted or comprehensive scope and aims. As our society continues to age, improved education for geriatric competence and enhanced health policy as a platform for research in adherence and concordance, and investigation of better resources and targeted technologies, is needed more than ever. Programmatic innovations offered by initiatives like the Geriatric Nursing Education Consortium and national implementation of American Association of Colleges of Nursing Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for Geriatric Nursing Care suggest oncology nurses can provide leadership in this critical aspect of oncology patient safety and quality and offer directions for future development.42,43 Nurses have long prided themselves on being excellent teachers of patients and their families. Advances in cancer care mandate that oncology nurses forge new directions in practice, education, research, and policy to provide better care and support adherence to oral agents and other treatments for our older patients.
REFERENCES 1. Lonardi S, Bortolami A, Stefani M, et al. Oral anticancer drugs in the elderly: an overview. Drugs Aging 2007;24:395-410.
2. Lichtman SM. Chemotherapy in the elderly. Semin Oncol 2004;31:160-174.
160
K.W. MALONEY AND S.H. KAGAN
3. Jorgensen TL, Hallas J, Herrstedt J. Polypharmacy in elderly cancer patients [abstract]. J Clin Oncol 2010;28(suppl 15):9074. 4. Lichtman SM, Boparai MK. Anticancer drug therapy in the older cancer patient: pharmacology and polypharmacy. Curr Treat Options Oncol 2008;9:191-203. 5. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol 2004;23:207-218. 6. Extermann M, Hurria A. Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol 2007;25:1824-1831. 7. White HK, Cohen HJ. The older cancer patient. Nurs Clin North Am 2008;43:307-322. 8. Irshad S, Maisey N. Considerations when choosing oral chemotherapy: identifying and responding to patient need. Eur J Cancer Care (Engl) 2010;19(suppl s1):5-11. 9. Moore S. Facilitating oral chemotherapy treatment and compliance through patient/family-focused education. Cancer Nurs 2007;30:112-122. 10. Aisner J. Overview of the changing paradigm in cancer treatment: oral chemotherapy. Am J Health Syst Pharm 2007;64(suppl 5):S4-S7. 11. So J. Improving the quality of oral chemotherapy services using home care. Eur J Cancer Care (Engl) 2010;19(suppl 1): 35-39. 12. Findlay M, von Minckwitz G, Wardley A. Effective oral chemotherapy for breast cancer: pillars of strength. Ann Oncol 2008;19:212-222. 13. Madden JM, Graves AJ, Zhang F, et al. Cost-related medication nonadherence and depending on basic needs following implementation of Medicare Part D. JAMA 2008;299:19221928. 14. Balducci L. Supportive care in elderly cancer patients. Curr Opin Oncol 2009;21:310-317. 15. Rao AV, Cohen HJ. Fatigue in older cancer patients: etiology, assessment, and treatment. Semin Oncol 2008;35:633-642. 16. Hartigan K. Patient education: the cornerstone of successful oral chemotherapy treatment. Clin J Oncol Nurs 2003;7:21-24. 17. Baker DW, Wolf MS, Feinglass J, et al. Health literacy and mortality among elderly persons. Arch Intern Med 2007;167:1503-1509. 18. Schapira MM, Fletcher KE, Gilligan MA, et al. A framework for health numeracy: how patients use quantitative skills in health care. J Health Commun 2008;13:501-517. 19. Fox S. Older Americans and the internet. Washington, DC: Pew Research Center; 2004. 20. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005;3:514-522. 21. Gates GA, Mills JH. Presbycusis. Lancet 2005;366:11111120. 22. Aldridge MD. Writing and designing readable patient education materials. Nephrol Nurs J 2004;31:373-377. 23. Banna GL, Collova E, Gebbia V, et al. Anticancer oral therapy: emerging related issues. Cancer Treat Rev 2010;36:595-605.
24. Kinnane N, Stuart E, Thompson L, et al. Evaluation of the addition of video-based education for patients receiving standard pre-chemotherapy education. Eur J Cancer Care (Engl) 2008;17:328-339. 25. Marks R. Ethics and patient education: health literacy and cultural dilemmas. Health Promot Pract 2009;10:328-332. 26. George J, Elliott RA, Stewart DC. A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications. Drugs Aging 2008;25:307-324. 27. van Vuuren PAC, Kagan SH, Chalian AA. Geriatric otolaryngology toolbox: what you and your nurse can do to improve outcomes for older adults. Ear Nose Throat J 2009;88:11621168. 28. Kripalani S, Robertson R, Love-Ghaffari MH, et al. Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Educ Couns 2007;66:368-377. 29. Rudd RE. Health literacy skills of US adults. Am J Health Behav 2007;31(suppl 1):S8-S18. 30. Lichtman SM. Chemotherapy in the elderly: are their needs being met? Therapy 2009;6:893-902. 31. Lichtman SM, Boparai MK. Potentially inappropriate medication use in elderly cancer patients. Crit Rev Oncol Hematol 2008;68(suppl 2):S40-S40. 32. Reidel K, Tamblyn R, Patel V, et al. Pilot study of an interactive voice response system to improve medication refill compliance. BMC Med Inform Dec Mak 2008;8:46. 33. Ruppar TM, Conn VS, Russell CL. Medication adherence interventions for older adults: literature review. Res Theory Nurs Pract 2008;22:114-147. 34. Malouff JM, Thorsteinsson EB, Schutte NS. The efficacy of problem solving therapy in reducing mental and physical health problems: a meta-analysis. Clin Psychol Rev 2007;27:46-57. 35. Yen Y-C, Rebok GW, Gallo JJ, et al. Depressive symptoms impair everyday problem-solving ability through cognitive abilities in late life. Am J Geriatr Psychiatry 2011;2:142-150. 36. Hoyl MT, Alessi CA, Harker JO, et al. Development and testing of a five-item version of the Geriatric Depression Scale. J Am Geriatr Soc 1999;47:873-878. 37. Rinaldi P, Mecocci P, Benedetti C, et al. Validation of the five-item geriatric depression scale in elderly subjects in three different settings. J Am Geriatr Soc 2003;51:694-698. 38. Balducci L, Extermann M. A practical approach to the older patient with cancer. Curr Probl Cancer 2001;25:7-76. 39. Moore S. Nonadherence in patients with breast cancer receiving oral therapies. Clin J Oncol Nurs 2010;14:41-47. 40. Lynch M, Marcone D, Kagan S. Developing a multidisciplinary geriatric oncology program in a community cancer center. Clin J Oncol Nurs 2007;11:929-933. 41. Boparai MK, Lichtman SM. A pilot program to improve medication management in elderly cancer patients: collaborative efforts between physicians and a pharmacist. Crit Rev Oncol Hematol 2008;68(suppl 2):S40. 42. Gilje F, Lacey L, Moore C. Gerontology and geriatric issues and trends in US nursing programs: a national survey. J Prof Nurs 2007;23:21-29. 43. Wilson LD. The American Association of Colleges of Nursing’s geriatric nursing education consortium. J Gerontol Nurs 2010;36:14-17.
Seminars in Oncology Nursing, Vol 27, No 2 (May), 2011: pp 154-160
ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS KRISTEN W. MALONEY AND SARAH H. KAGAN OBJECTIVE: Oral antineoplastic agents offer multiple advantages in cancer therapies. Thus, understanding issues of adherence to these agents for older adults becomes critical to successful comprehensive care of the older cancer patient. DATA SOURCES: This analysis of adherence to oral agents among older cancer patients draws on interdisciplinary geriatric and oncologic research reports and clinical reviews. CONCLUSION: Older adults are at increased risk for poor adherence to oral agents. Barriers to adherence are diverse. Problems emerge from age-related physical changes, comorbid conditions, polypharmacy, and drug interactions. Psychosocial barriers include limited insurance coverage and transportation problems to social isolation and inadequate social support.
IMPLICATION FOR NURSING PRACTICE: Nurses should lead interdisciplinary, individualized plans of care to mitigate barriers and support adherence to cancer therapy. KEY WORDS: Elderly, aged, adherence, oral medications, chemotherapy, patient education
DHERENCE to antineoplastic oral agents by older adults presents intertwined challenges of oncologic considerations and geriatric concerns.1 Older adults, especially those who are over 75 years of age who live alone, face many barriers to oral agent adherence.2 Among these barriers are adequate
A
access to these antineoplastic agents, sufficient knowledge of their cancer treatment and pharmacotherapy of comorbid condition to support adherence, the physical and cognitive capacity for self-administration, and risk of drug interactions and adverse events within the context of comorbid diseases and polypharmacy.1,3,4 Importantly,
Kristen W. Maloney MSN, RN: Clinical Nurse Specialist, Rhoads Three Inpatient Oncology Unit, Hospital of the University of Pennsylvania, Philadelphia, PA. Sarah H. Kagan, PhD, APRN-BC, AOCNÒ, FAAN: The Lucy Walker Honorary Term Professor of Gerontological Nursing, School of Nursing, Clinical Nurse Specialist, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA.
Address correspondence to Sarah H. Kagan, PhD, APRN-BC, AOCNÒ, FAAN, The Lucy Walker Honorary Term Professor of Gerontological Nursing, School of Nursing, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104-4217. e-mail: [email protected] Ó 2011 Elsevier Inc. All rights reserved. 0749-2081/2702-$36.00/0. doi:10.1016/j.soncn.2011.02.007
ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS
people over the age of 65 are users of the greatest proportion of all prescription drugs, including antineoplastic agents. Lichtman2 notes that older adults account for approximately 30% of drug costs annually and that about half of all medications are marketed for the geriatric population. Further barriers are specifically experienced by older adults who have limited financial resources and restricted transportation options, as well as limited fine motor capacity, and impaired memory and other cognitive capacities.5-7 Such barriers result in generalized risk of limited adherence and need for individualized plans of care to support oral agent adherence and prevention of adverse events and complications. Oral agents offer convenience and safety and are desirable for patients, their families, and clinicians alike.1,8 Irshad and Maisey8 note that patients and clinicians commonly prefer oral agents for convenience and comfort given equivalent efficacy to intravenous regimens and favorable safety records. As a result, a large proportion of antineoplastic agents in development are oral.2,4,9 Irshad and Maisey as well as Moore8,9 further point out the ability to avoid invasive treatments and attendant complications that may occur more often in older adults and the attractiveness of cost containment with oral regimens. Older adults, who may find transportation and coordination of complex ambulatory infusion regimens overwhelmingly burdensome, favor the advantages of oral agents.1 Thus, older cancer patients, who collectively account for the majority of people diagnosed with cancer, are increasingly likely to be prescribed oral antineoplastic regimens. This article integrates oncologic and geriatric concerns to adherence to oral agents for older adults. It presents implications for practice, education, research, and policy. Issues of access, knowledge, administration, and problem-solving are detailed to direct nursing and interdisciplinary care and to highlight education for older adults and their family caregivers.
ADHERENCE TO ORAL AGENTS FOR OLDER ADULTS Access Financial concerns are foremost among barriers to adherence with any oral medication prescribed to older adults. Like medications for many other chronic diseases, oral antineoplastic regimens
155
are expensive. They can often be extremely costly when the newest chemotherapeutic or targeted agents are prescribed.10,11 While the therapeutic gains of such agents are important, financially mediated poor adherence to prescribed care may negate potential therapeutic advantages. Older adults commonly live within fixed, limited incomes. As a result, they may have insufficient funds for copayments mandated for medications under insurance coverage or may have to prioritize spending on essentials such as food or utility costs.3,12 Hence, poor adherence is often the unintended consequence of combining oral agents with limited personal finances. Medicare beneficiaries now enjoy the most recent major change in benefits, called Medicare Part D. Medicare Part D was enacted in January 2006, providing prescription drug coverage through a variety of plans. Beneficiaries elect to enroll in a plan that best suits their prescription drug needs, and can alter enrollment should their needs change, though such alterations in enrollment are limited to once each year. Despite obvious advantages over no prescription drug coverage, most patients being treated for cancer, like other chronic diseases requiring often new and expensive medications, find they face gaps in the Medicare Part D because of costs for annualized treatment regimens that exceed coverage.13 Within Medicare Part D, there is a monetary limit to prescription coverage for each calendar year that varies by the available plan selected by an older patient. Those on fixed, limited incomes face a gap in coverage, better known as the ‘‘donut hole,’’ which requires them to pay out of pocket after the annual limit in coverage is met. Depending on prescription needs, this gap can occur weeks or even months before the end of the calendar year and initiation of renewed coverage with the first of the next year. Surprisingly, Madden and colleagues13 found that cost-related nonadherence to medications actually rose slightly after introduction of Medicare Part D. Hence, Medicare Part D requires careful scrutiny and must not be viewed as a panacea against financial mediated problems in adhering to oral antineoplastic agents. For some individuals, small grants offered by the American Cancer Society or other community agencies serving people with cancer or older adults and their families may bridge gaps in coverage. Additionally, pharmaceutical company prescription grants offer a useful resource for covered drugs and for eligible older patients.
156
K.W. MALONEY AND S.H. KAGAN
Transportation to obtain medications, like transportation to medical appointments and other care, also limits access and consequently impairs adherence to oral agents for some older adults.14 Older adults are less likely than younger counterparts to be independently able to navigate their communities. They may lack physical and mental capacities to safely use an automobile or lack the license and confidence to drive. Older adults may not have family and friends who can provide transportation or even obtain medications for them. Urban elders may rely on public transportation, but use of public services may be logistically difficult or unsafe for frail or fatigued individuals.6,15 Rural elders face equally complicated transportation challenges that include long distances and absent services. Additionally, while subsidized medical transportation services may be available to impoverished elders, these services almost never provide adequate flexibility and accessibility to insure medications will be obtained in a timely manner from specialized pharmacies that stock oral antineoplastic agents. Social services assessments gauge eligibility for community-based short- and long-term transportation systems often accessible through the local Area Agency on Aging or similar social services. Even those services intended for well elders may be invaluable to supporting adherence and overall outcomes of and satisfaction with care. Knowledge Knowledge to adequately schedule, ingest, and monitor response to oral agents is often exceedingly complex. Understanding oral antineoplastic regimens presents a challenge even for well-educated individuals who have no functional limitations.16 Thus, older adults who have functional limitations face the additional trial of understanding the agents prescribed, the cancer these agents treat, and the interactions with treatments taken for other chronic and acute conditions within the context of circumscribed capacity. Requisite knowledge is, however, foundational to comprehending complex matters of scheduling administration through the day and week, in addition to following prescriptions around timing vis- a-vis ingestion of food and other medications. Knowing expected response patterns and priority side effects to report, in contrast to side effects of other medications and effects of drug interaction, completes the knowledge foundation required for self-administration of oral agents. Acquiring and using this knowledge mandates
literacy, numeracy, and cognition, including executive function and memory. However, literacy, numeracy, and cognition are often limited among the current generations of older adults.17,18 Use of technologies to promote adherence further requires computer literacy. Computer literacy, while increasing in recent years, is limited among older adults.19 Patient and family education anchors adherence and cancer treatment when oral regimens are used. Assessment of health literacy and numeracy, as well as applicable issues in computer literacy and anxiety, is often the essential step overlooked in patient and family education.17 Baker and colleagues17 found significant associations between inadequate literacy and mortality among older adults, and noted that educational level is a poor indicator of literacy. They suggest fluency better assesses literacy. Weiss and colleague’s20 assessment of health literacy as the ‘‘new vital sign’’ offers a clinically useful and efficient assessment technique.20 Ideally, literacy and numeracy assessment should be combined with routine assessment of mental status, using a tool such as the Folstein Mini-Mental Status Examination at baseline.6,14 Alterations in adherence can then be understood in context of global mental function. Additionally, global assessment of hearing and vision with referral to specialists, as appropriate, are important. Marked changes from baseline or complaints about changes warrant referral and the potential need for compensatory aides.21,22 Baseline assessments of literacy, numeracy, learning style preferences, and computer literacy and access provide a strong foundation to create an individualized teaching plan. Each member of the team, including the patient, selected family or friends, and every clinician, play critical roles in successful education for self-administration of and adherence to oral agents.9 Moore9 underscores that, to promote adherence, patients prescribed oral agents must fundamentally understand how each medication works, how to take the medication, what side effects to expect and report, how to manage these side effects, and how to contact their health care provider for any follow-up questions. She further underscores the need for a full hour for education when initiating or changing therapies.9 Banna and colleagues23 extend these recommendations, suggesting that take-home information, medication diaries, and guidelines for dose reduction in
ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS
the event of side effects can augment successful patient education. A variety of teaching methods and materials targeted to the older person’s capacity, needs, and preferences must support and reinforce patient education (see Table 1).9,22,24-27 Teaching methods that match the patient’s and family or caregiver’s literacy and learning needs require evaluation of the available educational materials. Written materials that use approximately fifthgrade literacy skills and are formatted using a black, san serif font in 14-point or larger type accommodate most older adults’ visual capacity and literacy skills.22 Use of illustrations or cartoons can improve comprehension and retention, both for those older adults with low literacy skills as well as for those with adequate skills.28 Pharmaceutical companies, large hospitals and health systems, and patient advocacy organizations may have materials in video or other media format for patients with low literacy.24,25 Use of video, computer-based, or web-based materials may be less successful among older adults who are unfamiliar with computers or who do not
157
have home access to computers, CD or DVD players.19 Educating friends or family caregivers secures an additional means to support adherence to oral agents for older adults. DiMatteo5 found that social variables significantly influence adherence. For example, married individuals are more likely to adhere to medication regimens. Unmarried individuals were 1.13 times more likely to report nonadherence that married individuals. Older adults are also more likely to be socially isolated by widowhood and other losses, and, as a result, may have more factors contributing to poor adherence. Educating designated caregivers may then modify factors related to social isolation to support adherence. However, as with patients, assessing literacy, numeracy, and preferred learning styles is critical to successful engagement and education of these individuals.29 Administration Administration of oral agents, is the crux of adherence to oral treatment. Without the physical and mental capacity to ingest and metabolize oral
TABLE 1. Strategies to Improve Adherence to Oral Antineoplastic Agents Educational strategies Assess numeracy and computer literacy, as well as general literacy, for all older patients Match educational strategies to older patient’s and family caregiver’s literacy and learning preferences Insure that all educational materials are written at fifth-grade reading level or below for all older patients Include a glossary of medical terms in written educational materials to increase comprehension Write all educational materials in black using 14-point or larger sans serif font, like Arial or Calibri Use illustrated materials to help to improve information retention among all older adults Use illustrated written materials, video, and other media to support those older patients and family caregivers with low literacy skills Behavioral strategies Use a written medication schedule for all older patients who have sufficient literacy and cognitive capacity to remember and use them Try an alarmed medication box for older patients with complex regimens or for those with low literacy and numeracy Use telephone reminders provided by family members or caregivers, especially for isolated or shut-in older patients Suggest an electronic programmed telephone service in areas where available for dose and refill reminders Offer electronic, alarmed schedules for computer-literate older patients who have access to a computer Suggest using the alarm function on smart phones for older patients who use them Refer eligible older patients to a social workers who can help access Medicare home health services and services supplied through the local Area Agency on Aging (http://www.n4a.org/) Combining strategies Combine educational and behavioral strategies for optimal support of adherence Select strategies based on assessment of older patient and family caregiver capacities, skills, and preferences Ask for periodic return demonstration of behaviors and devices used to support adherence Review and revise adherence strategies used when the older patient’s status changes Data from Hartigan,16 Baker et al,17 Kinnane et al,24 George et al,26 and van Vuuren et al.27
158
K.W. MALONEY AND S.H. KAGAN
medications, older adults are at risk of not being able to adhere to and benefit from therapy before it begins. Candidates for oral therapy should be carefully selected from among all older adult patients. Lonardi and colleagues1 and Lichtman2,30 offer compelling analyses of chemotherapy use among older patients, highlighting that both biological and functional changes with age, as well as a paucity of clinical trials data with research involving older adults, may disadvantage older adults who are prescribed oral antineoplastic agents. Altered pharmacokinetics in older adults, along with a propensity for polypharmacy within this group of cancer patients, further contributes to the risk of problems in administration, absorption, and response.1,2,30,31 In fact, Jorgensen and colleagues3 suggest that polypharmacy may be associated with a decreased survival rate among older cancer patients. Older patients should be screened for adequate organ, physical, and mental function. Concerns about frailty, organ function, and capacity should trigger further specialized evaluation as well as decision-making conversations.6,14 Nurses who conduct intake interviews or other initial assessments have a critical opportunity to ascertain need for further screening and specialized assessment.7 Most ambulatory oncology care settings can conduct or refer patients for mental status examination, including recent recall, short- and long-term memory, as well as executive function. Ideally, occupational therapy and speech language pathology referrals complete specific assessment of fine motor skills and swallowing, respectively. Deficits in executive function and memory and in fine motor skills, such as those used to sort tablets or capsules for dose administration, that influence administration are often remediated with targeted interventions. Carefully planned use of devices and other technologies, in addition to available support services, may bridge gaps in older adults’ particular functional capacities (Table 1). At a very basic level, a written medication administration schedule and the written instruction that Moore9 and Banna and colleagues23 outline are essential to every older person’s oral agent adherence plans. Medication administration boxes, sometimes called pill boxes or ‘‘medi-sets,’’ can provide alarmed, timed dispensing of multiple doses per day. More elaborately, family and friends can offer telephone reminders and can visit daily when older adults are scheduled to take oral agents. Medicare home
care services and regionally specific telehealth and other services may be useful for some older adults. Social workers offer knowledge of available services and connections to those agencies, like the Area Agencies on Aging, that provide and coordinate a variety of programs. However, these services are commonly limited to those who are at least temporarily home bound. Alternatively, for those elders with independent financial means, privately paid staff or use of commercially available services may offer feasible support for adherence. Investigation of medication reminder interventions and adherence technologies is growing.26,32,33 Yet this research, systematically reviewed, shows limited evidence to select one intervention over others.26 Consequently, George and colleagues26 recommend combining an individualized set of educational and behavioral interventions to suit a specific patient’s needs to adherence and concordance. Additionally, referral to and collaboration with social workers and home service providers can establish eligibility and coverage for home, telehealth, and other electronic services including robotic aids and computerized reminder systems.26 Problem Solving Self-administration of oral antineoplastic agents requires a capacity for problem solving and judgment. Older patients must use their knowledge of the oral agents, expected response, potential side effects, and possible interactions with other medications, as well as foods, to monitor themselves, record events, and make choices about changing therapy within guidelines or contacting their treating clinicians. While clinically feasible, problem-solving assessment is not available, alterations in problem solving are associated with depression and thus, depression can serve as a proxy for some aspects of problem solving.34,35 Thus, assessment for depression to support adherence and achieve comprehensive care should be performed at baseline and on a periodic basis to insure adequacy of care and to support optimal adherence.35,36 Brief instruments along with more extensive assessments, such as the Geriatric Depression Scale, offer an array of options for screening, referral, and full assessment.36-38 However, additional support is necessary, even with adequate problem-solving skills. Older adults of the generation that experienced the Great Depression and World War II, as well as those older people who have surmounted imposing personal obstacles such as immigration, poverty,
ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS
and cumulative loss, may resort natively to selfreliance, resisting encouragement to contact clinicians with explanations of ‘‘not wanting to be a bother.’’ Problem solving and judgment may be augmented by well-timed telephone follow-up and triage of problems to members of the team, such as social workers, who can support development of new behavioral responses.9,23,39,40 Creating partnerships among physicians, advanced practice nurses, nurses, pharmacists, and social workers provides a collaborative basis for supporting problem solving and adherence among older patients. Boparai and Lichtman41 describe a multidisciplinary geriatric medication clinic, relying on the expertise of a pharmacist, to avoid potentially inappropriate medication use in patients over the age of 65 who were being treated at a tertiary cancer center. This sort of model is resource-intensive but offers a model that other facilities may adapt based on available resources. Lynch and colleagues40 describe a different model, based on the use of a geriatric social worker as the hub of the team approach, to limit threats to adherence and intervene to promote adherence and concordance. Appraisal of extant resources and patient needs may help facilities with varying needs and infrastructure to design locally relevant models to support older adult patient adherence in the setting of comprehensive cancer care.
CONCLUSION Achieving adherence to oral antineoplastic agents for older adults presents challenges to older patients and their family and other caregivers, as well as to their nurses, physicians, and other members of the interdisciplinary team. Older adults currently comprise the largest group of people diagnosed with cancer; this trend will grow as our society ages. Psychosocial barriers to adherence range from limited financial resources and gaps in prescription coverage, to low literacy and numeracy, and limited access to multi-media devices for education. Older patients also confront threats to adherence that
159
encompass biological and functional changes with age, as well as age-related comorbid conditions. Careful and detailed individualized assessment of intrapersonal and social resources grounds an interdisciplinary plan of care that targets each older patient’s particular needs. Use of assessment tools and other elements of comprehensive geriatric assessment allow for baseline data collection and comparison with repeated assessment.6,7,14,20 Engaging family and friends who are committed to supporting the older patient and who can be educated to provide support overcomes the threat of limited social support to adherence. Assessment of function and resources will direct interventions that can vary from medication schedules to use of more elaborate timed, alarmed medication administration sets and telephone follow-up. Assessing patient’s problem-solving capacity and judgment is also critical to success. Enhancing problem solving may range from one-on-one intervention to building skills through programmatic innovations such as interdisciplinary teams with targeted or comprehensive scope and aims. As our society continues to age, improved education for geriatric competence and enhanced health policy as a platform for research in adherence and concordance, and investigation of better resources and targeted technologies, is needed more than ever. Programmatic innovations offered by initiatives like the Geriatric Nursing Education Consortium and national implementation of American Association of Colleges of Nursing Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for Geriatric Nursing Care suggest oncology nurses can provide leadership in this critical aspect of oncology patient safety and quality and offer directions for future development.42,43 Nurses have long prided themselves on being excellent teachers of patients and their families. Advances in cancer care mandate that oncology nurses forge new directions in practice, education, research, and policy to provide better care and support adherence to oral agents and other treatments for our older patients.
REFERENCES 1. Lonardi S, Bortolami A, Stefani M, et al. Oral anticancer drugs in the elderly: an overview. Drugs Aging 2007;24:395-410.
2. Lichtman SM. Chemotherapy in the elderly. Semin Oncol 2004;31:160-174.
160
K.W. MALONEY AND S.H. KAGAN
3. Jorgensen TL, Hallas J, Herrstedt J. Polypharmacy in elderly cancer patients [abstract]. J Clin Oncol 2010;28(suppl 15):9074. 4. Lichtman SM, Boparai MK. Anticancer drug therapy in the older cancer patient: pharmacology and polypharmacy. Curr Treat Options Oncol 2008;9:191-203. 5. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol 2004;23:207-218. 6. Extermann M, Hurria A. Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol 2007;25:1824-1831. 7. White HK, Cohen HJ. The older cancer patient. Nurs Clin North Am 2008;43:307-322. 8. Irshad S, Maisey N. Considerations when choosing oral chemotherapy: identifying and responding to patient need. Eur J Cancer Care (Engl) 2010;19(suppl s1):5-11. 9. Moore S. Facilitating oral chemotherapy treatment and compliance through patient/family-focused education. Cancer Nurs 2007;30:112-122. 10. Aisner J. Overview of the changing paradigm in cancer treatment: oral chemotherapy. Am J Health Syst Pharm 2007;64(suppl 5):S4-S7. 11. So J. Improving the quality of oral chemotherapy services using home care. Eur J Cancer Care (Engl) 2010;19(suppl 1): 35-39. 12. Findlay M, von Minckwitz G, Wardley A. Effective oral chemotherapy for breast cancer: pillars of strength. Ann Oncol 2008;19:212-222. 13. Madden JM, Graves AJ, Zhang F, et al. Cost-related medication nonadherence and depending on basic needs following implementation of Medicare Part D. JAMA 2008;299:19221928. 14. Balducci L. Supportive care in elderly cancer patients. Curr Opin Oncol 2009;21:310-317. 15. Rao AV, Cohen HJ. Fatigue in older cancer patients: etiology, assessment, and treatment. Semin Oncol 2008;35:633-642. 16. Hartigan K. Patient education: the cornerstone of successful oral chemotherapy treatment. Clin J Oncol Nurs 2003;7:21-24. 17. Baker DW, Wolf MS, Feinglass J, et al. Health literacy and mortality among elderly persons. Arch Intern Med 2007;167:1503-1509. 18. Schapira MM, Fletcher KE, Gilligan MA, et al. A framework for health numeracy: how patients use quantitative skills in health care. J Health Commun 2008;13:501-517. 19. Fox S. Older Americans and the internet. Washington, DC: Pew Research Center; 2004. 20. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005;3:514-522. 21. Gates GA, Mills JH. Presbycusis. Lancet 2005;366:11111120. 22. Aldridge MD. Writing and designing readable patient education materials. Nephrol Nurs J 2004;31:373-377. 23. Banna GL, Collova E, Gebbia V, et al. Anticancer oral therapy: emerging related issues. Cancer Treat Rev 2010;36:595-605.
24. Kinnane N, Stuart E, Thompson L, et al. Evaluation of the addition of video-based education for patients receiving standard pre-chemotherapy education. Eur J Cancer Care (Engl) 2008;17:328-339. 25. Marks R. Ethics and patient education: health literacy and cultural dilemmas. Health Promot Pract 2009;10:328-332. 26. George J, Elliott RA, Stewart DC. A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications. Drugs Aging 2008;25:307-324. 27. van Vuuren PAC, Kagan SH, Chalian AA. Geriatric otolaryngology toolbox: what you and your nurse can do to improve outcomes for older adults. Ear Nose Throat J 2009;88:11621168. 28. Kripalani S, Robertson R, Love-Ghaffari MH, et al. Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Educ Couns 2007;66:368-377. 29. Rudd RE. Health literacy skills of US adults. Am J Health Behav 2007;31(suppl 1):S8-S18. 30. Lichtman SM. Chemotherapy in the elderly: are their needs being met? Therapy 2009;6:893-902. 31. Lichtman SM, Boparai MK. Potentially inappropriate medication use in elderly cancer patients. Crit Rev Oncol Hematol 2008;68(suppl 2):S40-S40. 32. Reidel K, Tamblyn R, Patel V, et al. Pilot study of an interactive voice response system to improve medication refill compliance. BMC Med Inform Dec Mak 2008;8:46. 33. Ruppar TM, Conn VS, Russell CL. Medication adherence interventions for older adults: literature review. Res Theory Nurs Pract 2008;22:114-147. 34. Malouff JM, Thorsteinsson EB, Schutte NS. The efficacy of problem solving therapy in reducing mental and physical health problems: a meta-analysis. Clin Psychol Rev 2007;27:46-57. 35. Yen Y-C, Rebok GW, Gallo JJ, et al. Depressive symptoms impair everyday problem-solving ability through cognitive abilities in late life. Am J Geriatr Psychiatry 2011;2:142-150. 36. Hoyl MT, Alessi CA, Harker JO, et al. Development and testing of a five-item version of the Geriatric Depression Scale. J Am Geriatr Soc 1999;47:873-878. 37. Rinaldi P, Mecocci P, Benedetti C, et al. Validation of the five-item geriatric depression scale in elderly subjects in three different settings. J Am Geriatr Soc 2003;51:694-698. 38. Balducci L, Extermann M. A practical approach to the older patient with cancer. Curr Probl Cancer 2001;25:7-76. 39. Moore S. Nonadherence in patients with breast cancer receiving oral therapies. Clin J Oncol Nurs 2010;14:41-47. 40. Lynch M, Marcone D, Kagan S. Developing a multidisciplinary geriatric oncology program in a community cancer center. Clin J Oncol Nurs 2007;11:929-933. 41. Boparai MK, Lichtman SM. A pilot program to improve medication management in elderly cancer patients: collaborative efforts between physicians and a pharmacist. Crit Rev Oncol Hematol 2008;68(suppl 2):S40. 42. Gilje F, Lacey L, Moore C. Gerontology and geriatric issues and trends in US nursing programs: a national survey. J Prof Nurs 2007;23:21-29. 43. Wilson LD. The American Association of Colleges of Nursing’s geriatric nursing education consortium. J Gerontol Nurs 2010;36:14-17.