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- Gabrielle S. Buma
With age comes the prospect of multiple health problems that may require treatment with several medications and multiple prescribers. The likelihood of morbidities and comorbidities such as, heart disease, arthritis, diabetes, and hypertension increases with age. Many older adults also take over the counter medications, vitamins, and other supplements along with their prescribed medications. The use of these multiple kinds of medications is called polypharmacy, and if done so correctly the use of multiple medications can have positive results in the treatment and maintenance of disease but if not used correctly the drugs could be less effective and result in expensive drug-related morbidity and mortality. The Agency for Healthcare Research and Quality claim that more than 770,000 people are injured or die each year from Adverse Drug Effects (ADEs) (Lynn, 2012). What makes this even more of a concern is that many experts believe that ADEs are significantly underreported. According to the Journal of the American Geriatrics Society, the annual cost associated with drug-related morbidity and mortality has been estimated to be at around $177 billion (Roth, Weinberger & Campbell, 2009). Many factors play a role in the quality medication use in older adults; these factors can be considered overuse, underuse, and misuse. The misuse of medication that leads to adverse drug effects in older adults can be greatly reduced by improving health literacy and prescribing physician and patient communication.
According to the Institute of Medicine, health literacy is considered an individual’s capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (Martin, Kripalani, & DuRapau, 2013). Currently in the United States, the older adults that are 65 years and older represent the largest group with the lowest general literacy and health literacy skills in the country (Bennett, Chen, Soroui & White, 2009). This means that there is a large portion of the older adults over 65 that are making health decisions with the likelihood of not fully understanding them. Older adults over 65 years of age also have the highest rate of chronic illness of any other age group. The combination of low levels of literacy and high prevalence of multiple chronic conditions with multiple medications are major contributing factors to the high rate of ADEs in older adults. The article, Preventing Medication Errors, in the Institute of Medicine cited that poor patient comprehension and unintentional misuse of prescription drugs as a significant cause for medication error and worse health outcomes (Martin, Kripalani, & DuRapau, 2013). Many older adults are simply accidentally misusing prescribed medications due to a low level of health literacy. Low literacy in older adults and Medicare recipients affects their understanding of complex medication labels, instructions, and regimens (Martin, Kripalani, & DuRapau, 2013). A way to improve older adult’s understanding of prescription drugs especially among those with limited literacy is greatly needed to prevent unintentional use that lead to AEDs, before the improvement can be made we need to first understand the factors associated with patients understanding of prescription drugs and their labeling.
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According to the National Assessment of Adult Literacy, adults who are socioeconomically disadvantaged that are a part of minority groups are more likely to be in poorer health (Davis, Wolf, Bass, Middlebrooks, Kennen, Baker, . . . . Parker, 2006 ). In the study, Low Literacy Impairs Comprehension of Prescription Drug Warning Labels, the authors measured a group of 251 adult’s ability to correctly interpret commonly used prescription medication labels. They measured the participant’s health literacy by having an expert panel evaluating the patient’s interpretation of the commonly used prescription medication labels. The results showed that one-third of patients were reading at or below a 6th grade level and that a patient’s comprehension of warning labels was associated with their level of literacy. The result that low literacy is associated with low comprehension and a difficulty understanding of warning labels on prescription medications is not a surprise because the labels use terminology about a 6th grade reading level (Davis, Wolf, Bass, Middlebrooks, Kennen, Baker, . . . . Parker, 2006 ). The multistep instructions were found difficult for patients across all literacy levels. I found it surprising that the multistep instructions were difficult for all reading levels, but the study explains that the more steps a labels has the less concise and clear it tends to be to the patient. If the multistep instructions are a challenge for all literacy levels to understand then I would assume that it is quite challenging for a large population of the older adults who tend to have the lowest levels of literacy and so many different medications to keep track of with each having multistep directions.
The study did offer recommendations that would help the understanding of medication labels for all literacy levels. These recommendations include; warning labels being developed with consumer participation, especially with lower literate populations, attempt to keep the steps short, clear and concise with familiar words and recognizable icons. After reading this study, I was surprised to learn that more prescription drug labels are not developed with the use of consumer participation, one would assume the in the developing of the instructions that it would be a priority to develop the instructions with consumer participation. It seems that more consumer participation with all health literacy levels would help create more user friendly labels that could result in a significant decrease in misuse of prescription drugs.
The study, Improving Medication Management among At-risk Older Adults, evaluates health literacy but also medication self-efficacy and medication adherence. One reference in the study shows an alarming 54.3% of Medicare enrollees with limited health literacy were unable to understand what is considered simple medication instructions such as. “take on an empty stomach, ” (Martin, Kripalani, & DuRapau, 2013). The study describes a quality improvement pilot project where they provide at-risk older adults with illustrated medication instructions as an approach to improve medication understating use. In the quality improvement pilot project they evaluated the effect of their intervention on the older adult’s confidence in managing their medication and their self-reported adherence. This study, Improving Medication Management among At-risk Older Adults, took place at an adult day center were medication errors and misunderstanding medication instructions were identified as a problem. The authors and staff provided the adult day care center’s participants with illustrated depiction of their daily schedule PictureRx™ with the goal to improve the older adult’s understanding of medication instructions and improve medication safety. The illustrated aid shows the older adult’s medications pictorially, uses what they consider plain language for the instructions, and uses icons to aid patients in understanding the purpose and the dosing schedule (Martin, Kripalani, & DuRapau, 2013). The PictureRx cards were used for six weeks and then the participants were surveyed along with reassessing their self-efficacy and adherence, as well as their perception on the PictureRx cards.
The results showed that after the use of the PictureRx cards the participants reported much less forms of non-adherence and confidence significantly improved in areas of self-efficacy, such as correctly taking medications and following a routine. This article provides a valuable assessment of older adult’s health literacy and applies an intervention that resulted in an improved adherence and self-efficacy in older adults. When comparing the participant assessment before for the use of PictureRx and then the reassessment after shows a notably significant improvement. This pilot study shows an efficient way to improve older adult’s various health literacy levels and provides them with a way to better understand their overall medication regimens. I think something very similar to the PictureRx would be a great tool to implement for pharmacists when filling medications for older adults at the pharmacy and can provide a good reference for doctors when explaining medications to patients especially since doctors are so limited on the amount of time they can spend with a patient.
Proper patient provider communication plays a huge role in a patient’s ability to understand their medications and ability to properly follow their medication regimes. Good communication about health history and medications with a provider and a patient could prevent the misuse of medication and an ADE. Before prescribing a new medication, the prescribing doctor is supposed to review the patient’s current medications, including over the counter medications, vitamins, supplements, and the patient’s health history. The article, Physician Communication When Prescribing New Medications from the Archives of Internal Medicine recommends that prescribing physicians should educate their patients about their medication’s purpose, how and when to take it, and the medications expected adverse effects. The patient and physician interaction is an opportunity for the physician to educate the patient on these topics which may reduce nonadherence that can be a result from poor understanding about medication use.
The article also describes and assesses the quality of physician communication with patients about newly prescribed medications. The authors assess the provider’s communication through an observational study that combined patient and physician surveys and audiotaped 860 of the 909 participating patients while 270 new medications were prescribed (Tarn, Heritage, Hays & Kravitz, 2006). During these visits the authors measured the quality of physician communication when prescribing new medications. The study by Tarn, Heritage, Hays, and Kravitz found that physicians stated full medication dosing directions for less than 60% of all of the medications that had been prescribed and informed the patients about the duration intake and ADEs for one third of the time. The study shares that ADEs were addressed for 35% of the medications and how long to take the medication was addressed at 34%. Although patients may be able to find information about their medications from different sources such as, a pharmacists and medication package inserts, information from their visits with the prescribing physician is inadequate to meet the patient’s needs.
The study found that the use of precise wording on prescription drug label instructions can improve patient understanding of how to take the medication patients with limited literacy were more likely to misinterpret instructions despite use of more explicit language Patients that have a limited literacy rate and those who are taking more medications are at a greater risk for misuse.
Davis, T. C., Federman, A. D., & Wolf, M. S. (2009). Improving patient understanding of prescription drug label instructions. Journal of General Internal Medicine, 24(1), 57-
Davis, T., Wolf, M., Bass, P., Middlebrooks, M., Kennen, E., Baker, D., . . . . Parker, R. (2006). Low literacy impairs comprehension of prescription drug warning labels. Journal of General Internal Medicine, 21(8), 847-851.
Martin, D., Kripalani, S., & DuRapau, J. (2012). Improving medication management among at-risk older adults. Journal of Gerontological Nursing, 38(6), 24-34.
Roth, M., Weinberger, M., & Campbell, W. (2009). Measuring the quality of medication use in older adults.Journal of the American Geriatrics Society,57(6), 1096-1102.
Tarn, D. M., Heritage, J., Paterniti, D. A., Hays, R. D., & Kravitz, R. L. (2006). Physician communication when prescribing new medications . Archive of Internal Medicine, 166(17), 1855-1862.
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