AIDES to Improving Medication Adherence in Older Adults Brenda Bergman-Evans, PhD, APRN, BC Medication regimens for older adults are often complex and costly. Designing, implementing, and maintaining an appropriate treatment regimen is challenging. The AIDES method is built on the principles of completing a comprehensive medication Assessment; partnering with patients to ensure Individualization of the regimen; choosing appropriate Documentation; providing accurate and ongoing Education tailored to the age group and needs of the individual; and continuing Supervision after initiation. (Geriatr Nurs 2006;27:174-182) edication use by older adults is a frequent topic of concern. For independent community-dwelling older adults, two-thirds take at least 1 medication daily and one-fourth average 3 drugs.1 For individuals living in the community but requiring assistance with activities of daily living, 71% take 3 to 7 medications per day, and 15% take 8 or more.2,3 The average nursing home resident routinely takes an average of 7 scheduled plus 3 asneeded medications; however, more than a fourth of these individuals (27.2%) take 9 or more medications.4 Older adults are also major consumers of over-the-counter (OTC) and complementary medications such as laxatives, pain medication, vitamins, and herbs.5,6 Because these products do not require a prescription, they may not be viewed as either medicine or as important. Older adults often fail to report the use of these agents to the primary health care provider.5,6 Many OTC and complementary products have similar actions to prescribed medications, so use of these substances by the older adults may influence adherence and safety. Multiple medication use is viewed as the norm for many older clients.7 Increasing age is often accompanied by chronic disease, and medications are frequently the primary treatment modality for chronic illnesses. At least 80% of senior citizens have 1 or more chronic conditions. For individuals aged 65 and older, almost two-thirds (62%) had 2 or more conditions,
M
174
and the prevalence in 80 year olds jumps to 70%.8 Diuretics, antipsychotics, anxiolytics, potassium supplements, digoxin, nonsteriodal anti-inflammatory drugs, insulin, theophylline, H2 blockers, anti-infectives, anticonvulsants, and thyroid supplements9 are frequently mainstays of chronic care but may place the individual at an increased risk for adverse drug reactions. Chemophilia, or placing great value on the power of pills and potions,10,11 may be a major factor contributing to the high consumption of medications. Additional factors include multiple providers and pharmacies, lack of a primary provider coordinator, drug regimen changes, and self-treatment.10,12 Clearly, older adults who take many medications are at an increased risk of experiencing side effects and drug-drug interactions.13,14 The polypharmacy phenomenon is often closely associated with poor adherence.12 Nonadherence may be purposeful (perceived as not needed, ineffective, or unsafe) or unintentional (inability to access, forgetting, interruption of routine, or lack of reminders).15 Clients may actually make a personal cost-benefit analysis of whether to follow instructions so that what may seem an irrational act to the provider is in fact a rational act for the client. Nonadherence may have significant consequences and take the form of overuse or disuse. Taking medications that are not ordered or taking different dosages of medications are common discrepancies that can threaten the therapeutic outcome as drugs fail to achieve expected goals.17 Nonadherence may lead to adverse drug reactions with subsequent need for relocation, increased physician office or ambulatory care visits, emergency room visits, and hospitalizations.18-21 Despite the fact that medication adherence has received considerable attention from clinicians and researchers, no clear evidencebased interventions have been found for all clients.22-25 A meta-analysis of 153 studies related to exercise, medication, diet, and appointment keeping (1977–1994) found that any intervention had a positive effect and that a
Geriatric Nursing, Volume 27, Number 3
Table 1. AIDES Model for Improving Medication Adherence for Older Adults A: Assessment Completing a comprehensive medication assessment I : Individualization Partnering with patients to ensure individualization of the regimen D: Documentation Choosing appropriate documentation to assist with communication between patient and provider(s) E: Education Providing accurate and ongoing education tailored to the age group and needs of the individual S: Supervision Continuing supervision of the medication regimen
combined focus resulted in larger results than did single-focus interventions.23 For example, an adherence intervention that included receiving telephone reminders from a family member, recording of medication adherence on a calendar, and getting updated information on the medication regimen at each visit to the health care provider, would likely have a greater impact in combination than any of the 3 components alone. In a Cochrane review of interventions for helping clients to follow prescriptions, Haynes and colleagues24 suggested that both short-term, simpler regimens and complex strategies including combinations of strategies could improve adherence and treatment outcomes. Nonetheless, an improved effectiveness for adherence with long-term medication prescriptions was not maintained even with the investment of significant effort and resources.24 Although medication adherence is not exclusively controlled by health care providers or amenable to a single strategy, the utilization of theory and research interventions matched to the patients needs has the potential to improve the process. The purpose of this article is to share the investigator developed AIDES (Assessment, Individualization, Documentation, Education, and Supervision) method for use by health care providers and nursing professionals to assist in improving short- and long-term medication adherence with older adult clients. This model builds on evidence-based practices from the professional literature and offers health professionals a number of strategies to assist in improving medication adherence for older adults. By addressing these concepts as described in Table 1, we have the opportunity to intervene and improve the care provided to this special population.
THE AIDES TOOL
Assessment Mental Status Assessment Clients with impaired cognitive status are at risk for problems with medication adherence.26 Routine screening for cognitive deficits is important to providing quality care to older adults. The Mini-Mental Status Exam 27 or a similar tool may alert the professional to potential problems and help them to understand why therapies either have been unsuccessful or are in need of change. Although a deficit in cognitive ability does not preclude medication adherence, it may make it more of a challenge and require the adoption of alternate plans. Medication trays or drug calendars may be more effective interventions for persons experiencing deficits in the language area than oral or written instructions.28 Reminders by family members or friends29 may be an option for older adults experiencing problems with orientation. Individuals with calculation and recall deficits may benefit from prefilled pill boxes.25 Brown-Bag Assessment The “brown-bag assessment” is a well-established method of providing information regarding the medication regimen.30,31 Better decisions are made when all medications (herbs, vitamins, ointments, prescriptions, and nonprescriptions) are available and evaluated in original containers.30,31 This review is pertinent in all settings, especially at initial visits. Telephone reminders before appointments that explain the process and stress the importance of the “brown-bag” assessment
Geriatric Nursing, Volume 27, Number 3
175
should improve participation by the older adult.32 Results of the Brown bag Assessment should be compared with the Beer’s list33,34 for appropriateness. If either high-risk medications or discrepancies from the Beer’s list are found, safer alternatives should be sought or the medications discontinued. Adherence Asking in a nonjudgmental manner how often doses are missed is the simplest and most practical method to establish what the older individual is taking.35 Although clients may respond with what they think the provider wants to hear, the following type of approach may make them feel comfortable enough to answer honestly: “Many people have trouble remembering to take medications regularly. How often do you miss taking your medications?”35 It is important to keep in mind that forgetting is the most common reason for missed doses.36 Other useful assessment procedures for nonadherence include reviewing clients’ calendars or diaries to determine adherence, selecting a medication with a known start date and counting pills, or ascertaining daily routines that the client has established to help with remembering medications.37 Table 2 lists external and internal cues that may be helpful when tailoring a plan for clients with adherence problems.38 Assessment of Medication-Taking Ability A comprehensive assessment of older adults’ ability to self-administer their own medications can be ascertained with the standardized and validated DRUGS (Drug Regimen Unassisted Grading Scale).20 The 4 steps of the DRUGS are included in Table 2. The DRUGS can be administered in any setting and takes only 4 to 5 minutes. The tool has been found to have both interrater (⬎90%) and test-retest reliability.20 Table 2 also lists clinical methods, education, and devices to use when deficits are identified with the tool.
Individualization Health care providers and nursing personnel can promote medication adherence by developing collaborative relationships with the client.46 Individualization of the medication regimen depends on knowledge of the client’s routines and abilities but also on a trusting relationship be-
176
tween health care staff and the client as well as his or her family. Researchers have found a consistent positive association between perceived communication with the health care professional and the proportion of clients with correct knowledge and compliance.47-49 Clients are more likely to adhere with individual medication schedules50 that they perceive as needed, effective, and safe.15,16 Cooperative client-provider relationships that support a quality plan of care rather than attempting to increase adherence can also reduce the incidence of adverse drug reactions.51 Clients should be asked about adherence at every visit to determine whether barriers exist.52 When nonadherence is identified, the plan of care should be adjusted to address root causes such as side effects, complicated regimens, or client uncertainty regarding the purpose of the therapy.22,29,52 The individualization of care and partnering with the client is especially important when medications are initiated or changed. Given the importance of and time required for assessment and management of medication regimens, use of a team approach is desirable.7,22 Registered nurses in office settings, assisted living, nursing homes, and home care often gain pertinent information regarding medication adherence during their assessment. Goals of nursing assessment of medications for older adults include identifying actual medication-taking behaviors and factors interfering with the prescribed regimen, as well as detecting the presence of adverse medication effects and the identification of opportunities for health education.53 By identifying pharmaceutical care issues, pharmacists also add a valuable dimension in the quest for the clarification of adherence challenges and improved clinical outcomes.54,55 Cost The cost of medications for older adults has frequently been cited as a factor in adherence.21,36,56 Medicare Part D, which took effect January 1, 2006, is designed to help with the challenges of medication costs for older adults. There is variability among these plans and often significant confusion regarding the enrollment process and the impact that enrollment will have on specific individuals. Table 3 present steps to follow for clients enrolling in Medicare Part D as well as important Web sites for ob-
Geriatric Nursing, Volume 27, Number 3
Table 2. Interventions for Identified Medication Taking Deficits* Steps
Forgetting
Identification: the client selects the appropriate medication Access: the client is able to open the appropriate container Dosage: the client is able to dispense the correct number per dosage
Timing: the client is able to demonstrate the appropriate timing of doses on a piece of paper marked with times
● Possible interventions ● Underlying premise: Keep it simple ● Plans and devices will not overcome a complicated regimen Cues ● Automated dispenser with voice-activated message Pills ● Charts and written instructions ● Leave the pills in a prominent place ● Relate pill taking to usual activities ● Plan medication taking around activities at the beginning of the day ● Concentrate hard to learn medication times ● Reread instructions to increase recall ● Read regimen instructions slowly ● Mentally repeating instructions ● Concentrate hard when receiving instructions ● Try hard to learn about new medications ● Caregiver preparation of a pill organizer. ● Careful labeling ● Color-code of pill bottles and tray Non-child-resistant caps ● Once daily dosing ● Daily dose reminder devices ● Monitored dosage systems ● Combination tablets ● Alternative delivery methods such as patches Devices ● Less complicated is preferable ● Adaptable to regimen changes is desirable ● Talking prescriptions ● Daily phone or videoconference reminders
*Data from Edelberg HK, Shallenberger E, Hausdorff JM, et al.20; Fulmer, Feldman, Kim, et al.25; Winland-Brown and Valiante39; McGraw and Drennan40; Salzman41; Eisen, Miller, Woodward, et al.42; Sweetman, Howard, O’Neill43; Melikian, White, Vanderplas, et al.44; Dezii.45
taining information. It is unclear what impact Medicare Part D will have on prescriptive habits of providers or medication adherence of older individuals. Nevertheless, prior research has indicated that neither compliance nor appropriate prescriptive drug use are ensured by prescription drug coverage.58 Polypharmacy may actually be increased by a combination of chemophilia10,11 and increased drug availability.
Documentation Although the importance of an accurate medication list is believed to be an important refer-
ence for the client as well as other members of the health care team,59 the reality of how to create, review, and update it remains a challenge in everyday practice. An up-to-date and easily accessible and transportable form is the ideal. Computers may also be used to create a medication page for each client that is updated at each visit by both the client (while waiting for their appointment) and the provider if medications are added, discontinued, or changed.61 A new sheet could then be generated and provided to the client before leaving the office, and—just as important—the old one should be discarded.
Geriatric Nursing, Volume 27, Number 3
177
Table 3. Steps to follow for selecting Medicare Part D Step
Resources and Considerations
Step 1: Determine what drug plans are available in the area Step 2: Coverage
Step 3: Convenience Step 4: Costs Step 5: Peace of mind
● ● ● ● ● ● ● ●
Medicare Rx Drug Plan Finder: www.medicare.gov www.shiptalk.org provides assistance with enrollment (800) MEDICARE Are patients’ prescriptions covered in the plan? ● Patients need to know the drugs name, indication, dosage, and schedule Is the patients pharmacy a part of the plan’s network? How much will be covered? What are the monthly premiums? Does the coverage protect them from higher drug costs in the future?
Data from Department of Health and Human Services.57
Education Education about clients’ medication does not guarantee adherence.62 However, they need at least a minimum amount of information regarding prescribed medications to be a partner in their own care. Two health education axioms may help when considering medication education for older adults: first, people learn in different ways; second, a variety of teaching approaches increase learner interest.23 Medication information comes to the client from many sources.16,79 Some are traditional— from physicians, nurse practitioners, nurses, pharmacists, or drug information pamphlets. Other information comes from less traditional sources, such as the neighbor, the media, colleagues, family members, and, more recently, the Internet. To maximize the impact of educational efforts, it is necessary to first identify what clients know about their medications and then address areas needing clarification of identified as deficits.63 An increased understanding of conditions and medications may encourage clients to persevere with treatment.15, 64 Older adults want specific information especially related to details of how the prescription will address their symptoms and if a new medication will interact with other medications.12,65 They also want to know the rates of side effects of prescribed medications.16, 66 Clients need realistic information on the chance of occurrence of side effects, expected duration, and methods to counteract or
178
tolerate the side effects.29,59 Side effects may at times be used to the client’s advantage.60 For instance, if an older adult suffered from depression, anorexia, and insomnia, a good choice of an antidepressant would be one that had side effects that increased appetite as well as caused somnolence. In a study of schematic organization of medication-taking information for older adults, recall has been found to be related to schema and verbal skills.6,67 Morrow and associates67 identified the schema outline in Table 4 as the most accurate for older adults. Possible strategies to use when implementing the schema are also included in the table. In 1988, Hayes68 effectively increased older adult’s knowledge of medications interventions by employing the Morrow and colleagues67 schema. In her study of older adults who visited the emergency room, the following geragogy-based principles were added: provide an individualized 1-page instruction sheet69,70 printed in a 14-point font size71 with a reading level of grade 5.1,72,73 remove extraneous information, and deliver the information in a quiet environment. Hayes’68 use of more than 1 educational strategy in teaching older adults about medications has been endorsed as a possible strategy for improving compliance.23 Additionally, the potential for drug interactions with over-the-counter drugs, alcohol, and caffeine needs to be a critical component of the educational care plan.72
Geriatric Nursing, Volume 27, Number 3
Table 4. Schema for Teaching Older Adults About Medications Medication Both trade and generic name Purpose ● Why the drug is necessary ● Disease ● Expected action ● How will patient know it is working Dose ● Units, milligrams, etc ● Number of pills Schedule ● Number of times per day, week, and/or month ● Routine or as needed Duration ● How long will it be needed? ● Take it all or stop when feeling better? Warnings ● Food or medication interactions ● Over-the-counter, herbal, and vitamin interactions ● Sunlight ● Activity Mild side effects ● Most common ● Duration ● Possible remedies Severe side effects ● Most common ● What to do if occur Doctor name ● Primary care provider Emergency ● Plan for worst-case scenario Data from Mokgele, du Rand66; Morrow, Leier, Andrassy, et al.67
The development of generic medication education material that can be individualized to client needs is particularly useful in the clinical setting. Using pictures or symbols on medication schedules for clients who are illiterate or hearing impaired and reinforcing medication teaching at regular intervals through home visits or phone calls are additional education methods that have been suggested.73 Simple sentences, no conjunctions or compound sentences, and a singular focus on essential information also aid in understanding.56,73 To ascertain reading level of client education material, standard formulas for calculation such
as the Fry Readability Graph74 or the McLaughlin SMOG Grading Formula75 may be used. An alternative method is to select a few areas of text from the handout and test them using the “reading level” function that is available with most computer word-processing programs. Environment and time of day may also influence learning and should be taken into consideration when planning medication education. Late morning has been suggested as the best time for teaching.76 Group education has been shown to produce moderately strong effects for compliance and utilization23,75 and may be appropriate for commonly experienced conditions such as diabetes or hypertensive medication. Many older adults require help with their medications. Spouses or adult children usually provide this assistance.36 Therefore, family members and significant others or proxies should be involved in the medication education process.6 By promoting caregiver participation and providing concise and unambiguous educational information in relation to medications, adherence may be improved.77
Supervision Client knowledge and adherence gained from education interventions is often not sustained.70 Consequently, supervision and ongoing education have a positive effect on medication adherence.62 In office settings, this process is often started with the nursing staff’s review of the medication list for accuracy and followed by the health care provider’s evaluation of whether the medication still matches the goals of therapy. An imperative part of supervision is maintaining the simplest medication regimen possible.52 The criteria set forth by Hamdy and associates78 for reviewing medication lists is an effective method for determining the continuing appropriateness of a medication (Table 5). If answers to any of the questions are yes, adjustments or discontinuance of the prescription should be considered. Careful consideration of answers to inquiries about symptoms in the standard review of systems may also be helpful for identifying side effects of medications that may be at the root of nonadherence. For instance, asking a person about a cough is standard for most providers seeing clients with congestive heart failure; the information gleaned is also relevant for investi-
Geriatric Nursing, Volume 27, Number 3
179
Table 5. Criteria for Continue Appropriateness of Medications Is the diagnosis still present? Are there duplications? Is this the simplest plan? Are adverse drug reactions present? Has the dosage been adjusted for age and renal status? Data from Hamdy, Moorse, Whalen, et al.78
gating a common side effect for angiotensinconverting enzyme inhibitors.
Summary Medication adherence is a challenging clinical problem for health care providers who care for older adults. The AIDES model builds on published interdisciplinary research and theory designed to optimize medication adherence and safety and is an intervention directed at factors under the control of health care providers and nurses caring for older adults who require medication therapy. Careful assessment to identify problems to be addressed, individualization based on the knowledge and needs of the client, documentation directed at currency and accuracy, education of the client and caregiver, and supervision and revision of the medication plan as needed are measures that should help to improve medication adherence.
References 1. US Food and Drug Administration. Medications and older adults: Improving Health Through Human Drugs. Rockville, MD: 1999. 2. Flaherty JH, Perry HM, Lynchard GS, et al. Polypharmacy and hospitalization among older home care patients. J Gerontol Med Sci 2000;55A:M554-9. 3. Quinn ME, Johnson MA, Andress EL, et al. Health characteristics of elderly personal care home residents. J Adv Nurs 1999;30:410-7. 4. Tobias DE, Sey M. General and psychotherapeutic medication use in 328 nursing facilities: a year 2000 national survey. Consult Pharmacist 2001;16: 54-64. 5. Astin JA, Pelletier, KR, Marie A, et al. Complementary and alternative medicine use among elderly persons: one-year analysis of a Blue Shield Medicare supplement. J Gerontol Med Sci 2000;55A:M4-M9. 6. Ellor JR, Kurz DJ. Misuse and abuse of prescription and nonprescription drugs by the elderly. Nurs Clin N Am 1982;17:319-30.
180
7. Cameron KA, Richardson AW. A guide to medication and aging. Generations 2000;24:8-21. 8. NGNA Center for Best Practices. Fast facts: wellness and disease management. Available at http://www.nga. org/cda/files/0401cifactsWellness.pdf. Cited August 26, 2005. 9. Classen DC, Pestonik SL, Evans RS, et al. Adverse drug events in hospitalized patients. JAMA 1997;277: 301-6. 10. Cooley CA, Lucas LM. Polypharmacy: the cure becomes the disease. J Gen Int Med 1993;8:278-83. 11. Lamy P. Prescribing for the elderly. Baltimore, MD: PSG, 1980. 12. Bedell SE, Jabbour S, Goldberg R. Discrepancies in the use of medications. Arch Int Med 2000;160:2129-34. 13. Beers MH. The medication list—A portrait of a patient’s health. J Gerontol 2000;55A:M549. 14. Garnett W. Polytherapy: quality or concern? Long-term care interface. 2005(February);12-14. 15. Johnson MJ, Williams M, Marshall ES. Adherent and nonadherent medication-taking in elderly hypertensive patients. Clin Nurs Res 1999;6:318-35. 16. Donovan JL, Blake DR. Patient non-compliance: Deviance or reasoned decision-making? Soc Sci Med 1992;34:507-13. 17. National Council of Patient Information and Education. Prescription medicine compliance: a review of baseline knowledge. Washington, DC: Author, 1995. 18. Hanlon JT, Schmader KE, Koronkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc 1997;45:945-8. 19. Hohl CM, Dankoff J, Colacone A, et al. Polypharmacy adverse drug-related events and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med 2001;38:66671. 20. Edelberg HK, Shallenberger E, Hausdorff JM, et al. One-year follow-up of medication management capacity in highly functioning older adults. J Gerontol Med Sci 2000;55a:M550-3 21. Col N, Finale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Int Med 1990;150: 841-5. 22. Becker MH, Maiman LA. Strategies for enhancing patient compliance. J Comm Health 1980;6:113-25. 23. Roter DL, Hall JA, Merisca R, et al. Effectiveness of interventions to improve patient compliance: a metanalysis. Med Care 1998;36:1138-61. 24. Haynes RB, McDonald H, Garg AX, et al. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev 2002(2). 25. Fulmer TT, Feldman PH, Kim TS, et al. Enhanced medication compliance. J Gerontol Nurs 1999;24:6-14. 26. Park DC, Hertzog C, Leventhal H, et al. Medication adherence in rheumatoid arthritis patients: older is wiser. J Am Geriatr Soc 1999;47:172-83. 27. Folstein M. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.
Geriatric Nursing, Volume 27, Number 3
28. Slelma T, Rochon PA. Pharmacotherapy. Geriatr Rev Syllabus. 5th edition. American Geriatric Society: Blackwell; 2002. 29. Burke MM, Laramie, JA. Primary care of the older adult: a multidisciplinary approach. St. Louis: Mosby; 2000. 30. Colt HG, Shapiro AP. Drug induced illness as a cause for admission to a community hospital. J Am Geriatr Soc 1989;37:323-6. 31. Fillit H, Futterman R, Orland BI, et al. Polypharmacy management in Medicare managed care: changes in prescribing by primary care physicians resulting from a program promoting medication review. Am J Managed Care 1999;5:587-94. 32. Planning a brown bag event. National Association of Retail Druggists J Suppl 1993;115:1-2. 33. Beers MF, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Int Med 1991;151: 1825-31. 34. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Int Med 2003;163:2716-24. 35. Osterberg L, Blashke T. Adherence to medication. N Engl J Med 2005;353:487-97. 36. Conn VS, Taylor SG, Kelley S. Medication regimen complexity and adherence among older adults. Image 1991;23:231-5. 37. OBQI Tips: improvement in the management of oral medications. Available at http://www.mrnc.org/ mrnc_web/mrnc/homehealth.aspx?ID⫽Downloads. Cited Jan. 1, 2006. 38. Gould ON, McDonald-Miszczak L, King B. Metacognition and medication adherence: how do older adults remember? Exp Aging Res 1997;23:315-42. 39. Winland-Brown JE, Valiante J. Effectiveness of different medication management approaches on elders’ medication adherence. Outcomes Nurs Pract 2000;4:172-6. 40. McGraw C, Drennan V. Self-administration of medicine and older people. Nurs Stand 2001;15:33-6. 41. Salzman C. Medication compliance in the elderly. JClin-Psychiatry 1995;56(suppl 1):18-22. 42. Eisen SA, Miller DK, Woodward RS, et al. The effect of prescribed daily dose frequency on patient medication compliance. Arch Int Med 2000;150:1881-4. 43. Sweetman L, Howard D, O’Neill D. Once-daily medications for older patients in the general hospital. JAGS 1999;47:629. 44. Melikian C, White TJ, Vanderplas A, et al. Adherence to oral antidiabetic therapy in a managed care organization: a comparison of montherapy combination therapy and fixed-dose combination therapy. Clin Ther 2002;24:460-7. 45. Dezii CM. A retrospective study of persistence with single-pill combination therapy vs concurrent two-pill therapy in patients with hypertension. Managed Care 2001;10(suppl):6-10. 46. Wood W, Gray J. An integrative review of patient medication compliance from 1990-1998. Online J Knowledge Synthesis Nurs 2000;7:Document Number 1.
47. German PS, Klein LW, McPhee SJ, et al. Knowledge of and compliance with drug regimens in the elderly. J Am Geriatr Soc 1982;30:568-71. 48. Hausman A. Taking your medicine: relational steps to improving patient compliance. Health Marketing Q 2001;19:49-71. 49. DiMatteo MR. Patient adherence to pharmacotherapy: the importance of effective communication. Formulary 1995;30:596-8, 601-2, 605. 50. Esposito L. The effects of medication education on adherence to medication regimens in an elderly population. J Adv Nurs 1995;21:935-43. 51. Carbonin P, Pahor M, Bernabei R, Sgadari A. Is age an independent risk factor of adverse drug reactions in hospitalized medical patients? J Am Geriatr Soc 1991; 39:1093-9. 52. Dezii C. Medication noncompliance: what is the problem? Managed Care Suppl 2000;9:7-12. 53. Miller C. Safe medication practices: nursing assessment of medications in older adults. Geriatr Nurs 2003;24:314-15, 317. 54. Krass I, Smith C. Impact of medication regimen review performed by community pharmacists for ambulatory patients through liaison with general medical practitioners. Int J Pharm Pract 2000;8:111-20. 55. Krska J, Cromarty JA, Arris F, et al. Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary care. Age Ageing 2001;30: 205-11. 56. Coons SJ, Sheahan SL, Martin SS, et al. Predictors of medication noncompliance in a sample of older adults. Clin Thera 1994;16:110-17. 57. Department of Health and Human Services. Medicare RX: prescription drug coverage. Author: Public No.l CMS-11181: October, 2005. 58. Culp K. Reshaping Medicare-prescription drug coverage for elderly adults. Journal of Gerontol Nurs 2004;30:3. 59. Sapio-Longo L. Health promotion for the elderly. Gerontological nursing: an advance practice approach. SL Molony, CM Wasznski, CH Lyder, editors. Stamford, CT: Appleton & Lange; 1999. 60. Brummel-Smith, K. Polypharmacy and the elderly patient. Arch Am Acad Orthop Surg 1998;2:39-44. 61. Raynor DK, Booth DG, Blenkinsopp A. Effects of computer generated reminder charts on patients’ compliance with drug regimens. Br Med J 1993;306: 1158-61. 62. Devine EC, Reifschneider E. A meta-analysis of the effects of psychoeducational care in adults with hypertension. Nurs Res 1995;44:237-45. 63. Ryan AA, Chambers M. Medication management and older patients: an individualized and systematic approach. J Clin Nurs 2000;9:732-41. 64. Walker MK, Foreman MD. Medication safety: a protocol for nursing action. Geriatr Nurs 1999;20:34-9. 65. Schmader K, Hanlon JT, Weinberger M, et al. Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994;42: 1241-7. 66. Mokgele E, du Rand PP. Maintaining compliance at home: helping the elderly with their medications. Curationis S Afr J Nurs 2000;23:72-5.
Geriatric Nursing, Volume 27, Number 3
181
67. Morrow DG, Leier VO, Andrassy JM, et al. Medication instruction design: younger and older adult schemas for taking medication. Hum Factors 1996;38:556-73. 68. Hayes KS. Randomized trial of geragogy-based medication instruction in the emergency department. Nurs Res 1988;47:211-8. 69. Taira F. Teaching independently living older adults about managing their medications. Rehabil Nurs 1991; 16:322-6. 70. Wendt DA. Evaluation of medication management interventions for the elderly. Home Healthcare Nurse 1998;16:612-7. 71. Sorenson HM. Medication management and older adults. AARC Times 1997;21:60-3. 72. Jones BA. Decreasing polypharmacy in clients most at risk. AACN Clin Issues 1997;8:627-34. 73. Weinrich SP, Boyd M. Education in the elderly. J Gerontol Nurs 1992;18:15-20. 74. Fry E. Fry readability graph: clarification, validity, and extension to level 17. J Reading 1977;21:242-52, 260. 75. McLaughlin GH. SMOG grading—a new readability formula. J Reading 1969;12:639-46.
182
76. Wynen EA. A key to successful aging: learning-style patterns of old age. J Gerontol Nurs 2001;2:6-15. 77. Boyle E, Chambers M. Medication compliance in older individuals with depression: gaining the view of family careers. J Psychiatr Ment Health Nurs 2000;7:515-22. 78. Hamdy R, Moore SW, Whalen K, et al. Reducing polypharmacy in extended care. South Med J 1995;88: 534-8. 79. Steiner JF, Earnest MA. Lingua medica: the language of medication-taking. Ann Int Med 2000;1322:926-30.
BRENDA BERGMAN-EVANS, PhD, APRN, BC, is Coordinator of the Nursing Home Network Alegent Health Home Care and Hospice. In compliance with national ethical guidelines, this author has indicated that she has no financial relationships with business or industry. 0197-4572/06/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2006.03.003
Geriatric Nursing, Volume 27, Number 3