School of MedicineDepartment of Medicine

Division of General Internal Medicine and Geriatrics

IU Center forAging Research

Noll Campbell, PharmD, FASCP, BCPP

Mick Murray, PharmD, MPH

Malaz Boustani, MD, MPH

Sujuan Gao, PhD

Medication Management in Older Adults with Cognitive Impairment

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Objectives

• Identify current evidence regarding medication adherence in older adults with cognitive impairment

• Discuss possible solutions to the problem of medication adherence in cognitive impairment

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The Problem: Case of Mrs. C

• 87 yo AA female with H/O CHF, CAD, CKD, HTN, hyperlipidemia, anemia, osteoarthritis

• Chief complaint: SOB and “heart fluttering”• Not taking meds previously prescribed, hasn’t

seen PCP in a few years• Dx of new-onset Atrial fibrillation and d/c with:

Metoprolol 100mg every 12 hoursSimvastatin 20mg every nightWarfarin 2.5mg daily at 1700

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The Problem: Case of Mrs. C

• Admitted on 2/27/11 with CC of SOB• Stopped meds one month after previous

discharge, states she “Just felt better”• Diagnosis – same as previous diagnosis• Lives in own house with grandson• MMSE 24/30 - Indep with ADL, most IADL• CAM negative, abnormal CDT

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Clock Drawing Test

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The Problem: Case of Mrs. C

• Following hospitalization, home visit reveals patient has correct medications at home:Medication distributed between two boxesMed box contains variable doses of 2/5 discharge

medsWarfarin doses in med box range from 2.5-15mg

Patient unaware of what her prescribed dose should be -

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WHAT INTERVENTIONS IMPROVE MEDICATION

ADHERENCE IN OLDER ADULTS

WITH CI?

Results of a systematic review

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Search criteria and sources

• Inclusion criteriaRandomized controlled trialBlinded outcome assessmentsAdults aged 45 years or greaterDiagnosis of cognitive impairment

• Search sourcesMedline, PsycINFO, CINAHL, Google ScholarPublished articles or abstracts from 1966-Nov. 1, 2010

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Search Results

192 Full text articles reviewed

192 Full text articles reviewed

267 Articles excluded

267 Articles excluded

189 Articles excluded

189 Articles excluded

22 Excluded from additional search22 Excluded from additional search

459 Titles and abstracts reviewed

459 Titles and abstracts reviewed

Additional search of bibliographies and

reviews (n=23)

Additional search of bibliographies and

reviews (n=23)

459 Articles met initial literature search

459 Articles met initial literature search

1 included from additional search1 included from

additional search

4 Included in final review4 Included in final review

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Possible SolutionsPopulation Sample

sizeMean

Age (yrs)Intervention

Insel, 2004 Ambulatory older adults 27 78 RN-driven reminder/cueing

system

Shen, 2006 Inpatient older adults 60 79 Inpatient medication

education

Smith, 2007Ambulatory older adults

with MCI or AD14 82

Telephone or televideo monitoring at each dosing

interval

Kripalani, 2010

Ambulatory adults with

CHD420 64

Refill reminder postcards, illustrated medication

schedules, or both

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Possible SolutionsAdherence

MeasureCI

MeasurePrimary

OutcomeResult

Insel, 2004 MEMSMMSE > 1 SD below

norm

% of correct days

Adherence improved from 64.5% to 78%; no

improvement in CI group

Shen, 2006 Pill count MMSE 20-24

Medication knowledge

Improved recall of med name, dose, admin time, purpose,

and side effects

Smith, 2007 Pill count DSM-IV (MCI or AD)

% Adherence

Both methods prevented decline in adherence (seen in control group) over 6 months

Kripalani, 2010 MPR MMSE < 24

Odds of being

adherent

No benefit of any intervention in cognitively impaired group

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Summary of Interventions

• Three interventions studied medication adherence in subjects with CI: Behavioral cueing and reminder systems Telephone/televideo monitoring Inpatient medication education

• Two of three interventions revealed positive results Medication education improved knowledge Telemonitoring prevented decline in adherence

• Behavioral and reminder interventions had no impact

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Medication Assistance in CI

30

25

20

15

10

5

Cotrell V, et al. J Gerontol Soc Work 2006;47(3/4):31-46

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Potential Targets

• Caregivers report hassles with medication administration schedulesMore frequent amongst employed carers or those

caring for > 1 loved one

• Keeping multiple prescriptions filled• Medication administration difficult during “conflict

periods” Verifying response if dose not administered

• How to react to emergency or safety situations

Travis S, et al. J Gerontol A Biol Sci Med Sci 2000;55(7):M412-7

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Potential Targets

• Lack of understanding (drug vs. disease)

• Dexterity & vision (ability to open drug container)

• More frequent changes in regimen

• Higher pill burden and cost

• Forgetfullness/planning

Nikolaus T, et al. Eur J Clin Pharm 1996;49(4):255-9.Borah, et al. Curr Med Res Opin 2010;26:1957-65.Hayes T, et al. J Aging Health 2009; 21(4):567-580.

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Potential Targets

• Older adults open to electronic interventions, but not willing to payCost ranges from $40-$750Clinicians rated dispensing devices not usable by those

with cognitive impairmentAuthors felt participants were unlikely to use device

Wakefield, et al. J Gerontol Nursing 2008;34(7):15-25.

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Deliberation:

• What methods have success at individual level?

• What content should be considered?

• How should the content be delivered?

• How might an intervention change with degree of cognitive function?