- Email: [email protected]
Objective evaluation of applying eye drops by elderly patients
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Original article
Objective evaluation of applying eye drops by elderly patients夽 J. Colomé-Campos a,∗, I. Martínez-Salcedo a, M.C. Martorell-Hallado b , P. Romero-Aroca c a b c
Servicio de Oftalmología, Hospital Comarcal de Mora, Mora d’Ebre, Spain Universidad Rovira y Virgili, Tortosa, Spain Servicio de Oftalmología, Hospital Universitario San Juan, Reus, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: To objectively evaluate the ability and skills of patients older than 65 years to
Received 24 June 2013
successfully administer a topical ocular eye drop.
Accepted 9 February 2014
Methods: A prospective study was conducted on a group of 25 patients with a diagnosis of
Available online 12 August 2014
dry eye or glaucoma, undergoing daily treatment with eye drops for at least one year. The procedure was recorded with a video camera at the time of the application.
Keywords:
Results: Of the total, 64% were diagnosed with glaucoma and 36% with dry eye. Almost half
Eye drops
(44%) needed a single attempt to apply the drop, and 56% required 2 attempts. In terms of
Glaucoma
the number of eye drops applied, 52% managed with a single drop, 16% 2 drops, 12% 3 drops,
Dry eye
and 20% 4 or more eye drops. Areas where the eye drop was deposited in the first attempt
Therapeutic compliance
was 32% into the conjunctival sac, 32% on the outer corner of the eye, 8% in the inner angle,
Senescence
8% in the nose, 12% on the cheek, 8% in other areas. Conclusions: Self-administration of eye drops by the elderly is a complex activity that can have an effect on the expected results. ˜ © 2013 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.
Evaluación objetiva de la aplicación de colirios en personas mayores ˜ de 65 anos r e s u m e n Palabras clave:
˜ Objetivo: Evaluar las habilidades y destrezas de los pacientes mayores de 65 anos en el
Colirios
momento de instilarse un tratamiento ocular en forma de colirio.
Glaucoma
Métodos: Se realizó un estudio prospectivo sobre un grupo de 25 pacientes afectos de ojo
Ojo seco
˜ de evolución seco o de glaucoma en tratamiento diario con gotas con, por lo menos, un ano
Cumplimento terapéutico
a los que procedimos a grabar con una cámara de vídeo en el momento de la instilación.
Senectud
Resultados: Un 64% del total estaban diagnosticados de glaucoma y un 36% de ojo seco. Un 44% necesitaron un único intento para aplicarse la gota y un 56%, dos intentos. En cuanto al número de gotas instiladas, un 52% se instilaba una única gota, un 16% dos gotas,
夽
Please cite this article as: Colomé-Campos J, Martínez-Salcedo I, Martorell-Hallado M, Romero-Aroca P. Evaluación objetiva de la ˜ aplicación de colirios en personas mayores de 65 anos. Arch Soc Esp Oftalmol. 2014;89:177–181. ∗ Corresponding author. E-mail address: [email protected] (J. Colomé-Campos). ˜ 2173-5794/$ – see front matter © 2013 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.
178
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
un 12% 3 gotas y un 20% cuatro o más gotas. Las zonas donde se depositó la gota en el primer intento fue en un 32% en el saco conjuntival, en un 32% en el ángulo externo del ojo, en un 8% en el ángulo interno, en un 8% en la nariz, en un 12% en la mejilla y en un 8% en otras zonas. Conclusiones: La autoadministración de colirios en la población de la tercera edad se presenta como una actividad compleja que puede modificar los resultados esperados. ˜ de Oftalmología. Publicado por Elsevier España, S.L.U. Todos © 2013 Sociedad Espanola los derechos reservados.
Introduction One of the effects of aging is a progressive reduction of psychomotor skills as a consequence of physical and cognitive deterioration, the appearance of various types of chronic diseases or psychosocial changes that prevent or inhibit the execution of numerous daily activities. In a study carried out in Cuba, Pérez and García1 observed that 69.6% of individuals over 60 have at least one chronic disease, while 13.9% exhibited some sense organ alteration which inhibited the ability to carry out actions requiring a certain degree of dexterity and skill. In the USA, data published in 1998 demonstrated that 30–40% of people over 85 exhibited some psychomotor or cognitive dysfunction. The most frequently altered cognitive functions are short, medium or long term memory, language areas, manual skills and brain functions for resolving problems.2 Together with eyesight, some of the said skills play a very important role in meeting the 6 steps recommended by the General Counsel of Pharmaceutical Societies of Spain for adequate administration of eye drops.3 These are: washing of hands, reclining the head backward, slightly pressing the lower eyelid downward, applying the drop in the conjunctival sac, closing the eye and slightly pressing the lacrimal duct a few seconds and, if a concurrent treatment has been prescribed, wait 5 min between both. It must be taken into account that said maneuvers must be executed with eye drops contained in small dispensers which require adequate orientation, approach and a given amount of pressure. Accordingly and considering that the majority of chronic treatments we prescribe are for the elderly, we should take into account when prescribing eye drops the difficulty our patients may experience for adequately applying said eye drops on the ocular surface. Severe dry eye and mainly glaucoma are 2 diseases which require prolonged and meticulous treatment to preserve in some cases the integrity of vision.4 Due to the progressive increase of life expectancy, these 2 diseases are increasing in prevalence as attested by the numerous products available in the pharmaceutical market. For instance, glaucoma currently accounts for 6.7–21% of causes of blindness.5 In addition, approximately 5% of the adult population requires medical attention due to dry eye discomfort and 30% experiences symptoms in ordinary situations such as air conditioning environments, use of contact lenses, medication and wind.6 Psychomotor skills and vision are important for selfadministering drugs on the ocular surface. Very few references have been found on the efficiency of eye drop application in the elderly. This study is presented with the purpose of
assessing the skills and abilities of patients over 65 for selfadministering eye drops on their ocular surface.
Materials and methods A prospective study in the external practices of the Hospital Comarcal de Mora (Mora d’Ebre, Tarragona, Spain) with a group of 25 patients over 65 years of age who were recorded on a video camera when self-administering eye drops. The patients selected for the study had to fulfill the following conditions: visual acuity above 0.5, adequate binocular vision and using eye drops on a daily frequency and with more than one year of evolution. Patients with monocular vision, low psychomotor dexterity in upper limbs, dementia and those recently diagnosed who required treatment with eye drops were discarded from the study. Patients meeting said criteria were those exhibiting chronic diseases such as glaucoma or dry eye and accordingly these patients were admitted in the study. The research protocol complied with the principles of the Helsinki Declaration and was approved by the Ethics Committee of the San Juan University Hospital of Reus. All patients signed an informed consent and authorized the use of their images for presenting the study. After informing patients on the innocuous nature of the test, they were asked to apply one drop in the eyes in the same way they did it at home using similar dispensers containing a sterile solution of artificial tears without any active principles. The operation was recorded, emphasizing the application technique and the dynamics of the drop when making contact with the eye. Two different types of available artificial tears were used, one in a single dose dispenser (Acuolens, Alcon SA, Kayersberg, France) and another in a multidose 5 ml bottle (Systane, Alcon SA, Hünenberg, Switzerland) depending on the type of dispenser used by patients on a daily basis. Subsequently, the patient was taken to a hospital room equipped with washbasin, hand soap and paper towels. Two different types of chairs were offered in order to simulate as closely as possible the usual home context in which the eye drops were applied. When the patient began the instillation procedure, a video camera (Everio Dock, GZ-MG365HE, JVC Technology GmbH, Friedberg, Germany) located at a distance of about 1 m began to record on automatic video mode. Only one researcher was in charge of the recordings and the interpretation of results. The following variables were taken during the recordings (Table 1): use of a mirror, previous washing of hands, dispenser contact with ocular globe or eyelid, patient position
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
Table 1 – Variables applied in the study. 1. Use of mirror 2. Previous washing of hands 3. Contact of dispenser with eyelids or ocular globe 4. Patients position when instilling the drops (sitting, standing, lying down) 5. Number of drops applied by patients 6. Form of pressing the button to produce the drop 7. Use of fingers for separating eyelids 8. Number of attempts, taken as approaches, before instilling the drop 9. Location of the instilled drop (conjunctival sac, external or internal angle, eyelid, nose, face or other locations) 10. Number of instilled drops 11. Contact of the drop with ocular surface
when administering the drop (sitting, standing, lying down), number of drops applied by the patient, the way in which the dispenser was pressed for producing the drop, the use of fingers to keep eyelids separated, the number of attempts taken as approaches before actually instilling the drop, the location in which the drop fell (conjunctival sac, external angle, internal angle, eyelid, nose, cheek or other locations) and type of contact of the drop with the ocular surface (full, partial or no contact). For this, 2 variables were considered on the basis of the classification by Hennessy et al.7 ; the first variable assesses the success of the application of the first drop and comprises 3 levels, where the first is the absence of contact on the drop with the eye surface, the second is the contact of the drop and the tip of the dispenser with the ocular mucosa and the third level is the correct application of the drop without contact of the dispenser with the ocular surface. The second variable refers to adequate contact of the entire drop with the ocular surface. The statistical methods were for the descriptive analysis, the calculation of various median values and proportions observed with their corresponding confidence intervals (IC) at 95%. For bivariance analysis, the continuous variables were compared by means of the T for Student’s test, and the category variations by means of the Chi square or the Fisher’s test as required. The analysis was carried out using the SPSS application, version 15.0.
Results Overall, 25 patients were studied having a mean age of 74.2 years (SD 7.5), 68% female and 32% male. Glaucoma was the diagnostic for 64% of patients, 36% had dry eye (Table 2). The mean time of eye drops application recordings was of 3.4 min, while none of the patients exceeded 5 min. All patients stated they would have felt more comfortable applying the eye drops in their own home, above all those who lay down to do so (8%). Even so, a majority admitted that the mechanics of the treatment would have been the same, as can be seen in the results table which shows that only 16% of patients used the mirror. One of the observations was the lack of clear awareness about the need of maintaining therapeutic hygiene, considering the high frequency with which the tip of the dispenser made contact with the eyelids (28%) without the patient
179
becoming aware of this. A further observation in this regard was the low frequency of handwashing throughout the instillation process, to the extent that none of the dry eye patients carried out this procedure and only 16% of glaucoma patients washed their hands prior to the operation. In what concerns acquired habits involving the use of fingers for separating eyelids, 92% of patients did so, and 72% of these manipulated only the lower eyelid, 8% only the upper eyelid and 12% separated both. The remaining 8% did not touch the eyelids with their fingers. As regards the point of contact of the drops, only 44% of patients required a single drop to make contact with the target, while 56% of patients needed more than 2 drops and of all these 5% needed 4 or more drops. As for the number of instilled eye drops, 52% of patients instilled a single drop, 16% 2 drops, 12% 3 drops and 20% used 4 or more drops. The areas in which the drop made contact in the first attempt was in the conjunctival sac in 32% of patients, the external angle of the eye in a further 32%, the internal angle in 8%, as well as 8% on the nose and 12% on the cheeks, with 8% making contact with other areas.
Discussion Poor compliance of prescribed pharmacological treatments for glaucoma and dry eye still remains a significant obstacle for adequate treatment of these 2 diseases. The Early Manifest Glaucoma Trial observed that glaucoma progressed in 59% of patients despite pharmacological treatment with eye drops. These results arose interest on the possibility that the active principle was not making sufficient contact with the target. On the other hand, it is difficult for health staff to determine which patients comply fully with the prescribed treatment. Consequently, noncompliance can be confused with inefficient therapy and could prompt the physician to prescribe new drugs or to adopt more aggressive therapeutic measures such as laser or surgery. Most of published literature on correct eye drop application is in reference to glaucoma patients. Even though this was not the objective of this study, the authors have observed better results in glaucoma patients than in dry eye patients, mainly in handwashing and dispenser manipulation (Table 2). Perhaps the inclusion in this group of dry eye patients explains why the results are not as positive as other published results involving only glaucoma patient groups. For instance, the article by Tsai et al.8 reported that 37% of patients instilled more than 2 drops while in this study this percentage reached 48%. It is likely that glaucoma patients are more aware of the severity of the disease and consequently the results are better than those obtained with dry eye patients. Robin et al.9 and Becker et al.10 observed that pharmacological overdosage in the form of eye drops could produce iatrogeny due to increased risk of possible side effects. A study carried out in a health center of Oviedo, which published that the number of drugs consumed by the population over 65 was of 3.1 and 39.2% of this group exhibited consumption-related problems identified in 54.8% as interactions, in 36.9% as inadequate use or 8.2% for both.11 Fortunately these problems
180
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
Table 2 – Results of video recordings per condition type. Glaucoma n (%)
Dry eye n (%)
p*
Total n (%)
9 (56.3) 7 (43.8)
4 (44.4) 5 (55.6)
0.571
13 (52) 12 (48)
6 (37.5) 10 (62.5)
7 (22.2) 9 (77.8)
0.432
8 (32) 17 (68)
1 (6.3) 4 (25) 3 (18.8)
3 (33.3) 0 (0) 4 (44.4)
0.076 0.102 0.170
4 (16) 4(16) 7 (28)
Position Sitting Standing Supine Pressing bottle
12 (75) 2 (12.5) 2 (12.5) 10 (62.5)
6 (66.7) 3 (33.3) 0 (0) 5 (55.6)
0.297
18 (72) 5 (20) 2 (8) 15 (60)
Separation of eyelids No separation of eyelids Separation of lower eyelid Separation of upper eyelid Separation of both eyelids
1 (6.3) 12 (75) 2 (12.5) 1 (6.3)
1 (11.1) 6 (66.7) 0 (0) 2 (22.2)
0.462
2 (8) 18 (72) 2 (8) 3 (12)
Number of attempts 1 2
8 (50) 8 (50)
3 (33.3) 6 (66.7)
0.420
11 (44) 14 (56)
Location of first attempt Conjunctival sac External angle Internal angle Nose Cheek Other
6 (37.5) 5 (31.3) 0 (0) 2 (12.5) 2 (12.5) 1 (6.3)
2 (22.2) 3 (33.3) 2 (22.2) 0 (0) 1 (11.1) 1 (11.1)
0.382
8 (32) 8 (32) 2 (8) 2 (8) 3 (12) 2 (8)
Location of second attempt Conjunctival sac External angle Internal angle Eyelid
2 (25) 3 (37.5) 2 (25) 1 (12.5)
2 (33.3) 2 (33.3) 1 (16.7) 1 (16.7)
0.969
4 (28.6) 5 (35.7) 3 (21.4) 2 (14.3)
Location of drop contact (first attempt) Outside ocular surface Full Contact Partial contact
6 (37.5) 6 (37.5) 4 (25)
6 (66.7) 2 (22.2) 1 (11.1)
0.369
Location of drop contact (second attempt) Full Contact Partial contact
5 (62.5) 3 (37.5)
0 (0) 6 (100)
0.016
Number of drops 1 drop 2 drops 3 drops ≥4 drops
9 (56.3) 2 (12.5) 3 (18.8) 2 (12.5)
4 (44.4) 2 (22.2) 0 (0) 3 (33.3)
0.330
Age 65–74 ≥75 Sex Male Female Use of mirror Previous handwashing Contact of dispenser
∗
0.734
12 (48) 8 (32) 5 (20)
5 (35.7) 9 (64.3)
13 (52) 4 (16) 3 (12) 5 (20)
The value of p was calculated with the Chi square test, Fisher’s test or T for Student’s test as required.
diminish when application is topical. An additional aspect which is attracting an increasing amount of attention is the unnecessary health expenditure that this wasteful consumption involves. Even though all patients stated that the treatment dynamics would have been the same had they applied the eye drops at home, it must be considered that results could be partially biased due to the fact that patients did not execute the operation in their usual context. Variations in
lighting, position, visualization and the presence of a video camera could be factors giving rise to changes in patient routine. The authors have not found a practical and effective method to objectively assess the adequate application of a treatment. For this reason, when introducing a patient to a new treatment in the form of eye drops, it is advisable to question the patient and verify psychomotor and cognitive skills, among others. In some cases it would be practical to request
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
the patient to have the eye drops applied by a competent person. Even though it was not the purpose of the study and no statistical verification has been carried out, the authors have observed greater ease in the application of eye drops using multidose instead of single dose dispensers, in contrast with Stone et al.12 who found greater ease of use in single dose units. The results of this study match those of other published reports and lead us to reflect upon the need of instructing patients when prescribing eye drops for the first time. Salyani et al.13 demonstrated that with adequate instructions eye drop administration by patients newly diagnosed with glaucoma improved success rates by 18%. The high pressure many health centers are under, even more so in the public health system, reduces the availability of time to meticulously explain application procedure. The distribution of said procedure in writing is an option which supports patient knowledge on the adequate therapeutical technique14 but unfortunately it cannot be generalized as a general practice to the entire population. Perhaps in a context of high patient demand auxiliary and nursing staff could make a valuable contribution.
Conflict of interests No conflict of interests has been declared by the authors.
references
1. Pérez J, García E. Influencia de algunos factores sociales en la tercera edad en la comunidad pastorita. Rev Cubana Enferm. 2003;18:18–21. 2. Vaupel JW, Carey JR, Vhristensen K, Johnson TE, Yashin AI, Holm NV, et al. Biodemographic trajectories of longevity. Science. 1998;280:855–60.
181
3. Cómo utilizar los colirios. Salud pública. Available from: http://www.portalfarma.com/Ciudadanos/saludpublica/ consejosdesalud/Paginas/15colirios.aspx [accessed December 2013]. 4. Hyman L, Heijl A, Leske MC, Bengtsson B, Yang Z. Natural history of intraocular pressure in the early manifest glaucoma trial: a 6-year follow-up. Arch Ophthalmol. 2010;128: 601–7. 5. Thylefors B, Négrel AD, Pararajasegaram R, Dadzie KY. Global data on blindness. Bull World Health Organ. 1995;73: 115–21. 6. Murube J. Cirugía sustitutiva del ojo seco y trasplantes glandulares. Ojo seco-Dry eye. Madrid: Tecnimedia Editorial; 1997. p. 220–1. 7. Hennessy AL, Katz J, Covert D, Protzko C, Robin AL. Videotaped evaluation of eyedrop instillation in glaucoma patients with visual impairment or moderate to severe visual field loss. Ophthalmology. 2010;117:2345–52. 8. Tsai T, Robin A, Smith P. An evaluation of how glaucoma patients use topical medications: a pilot study. Trans Am Ophthalmol Soc. 2007;105:29–35. 9. Robin AL, Novack GD, Covert DW, Crockett RS, Marcic TS. Adherence in glaucoma: object measurements of once-daily and adjunctive medication use. Am J Ophthalmol. 2007;144:533–40. 10. Beckers HJ, Schouten JS, Webers CA, van der Valk R, Hendrikse F. Side effects of commonly used glaucoma medications: comparison of tolerability, chance of discontinuation and patient satisfaction. Graefes Arch Clin Exp Ophthalmol. 2008;246:1485–90. 11. Arjona C, Criado J, Sánchez L. Enfermedades crónicas y ˜ consumo de fármacos en mayores de 65 anos. Med Gen. 2002;47:684–95. 12. Stone JL, Robin AL, Novack GD, Covert DW, Cagle GD. An objective evaluation of eyedrop instillation in patients with glaucoma. Arch Ophtalmol. 2009;127:732–6. 13. Salyani A, Birt C. Evaluation of an eye drop guide to aid self-administration by patients experienced with topical use of glaucoma medication. Can J Ophthalmol. 2005;40:170–4. 14. Kharod BV, Johnson PB, Nesti HA, Rhee DJ. Effect of written instructions on accuracy of self-reporting medication regimen in glaucoma patients. J Glaucoma. 2006;15:244–7.
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Original article
Objective evaluation of applying eye drops by elderly patients夽 J. Colomé-Campos a,∗, I. Martínez-Salcedo a, M.C. Martorell-Hallado b , P. Romero-Aroca c a b c
Servicio de Oftalmología, Hospital Comarcal de Mora, Mora d’Ebre, Spain Universidad Rovira y Virgili, Tortosa, Spain Servicio de Oftalmología, Hospital Universitario San Juan, Reus, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: To objectively evaluate the ability and skills of patients older than 65 years to
Received 24 June 2013
successfully administer a topical ocular eye drop.
Accepted 9 February 2014
Methods: A prospective study was conducted on a group of 25 patients with a diagnosis of
Available online 12 August 2014
dry eye or glaucoma, undergoing daily treatment with eye drops for at least one year. The procedure was recorded with a video camera at the time of the application.
Keywords:
Results: Of the total, 64% were diagnosed with glaucoma and 36% with dry eye. Almost half
Eye drops
(44%) needed a single attempt to apply the drop, and 56% required 2 attempts. In terms of
Glaucoma
the number of eye drops applied, 52% managed with a single drop, 16% 2 drops, 12% 3 drops,
Dry eye
and 20% 4 or more eye drops. Areas where the eye drop was deposited in the first attempt
Therapeutic compliance
was 32% into the conjunctival sac, 32% on the outer corner of the eye, 8% in the inner angle,
Senescence
8% in the nose, 12% on the cheek, 8% in other areas. Conclusions: Self-administration of eye drops by the elderly is a complex activity that can have an effect on the expected results. ˜ © 2013 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.
Evaluación objetiva de la aplicación de colirios en personas mayores ˜ de 65 anos r e s u m e n Palabras clave:
˜ Objetivo: Evaluar las habilidades y destrezas de los pacientes mayores de 65 anos en el
Colirios
momento de instilarse un tratamiento ocular en forma de colirio.
Glaucoma
Métodos: Se realizó un estudio prospectivo sobre un grupo de 25 pacientes afectos de ojo
Ojo seco
˜ de evolución seco o de glaucoma en tratamiento diario con gotas con, por lo menos, un ano
Cumplimento terapéutico
a los que procedimos a grabar con una cámara de vídeo en el momento de la instilación.
Senectud
Resultados: Un 64% del total estaban diagnosticados de glaucoma y un 36% de ojo seco. Un 44% necesitaron un único intento para aplicarse la gota y un 56%, dos intentos. En cuanto al número de gotas instiladas, un 52% se instilaba una única gota, un 16% dos gotas,
夽
Please cite this article as: Colomé-Campos J, Martínez-Salcedo I, Martorell-Hallado M, Romero-Aroca P. Evaluación objetiva de la ˜ aplicación de colirios en personas mayores de 65 anos. Arch Soc Esp Oftalmol. 2014;89:177–181. ∗ Corresponding author. E-mail address: [email protected] (J. Colomé-Campos). ˜ 2173-5794/$ – see front matter © 2013 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.
178
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
un 12% 3 gotas y un 20% cuatro o más gotas. Las zonas donde se depositó la gota en el primer intento fue en un 32% en el saco conjuntival, en un 32% en el ángulo externo del ojo, en un 8% en el ángulo interno, en un 8% en la nariz, en un 12% en la mejilla y en un 8% en otras zonas. Conclusiones: La autoadministración de colirios en la población de la tercera edad se presenta como una actividad compleja que puede modificar los resultados esperados. ˜ de Oftalmología. Publicado por Elsevier España, S.L.U. Todos © 2013 Sociedad Espanola los derechos reservados.
Introduction One of the effects of aging is a progressive reduction of psychomotor skills as a consequence of physical and cognitive deterioration, the appearance of various types of chronic diseases or psychosocial changes that prevent or inhibit the execution of numerous daily activities. In a study carried out in Cuba, Pérez and García1 observed that 69.6% of individuals over 60 have at least one chronic disease, while 13.9% exhibited some sense organ alteration which inhibited the ability to carry out actions requiring a certain degree of dexterity and skill. In the USA, data published in 1998 demonstrated that 30–40% of people over 85 exhibited some psychomotor or cognitive dysfunction. The most frequently altered cognitive functions are short, medium or long term memory, language areas, manual skills and brain functions for resolving problems.2 Together with eyesight, some of the said skills play a very important role in meeting the 6 steps recommended by the General Counsel of Pharmaceutical Societies of Spain for adequate administration of eye drops.3 These are: washing of hands, reclining the head backward, slightly pressing the lower eyelid downward, applying the drop in the conjunctival sac, closing the eye and slightly pressing the lacrimal duct a few seconds and, if a concurrent treatment has been prescribed, wait 5 min between both. It must be taken into account that said maneuvers must be executed with eye drops contained in small dispensers which require adequate orientation, approach and a given amount of pressure. Accordingly and considering that the majority of chronic treatments we prescribe are for the elderly, we should take into account when prescribing eye drops the difficulty our patients may experience for adequately applying said eye drops on the ocular surface. Severe dry eye and mainly glaucoma are 2 diseases which require prolonged and meticulous treatment to preserve in some cases the integrity of vision.4 Due to the progressive increase of life expectancy, these 2 diseases are increasing in prevalence as attested by the numerous products available in the pharmaceutical market. For instance, glaucoma currently accounts for 6.7–21% of causes of blindness.5 In addition, approximately 5% of the adult population requires medical attention due to dry eye discomfort and 30% experiences symptoms in ordinary situations such as air conditioning environments, use of contact lenses, medication and wind.6 Psychomotor skills and vision are important for selfadministering drugs on the ocular surface. Very few references have been found on the efficiency of eye drop application in the elderly. This study is presented with the purpose of
assessing the skills and abilities of patients over 65 for selfadministering eye drops on their ocular surface.
Materials and methods A prospective study in the external practices of the Hospital Comarcal de Mora (Mora d’Ebre, Tarragona, Spain) with a group of 25 patients over 65 years of age who were recorded on a video camera when self-administering eye drops. The patients selected for the study had to fulfill the following conditions: visual acuity above 0.5, adequate binocular vision and using eye drops on a daily frequency and with more than one year of evolution. Patients with monocular vision, low psychomotor dexterity in upper limbs, dementia and those recently diagnosed who required treatment with eye drops were discarded from the study. Patients meeting said criteria were those exhibiting chronic diseases such as glaucoma or dry eye and accordingly these patients were admitted in the study. The research protocol complied with the principles of the Helsinki Declaration and was approved by the Ethics Committee of the San Juan University Hospital of Reus. All patients signed an informed consent and authorized the use of their images for presenting the study. After informing patients on the innocuous nature of the test, they were asked to apply one drop in the eyes in the same way they did it at home using similar dispensers containing a sterile solution of artificial tears without any active principles. The operation was recorded, emphasizing the application technique and the dynamics of the drop when making contact with the eye. Two different types of available artificial tears were used, one in a single dose dispenser (Acuolens, Alcon SA, Kayersberg, France) and another in a multidose 5 ml bottle (Systane, Alcon SA, Hünenberg, Switzerland) depending on the type of dispenser used by patients on a daily basis. Subsequently, the patient was taken to a hospital room equipped with washbasin, hand soap and paper towels. Two different types of chairs were offered in order to simulate as closely as possible the usual home context in which the eye drops were applied. When the patient began the instillation procedure, a video camera (Everio Dock, GZ-MG365HE, JVC Technology GmbH, Friedberg, Germany) located at a distance of about 1 m began to record on automatic video mode. Only one researcher was in charge of the recordings and the interpretation of results. The following variables were taken during the recordings (Table 1): use of a mirror, previous washing of hands, dispenser contact with ocular globe or eyelid, patient position
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
Table 1 – Variables applied in the study. 1. Use of mirror 2. Previous washing of hands 3. Contact of dispenser with eyelids or ocular globe 4. Patients position when instilling the drops (sitting, standing, lying down) 5. Number of drops applied by patients 6. Form of pressing the button to produce the drop 7. Use of fingers for separating eyelids 8. Number of attempts, taken as approaches, before instilling the drop 9. Location of the instilled drop (conjunctival sac, external or internal angle, eyelid, nose, face or other locations) 10. Number of instilled drops 11. Contact of the drop with ocular surface
when administering the drop (sitting, standing, lying down), number of drops applied by the patient, the way in which the dispenser was pressed for producing the drop, the use of fingers to keep eyelids separated, the number of attempts taken as approaches before actually instilling the drop, the location in which the drop fell (conjunctival sac, external angle, internal angle, eyelid, nose, cheek or other locations) and type of contact of the drop with the ocular surface (full, partial or no contact). For this, 2 variables were considered on the basis of the classification by Hennessy et al.7 ; the first variable assesses the success of the application of the first drop and comprises 3 levels, where the first is the absence of contact on the drop with the eye surface, the second is the contact of the drop and the tip of the dispenser with the ocular mucosa and the third level is the correct application of the drop without contact of the dispenser with the ocular surface. The second variable refers to adequate contact of the entire drop with the ocular surface. The statistical methods were for the descriptive analysis, the calculation of various median values and proportions observed with their corresponding confidence intervals (IC) at 95%. For bivariance analysis, the continuous variables were compared by means of the T for Student’s test, and the category variations by means of the Chi square or the Fisher’s test as required. The analysis was carried out using the SPSS application, version 15.0.
Results Overall, 25 patients were studied having a mean age of 74.2 years (SD 7.5), 68% female and 32% male. Glaucoma was the diagnostic for 64% of patients, 36% had dry eye (Table 2). The mean time of eye drops application recordings was of 3.4 min, while none of the patients exceeded 5 min. All patients stated they would have felt more comfortable applying the eye drops in their own home, above all those who lay down to do so (8%). Even so, a majority admitted that the mechanics of the treatment would have been the same, as can be seen in the results table which shows that only 16% of patients used the mirror. One of the observations was the lack of clear awareness about the need of maintaining therapeutic hygiene, considering the high frequency with which the tip of the dispenser made contact with the eyelids (28%) without the patient
179
becoming aware of this. A further observation in this regard was the low frequency of handwashing throughout the instillation process, to the extent that none of the dry eye patients carried out this procedure and only 16% of glaucoma patients washed their hands prior to the operation. In what concerns acquired habits involving the use of fingers for separating eyelids, 92% of patients did so, and 72% of these manipulated only the lower eyelid, 8% only the upper eyelid and 12% separated both. The remaining 8% did not touch the eyelids with their fingers. As regards the point of contact of the drops, only 44% of patients required a single drop to make contact with the target, while 56% of patients needed more than 2 drops and of all these 5% needed 4 or more drops. As for the number of instilled eye drops, 52% of patients instilled a single drop, 16% 2 drops, 12% 3 drops and 20% used 4 or more drops. The areas in which the drop made contact in the first attempt was in the conjunctival sac in 32% of patients, the external angle of the eye in a further 32%, the internal angle in 8%, as well as 8% on the nose and 12% on the cheeks, with 8% making contact with other areas.
Discussion Poor compliance of prescribed pharmacological treatments for glaucoma and dry eye still remains a significant obstacle for adequate treatment of these 2 diseases. The Early Manifest Glaucoma Trial observed that glaucoma progressed in 59% of patients despite pharmacological treatment with eye drops. These results arose interest on the possibility that the active principle was not making sufficient contact with the target. On the other hand, it is difficult for health staff to determine which patients comply fully with the prescribed treatment. Consequently, noncompliance can be confused with inefficient therapy and could prompt the physician to prescribe new drugs or to adopt more aggressive therapeutic measures such as laser or surgery. Most of published literature on correct eye drop application is in reference to glaucoma patients. Even though this was not the objective of this study, the authors have observed better results in glaucoma patients than in dry eye patients, mainly in handwashing and dispenser manipulation (Table 2). Perhaps the inclusion in this group of dry eye patients explains why the results are not as positive as other published results involving only glaucoma patient groups. For instance, the article by Tsai et al.8 reported that 37% of patients instilled more than 2 drops while in this study this percentage reached 48%. It is likely that glaucoma patients are more aware of the severity of the disease and consequently the results are better than those obtained with dry eye patients. Robin et al.9 and Becker et al.10 observed that pharmacological overdosage in the form of eye drops could produce iatrogeny due to increased risk of possible side effects. A study carried out in a health center of Oviedo, which published that the number of drugs consumed by the population over 65 was of 3.1 and 39.2% of this group exhibited consumption-related problems identified in 54.8% as interactions, in 36.9% as inadequate use or 8.2% for both.11 Fortunately these problems
180
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
Table 2 – Results of video recordings per condition type. Glaucoma n (%)
Dry eye n (%)
p*
Total n (%)
9 (56.3) 7 (43.8)
4 (44.4) 5 (55.6)
0.571
13 (52) 12 (48)
6 (37.5) 10 (62.5)
7 (22.2) 9 (77.8)
0.432
8 (32) 17 (68)
1 (6.3) 4 (25) 3 (18.8)
3 (33.3) 0 (0) 4 (44.4)
0.076 0.102 0.170
4 (16) 4(16) 7 (28)
Position Sitting Standing Supine Pressing bottle
12 (75) 2 (12.5) 2 (12.5) 10 (62.5)
6 (66.7) 3 (33.3) 0 (0) 5 (55.6)
0.297
18 (72) 5 (20) 2 (8) 15 (60)
Separation of eyelids No separation of eyelids Separation of lower eyelid Separation of upper eyelid Separation of both eyelids
1 (6.3) 12 (75) 2 (12.5) 1 (6.3)
1 (11.1) 6 (66.7) 0 (0) 2 (22.2)
0.462
2 (8) 18 (72) 2 (8) 3 (12)
Number of attempts 1 2
8 (50) 8 (50)
3 (33.3) 6 (66.7)
0.420
11 (44) 14 (56)
Location of first attempt Conjunctival sac External angle Internal angle Nose Cheek Other
6 (37.5) 5 (31.3) 0 (0) 2 (12.5) 2 (12.5) 1 (6.3)
2 (22.2) 3 (33.3) 2 (22.2) 0 (0) 1 (11.1) 1 (11.1)
0.382
8 (32) 8 (32) 2 (8) 2 (8) 3 (12) 2 (8)
Location of second attempt Conjunctival sac External angle Internal angle Eyelid
2 (25) 3 (37.5) 2 (25) 1 (12.5)
2 (33.3) 2 (33.3) 1 (16.7) 1 (16.7)
0.969
4 (28.6) 5 (35.7) 3 (21.4) 2 (14.3)
Location of drop contact (first attempt) Outside ocular surface Full Contact Partial contact
6 (37.5) 6 (37.5) 4 (25)
6 (66.7) 2 (22.2) 1 (11.1)
0.369
Location of drop contact (second attempt) Full Contact Partial contact
5 (62.5) 3 (37.5)
0 (0) 6 (100)
0.016
Number of drops 1 drop 2 drops 3 drops ≥4 drops
9 (56.3) 2 (12.5) 3 (18.8) 2 (12.5)
4 (44.4) 2 (22.2) 0 (0) 3 (33.3)
0.330
Age 65–74 ≥75 Sex Male Female Use of mirror Previous handwashing Contact of dispenser
∗
0.734
12 (48) 8 (32) 5 (20)
5 (35.7) 9 (64.3)
13 (52) 4 (16) 3 (12) 5 (20)
The value of p was calculated with the Chi square test, Fisher’s test or T for Student’s test as required.
diminish when application is topical. An additional aspect which is attracting an increasing amount of attention is the unnecessary health expenditure that this wasteful consumption involves. Even though all patients stated that the treatment dynamics would have been the same had they applied the eye drops at home, it must be considered that results could be partially biased due to the fact that patients did not execute the operation in their usual context. Variations in
lighting, position, visualization and the presence of a video camera could be factors giving rise to changes in patient routine. The authors have not found a practical and effective method to objectively assess the adequate application of a treatment. For this reason, when introducing a patient to a new treatment in the form of eye drops, it is advisable to question the patient and verify psychomotor and cognitive skills, among others. In some cases it would be practical to request
a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(5):177–181
the patient to have the eye drops applied by a competent person. Even though it was not the purpose of the study and no statistical verification has been carried out, the authors have observed greater ease in the application of eye drops using multidose instead of single dose dispensers, in contrast with Stone et al.12 who found greater ease of use in single dose units. The results of this study match those of other published reports and lead us to reflect upon the need of instructing patients when prescribing eye drops for the first time. Salyani et al.13 demonstrated that with adequate instructions eye drop administration by patients newly diagnosed with glaucoma improved success rates by 18%. The high pressure many health centers are under, even more so in the public health system, reduces the availability of time to meticulously explain application procedure. The distribution of said procedure in writing is an option which supports patient knowledge on the adequate therapeutical technique14 but unfortunately it cannot be generalized as a general practice to the entire population. Perhaps in a context of high patient demand auxiliary and nursing staff could make a valuable contribution.
Conflict of interests No conflict of interests has been declared by the authors.
references
1. Pérez J, García E. Influencia de algunos factores sociales en la tercera edad en la comunidad pastorita. Rev Cubana Enferm. 2003;18:18–21. 2. Vaupel JW, Carey JR, Vhristensen K, Johnson TE, Yashin AI, Holm NV, et al. Biodemographic trajectories of longevity. Science. 1998;280:855–60.
181
3. Cómo utilizar los colirios. Salud pública. Available from: http://www.portalfarma.com/Ciudadanos/saludpublica/ consejosdesalud/Paginas/15colirios.aspx [accessed December 2013]. 4. Hyman L, Heijl A, Leske MC, Bengtsson B, Yang Z. Natural history of intraocular pressure in the early manifest glaucoma trial: a 6-year follow-up. Arch Ophthalmol. 2010;128: 601–7. 5. Thylefors B, Négrel AD, Pararajasegaram R, Dadzie KY. Global data on blindness. Bull World Health Organ. 1995;73: 115–21. 6. Murube J. Cirugía sustitutiva del ojo seco y trasplantes glandulares. Ojo seco-Dry eye. Madrid: Tecnimedia Editorial; 1997. p. 220–1. 7. Hennessy AL, Katz J, Covert D, Protzko C, Robin AL. Videotaped evaluation of eyedrop instillation in glaucoma patients with visual impairment or moderate to severe visual field loss. Ophthalmology. 2010;117:2345–52. 8. Tsai T, Robin A, Smith P. An evaluation of how glaucoma patients use topical medications: a pilot study. Trans Am Ophthalmol Soc. 2007;105:29–35. 9. Robin AL, Novack GD, Covert DW, Crockett RS, Marcic TS. Adherence in glaucoma: object measurements of once-daily and adjunctive medication use. Am J Ophthalmol. 2007;144:533–40. 10. Beckers HJ, Schouten JS, Webers CA, van der Valk R, Hendrikse F. Side effects of commonly used glaucoma medications: comparison of tolerability, chance of discontinuation and patient satisfaction. Graefes Arch Clin Exp Ophthalmol. 2008;246:1485–90. 11. Arjona C, Criado J, Sánchez L. Enfermedades crónicas y ˜ consumo de fármacos en mayores de 65 anos. Med Gen. 2002;47:684–95. 12. Stone JL, Robin AL, Novack GD, Covert DW, Cagle GD. An objective evaluation of eyedrop instillation in patients with glaucoma. Arch Ophtalmol. 2009;127:732–6. 13. Salyani A, Birt C. Evaluation of an eye drop guide to aid self-administration by patients experienced with topical use of glaucoma medication. Can J Ophthalmol. 2005;40:170–4. 14. Kharod BV, Johnson PB, Nesti HA, Rhee DJ. Effect of written instructions on accuracy of self-reporting medication regimen in glaucoma patients. J Glaucoma. 2006;15:244–7.