Aging, Cognition, and Medication Adherence Research Paper

This sample Aging, Cognition, and Medication Adherence Research Paper is published for educational and informational purposes only. Free research papers are not written by our writers, they are contributed by users, so we are not responsible for the content of this free sample paper. If you want to buy a high quality research paper on any topic at affordable price please use custom research paper writing services.

Abstract

Medication  adherence   is  increasingly  recognized   as a complex task involving many cognitive abilities, and adherence errors are common in both younger and older adults. Patients must integrate often complicated instructions  on how to take medication into their daily routines, remember to take the medication at the appropriate  time,  and  remember  that  the  medication has been taken. Although age-related declines in many cognitive abilities are clear, older adults manage familiar tasks such as medication taking quite well, at least until very late age. Many mnemonic supports have been found to function quite effectively to remind  patients to take their medication. However, more and more, researchers and health care providers are focusing on multifaceted interventions that are tailored to the specific needs, abilities, and beliefs of older patients.

Outline

  1. Extent and Cost of Medication Nonadherence in the Elderly
  2. Types of Nonadherence
  3. Adherence: A Complex Cognitive Task
  4. Prospective Memory and Episodic Memory: Age-Related Changes and Effects on Adherence
  5. Knowledge, Beliefs, and Communication: Age-Related Changes and Effects on Adherence
  6. Measuring Adherence: A Difficult Challenge
  7. Interventions: How Cognitive Psychology Can Help

1. Extent And Cost Of Medication Nonadherence In The Elderly

Individuals over 65 years of age make up an increasingly large  percentage  of  the  population   in  industrialized countries around the world, and the trend is expected to continue  for many decades to come. Indeed, the World Health Organization has projected that the percentage of older  adults  in developed  countries  will increase from

14.3% in 2000 to 19.2% by 2020. The majority of older adults  suffer from  at least one  chronic  illness; consequently, older adults are the largest consumers of medications of any age group. Many of the illnesses that afflict older  adults  can be treated  or at least controlled  quite successfully through the use of prescription medication— if medications  are  taken  as prescribed.  Unfortunately, rates of adherence  to medication  regimens are believed to be quite low. It is quite difficult to establish adherence rates precisely, but in general, as few as 50% of patients treated for chronic conditions  are believed to take their medications  as prescribed.  Rates of adherence  are also thought  to be particularly  low in asymptomatic  conditions such as hypertension that afflict many older adults. Surprisingly, most studies have not found evidence that older adults in general are more nonadherent  to medication than are middle-aged or younger adults. Recent work by Park and colleagues even indicated that older adults, between 65 and 74 years of age, made the fewest number of adherence  errors  of any age group,  although  adults over 75 years of age made the most.

The risks of nonadherence  are numerous and serious.

Up to 40% of hospital admissions in adults over 65 years of  age  are  due  directly  to  medication  errors.  Even though  older  adults  do not  seem to be more  nonadherent than younger adults, they are more likely to experience  serious  health  consequences  because their bodies are less tolerant  of medication  errors and drug interactions. When treatment regimens are not followed, the risk of toxicity is heightened, medical conditions are likely to worsen, and expensive and often invasive treatments become necessary. Clearly, enhancing medication adherence is a priority for the effective treatment of chronic  diseases,  for  enhancing  the  well-being  of elderly individuals, and for reducing health care costs.

2. Types Of Nonadherence

Medical nonadherence   occurs  when  patients  do  not carry out medical regimens as prescribed and includes any of the following: (a) not taking the medication  at all, (b) taking smaller or larger doses than prescribed, (c)  taking  fewer or  more  doses  than  prescribed,  or (d) not following recommendations  regarding food or beverages  while  medicated.  Such  behaviors  can  be either intentional  (i.e., the patient chooses not to take the medication as prescribed) or unintentional (i.e., the patient intends to take the medication correctly but does not).  In general, unintentional overuse or underuse  of medication is due to cognitive variables such as forgetfulness and misinterpretation of instructions. Intentional noncompliance, on the other hand, can be seen as relatively more complex and is linked to either external circumstances  or motivational issues. External circumstances include factors such as not being able to pay for the medication, not being able to reach the pharmacy to get the prescription  filled, and not being able to open resistant packaging (e.g., childproof bottle tops) due to physical handicaps. Motivational issues refer to the fact that many individuals, both young and old, hold views about their illness and their medication that are incompatible with adherence.

3. Adherence: A Complex Cognitive Task

In the past, medication adherence has been presented as an example of a simple everyday prospective  memory task, where prospective memory is defined as remembering  to do things  in the  future.  Recently, however, there  is a  clear  consensus  emerging  that  medication adherence is a complex process involving a host of variables. Although  many  of these  factors are  clearly cognitive, others (e.g., motivation to adhere to the medication regimen) involve the interplay between cognitive and social factors.

From a cognitive standpoint,  the patient must understand the instructions  for how to take the medication. These instructions  are often complex,  especially when multiple medications, each with its own regimen of doses and times, are presented. Thus, combining the information across multiple medications,  and integrating  all of this information  with daily activities to form a plan of action, can be quite challenging. Once the plan of action is created, the patient must remember to take the medication at the correct time and must remember what dose and what medication to take. Moreover, the patient must keep track of whether or not the medication was taken so that extra doses are not taken inadvertently (i.e., reality monitoring). Reality monitoring can be particularly challenging when a medication for a chronic condition  has been taken at the same time of day for months or years. Finally, the patient should monitor his or her health for a range of possible side effects from the medication, including symptoms such as confusion and forgetfulness.

4. Prospective Memory And Episodic Memory: Age-Related Changes And Effects on Adherence

Clearly, cognitive factors such as language comprehension (e.g., understanding  the medication instructions), long-term memory (e.g., remembering what to do), working  memory  (e.g., juggling the  competing demands  of everyday  tasks  and  medication  taking), problem solving (e.g., integrating complex medication instructions  with the daily routine),  prospective memory (e.g., remembering  to take the medication  at the correct time), and metamemory (e.g., monitoring memory performance and judging whether external support is needed for adequate adherence) all are involved  in  determining  whether  correct  adherence will  occur.  Although  age-related  losses  in  many  of these areas have been clearly established,  many older adults are able to maintain high levels of performance, especially on everyday tasks such as medication taking.

Many language abilities are maintained into very old age. However, the comprehension  of complex medication instructions  may depend heavily on working memory capacity as well as language abilities. Age-related losses  in  working  memory  and  problem  solving  are well documented.  It is clear that if information  is presented  quickly or is presented  using an unfamiliar  or disorganized format, many older adults will have difficulty in comprehending  and recalling the information. Many studies  have  shown  that  older  adults  are  at  a distinct disadvantage, compared with younger adults, when  asked to combine  complex  medication  instructions into a plan of action, especially if the instructions require inferences. Such problems have also been found when older adults are asked to transfer medication into weekly pillboxes, especially if the pillboxes do not contain multiple compartments  for each day.

To take medications  correctly,  the patient  not  only must understand  the instructions  when they are given but also must remember these instructions over the days and weeks following the meeting with the physician. In general, age-related losses are also observed when the ability to recall verbal information after a relatively long interval (i.e., hours or days) is measured. However, age differences can be greatly reduced, at least for relatively healthy older adults, if environmental supports for recall are present.  For  example,  if information  is presented clearly, if multiple  formats are used (e.g., written  and verbal presentation), if recall is based on  habitual  or familiar activities, if cues for recall are present  in the environment,  and  if the  person  is  not  distracted  by competing  stimuli at time of recall, age differences in episodic memory are greatly reduced or even eliminated. Although it is well documented  that  there  are age-related  losses in  working  memory,  problem  solving, and long-term memory, prospective memory does not show the same rates of decline with age. For example, when asked to make a telephone call or mail a postcard at a certain time, older adults attain performance levels similar or superior to those of younger adults through the use of memory strategies. This may help to explain why older adults do not make more medication errors than  do  younger  adults.  Park  and  colleagues  have speculated  that adults in their  60s and 70s may have few adherence  errors because (a) they are sufficiently focused on their health to adopt mnemonic  strategies for  medication  (unlike  middle-aged  adults)  and  (b) they have the cognitive ability to adopt and use mnemonic strategies (unlike much older adults).

In laboratory-based studies of prospective memory, it has been suggested that prospective memory tasks can be divided into time-based and event-based tasks. In a time-based task, the individual must accomplish the task at a certain time (e.g., ‘‘Take your pill at 8 AM’’), whereas in an event-based task, the individual must accomplish the task when cued by a specific event (e.g., ‘‘Take your pill before breakfast’’). Computer-based  simulations  of prospective memory tasks have shown that event-based tasks are easier for older adults to accomplish, especially if the accompanying background task is not particularly difficult. This may also explain why many older adults report that the main strategy they use to remember their medication is to mentally link the medication with routine daily activities. It may also explain why some studies have  found   that   tailoring   medication   regimens   to patients’ routines enhances adherence significantly.

5. Knowledge, Beliefs, And Communication: Age-Related Changes And Effects On Adherence

At least three major foci in the research on the motivational factors of adherence in old age can be identified. First, the beliefs and attitudes that the patient has about his or her illness have been shown to predict adherence. Some people may deny that  they are ill or might not believe that their conditions have serious consequences.

Patients who are more knowledgeable about their conditions are more likely to follow recommended medication regimens. This may also explain why social support has been  found  to predict  adherence.  It may be that significant others play a role in motivating an individual to adhere.  Providing  cues or reminders  to follow the prescription  also may play a role.

A second factor concerns the beliefs that the patient holds  about  his  or  her  treatment.  Beliefs about  the effectiveness of the medication, about whether the regimen prescribed is appropriate, about whether medications cause uncomfortable side effects, and about how important  it is to adhere  to medication  regimens  as prescribed have been shown to contribute  to treatment adherence.  Thus,  some older  adults  may simply not believe that  their  medication  is helpful.  Others  may choose  underadherence to avoid side effects or  may overmedicate because they believe that the prescribed dose is ineffective. (It  should  be noted  that  because many health care professionals lack extensive knowledge about the effects of medications—especially multiple medications—on the older body, partial adherence may be beneficial in at least some cases.)

Finally,  a  third  set  of factors  revolves around  the relationship with the health care provider. This relationship is critical in many ways. Medication adherence can be seen as the outcome of a process that begins before the physician and patient even meet. Namely, the attitudes  and beliefs that  each holds about  the other  are likely to affect patient–physician  interactions  in at least two ways. First, the quality of the interaction and the satisfaction that the patient feels with his or her health care are very important predictors of motivation to adhere to a medication regimen. Second, the relationship may also affect the quantity and quality of the information that is exchanged during the patient–physician  encounter.  For adherence to occur, the patient must be told how to take the medication in detail and must be informed about his or her condition and its associated risks. Unfortunately, many studies suggest that health care providers are less likely to provide this information to older patients than to younger ones, and older patients are also less likely to question  their  physicians.  Thus,  even  though  older adults are likely to be taking more medications and to have more  complex  regimens,  they are also likely to receive   less   information    about   their   medications. Finally, the relationship  between the health  care provider and the patient also affects the quality of the information  that  the patient  provides.  In other  words, the patient is more likely to provide accurate and detailed information  about his or her symptoms and adherence to existing medications when the patient perceives the health care provider to be caring and approachable. Such accurate information is key for the health care provider to be able to make accurate  diagnoses and  treatment decisions.

In conclusion, even though the relationship between the health care provider and the patient  is commonly addressed  from a social psychology perspective,  this relationship  has important  cognitive repercussions  as well. The  patient’s knowledge  about  the  illness  and medication and his or her beliefs about the importance of adherence  are often highly dependent  on how well and how comfortably the patient  communicates  with the health care provider.

6. Measuring Adherence: A Difficult Challenge

The  difficulty of measuring  medication  adherence  is well established  and often discussed in the literature. Both technical and nontechnical  approaches have been used. One technical approach  has been the evaluation of body fluids (e.g., blood, urine)  for the presence of the  prescribed  medication.  However,  this  technique only recognizes drugs ingested during  the recent past and does not indicate whether the patient has taken the medication regularly. Pharmacy refill rates and pill counts have also been used; however, with these methods, flawed data  are obtained  if the  patient  is using multiple pharmacies, disposing of pills, hoarding pills, and/or  sharing  pills  with  others.  The  most  accurate data come from a specially designed pill bottle with a lid containing a microchip that records every time the bottle is opened.  However, even this system still does not provide an accurate measure of whether the drugs were actually taken  when  the pill bottle  was opened and  does not  verify whether  the  correct  doses  were taken.  Although  these  special  pill  bottles  are  useful for research  purposes,  their  general use remains limited because they are very costly.

The most convenient and the most often used means of assessing adherence  is self-reports.  However, it is clear that  self-reports  underestimate  medication  errors. Patients are likely to overestimate their adherence levels, not only because they do not recall errors but also because they hope to avoid confrontations and/or embarrassment. Cognitive  factors  also  contribute   to  the  accuracy  of self-reports.  When  asked  to  recall  the  frequency  of a behavior,  respondents  are likely to reduce  their  efforts by estimating rather than counting, and this is especially true of older adults. Moreover, with older adults, memory complaints are often not predictive of objective memory performance. Thus, the older adults who complain about having bad memories might not be the ones who make adherence errors due to forgetting. Despite the potential pitfalls of self-reports, recent work by Hertzog and colleagues suggests that when older patients are asked specific questions about memory problems relating to medication  adherence  rather  than general memory performance, self-reports can be quite useful.

7. Interventions: How Cognitive Psychology Can Help

Much of the intervention research has focused exclusively on compensating for either cognitive or motivational deficits. Many studies have focused on providing  older adults with external mnemonic strategies. Such strategies involve effecting changes in the environment  so that it provides  prospective  memory cues. Many studies  have been carried out to investigate the effectiveness of aids such as pillboxes and pill bottle alarms, memory training, voice mail reminders, and organizational charts. Most of these studies found such memory aids to be at least somewhat effective in enhancing  medication  adherence. However, many of these studies were conducted  over a short period of time, and neither young nor older adults are likely to continue using memory strategies assigned to them after the training period has ended. It is also interesting to note  that  the  few studies  that  examine  what strategies  older  adults  use spontaneously  tend  to  find that internal strategies (i.e., using mental actions to help encode or retrieve information) are reported quite often. However, very little is known about the effectiveness of internal  strategies for routinized,  long-term prospective tasks such as medication adherence. Also, little is known about what drives the process of determining that a mnemonic strategy is necessary, deciding which one to use, and evaluating its effectiveness.

One external strategy that is being adopted by many older adults is the use of pillboxes with daily compartments.  However, as noted  previously,  at  least  some older adults have difficulty in transferring  pills to the container  correctly, at least when the smaller versions are used (i.e., only one compartment  per day), and the larger containers have the disadvantage of being bulky and   might   not   be   practical   unless   patients   are housebound.  Recently, attempts  to reduce  adherence errors have focused on using technological advances in how medication  is presented  to patients.  Some have speculated that as pharmaceutical  science continues to advance, medications will be released into the body in a controlled  fashion (e.g., slow-release pills), thereby making  frequent  doses and  complex  regimens  unnecessary. More immediately,  the use of individualized packaging is becoming more affordable and common. For example, when blister packs are used, the time to take the medication  can be listed on the package, and monitoring whether the medication has been taken becomes much  easier. However, when  patients  must take many different medications, each in its own blister pack, the packaging may increase rather than decrease the confusion (and be large and bulky to transport  as well). Finally, increases in adherence  levels have also been obtained  in studies  that  addressed  motivational factors. These studies focused on improving the relationship between the physician and the patient or tried to  educate  the  patient  as  to  the  seriousness  of the illness or the importance of the medication.

In conclusion,  many  different  interventions  can  be useful, but there is a growing recognition that the intervention applied must be tailored to the characteristics of the patient.  Clearly, it is not helpful to provide  mnemonic  strategies  to  someone  who  is nonadherent by choice, and neither is it helpful to convince someone of the importance  of medications if the person cannot remember  to  take  them.  Thus,  cognitive  psychologists today are working in collaboration with health care providers  to develop exciting multifaceted  approaches that  tailor  cognitive and motivational  interventions  to the needs, abilities, and beliefs of individual older adults.

References:

  1. Brandimonte, M., Einstein, G. O., & McDaniel, M. A. (1996). Prospective memory: Theory and applications. Mahwah, NJ: Lawrence Erlbaum.
  2. Johnson, M. J. (2002). The medication  adherence  model: A guide for assessing medication taking. Research and Theory for Nursing Practice: An International Journal, 16, 179–192.
  3. McElnay, J. C., & McCallion, R. (1998). Adherence in the elderly. In L. B. Myers, & K. Midence (Eds.), Adherence to treatment in medical conditions (pp. 223–253). Amsterdam: Harwood Academic.
  4. Murdaugh, L. (1998).  Problems  with  adherence  in  the elderly.  In S. A. Shumaker,  E. B.  Shron,  J. Ockene,  & W.  L. McBee (Eds.),  The handbook of health  behavior change (2nd ed., pp. 357–376). New York: Springer.
  5. Park, D. C., & Jones, T. R. (1997). Medication adherence and aging. In A. D. Fisk, & W. A. Rogers (Eds.), The handbook of human factors and the older adult (pp. 257–287).  San Diego: Academic Press.
  6. Park, D. C., Morrell, R. W., & Shifren, K. (1999). Processing of medical information in aging patients: Cognitive and human factors perspectives. Mahwah, NJ: Lawrence Erlbaum.

See also:

Free research papers are not written to satisfy your specific instructions. You can use our professional writing services to order a custom research paper on any topic and get your high quality paper at affordable price.

ORDER HIGH QUALITY CUSTOM PAPER


Always on-time

Plagiarism-Free

100% Confidentiality
Special offer! Get discount 10% for the first order. Promo code: cd1a428655