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Enhancing Medication Adherence in Older Adults: Impact of Presentation Formats

This study explores the impact of different presentation formats on medication adherence in young and older adults. The goal is to improve drug prescription comprehension and execution in elderly and Parkinsonian patients.

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Enhancing Medication Adherence in Older Adults: Impact of Presentation Formats

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  1. Filling a pillbox from a medication prescription displayed on a tablet Impact of presentation formats in young and older adults Vandenbergh*, Élodie ; Hainselin*, Mathieu ; Quaglino*, Véronique ; Mouras*, Harold & Heurley*, Laurent * CRP-CPO EA 7273 Université de Picardie Jules Verne - 80025 Amiens CEDEX 1 elodie.vandenbergh@gmail.com laurent.heurley@u-picardie.fr

  2. The CONSIGNELA Project • Context: the presentstudyis part of the CONSIGNELA Project CONSIGNELA = CONSIGNes Électroniques Adaptées (Adaptedelectronic instructions) • Goal: to improve drug prescription comprehension and execution in elderly and parkinsonian patients • Partners: • Funding: Regional Council Hauts-de-France and the European Regional Development Fund (FEDER)

  3. Medication non-adherence • Medication non-adherence (non-compliance) • Non-adherence = deviationsfromprescription • Veryfrequent:  50% non-adherent patients • Consequences: reducedquality of life, rehospitalisations,… death. • Multifactorial and complexphenomenon Baudrant-Boga, Lehmann, &Allenet (2012) • Older patients: Three important factors(Heinrich& Karner, 2011; Morrow et al., 2004) • Regimencomplexity • Age-relateddecrease of perceptual, motor and cognitive capacities • Inadequate patient-provider communication

  4. Regimen complexity • Multiple chronic illnesses & polypharmacy: • Multiple chronic illnesses (Bainbridge & Ruskin, 2009) • “many drugs” or “too many drugs” (Hughes et al., 2016; Tandy & Bamford, 2010) • Self-medication(Bainbridge & Ruskin, 2009) • Complex and changing administration schedules: • Multiple doses at different moments of the day (Bainbridge & Ruskin, 2009) • Multiple changes in the patient’s therapy (Malek& Grosset, 2015)

  5. Decrease of: Executivefunctions: planning, inhibition, … (Collette & Salmon, 2014) Memory: working memory, prospective memory (Guillaume et al., 2009; Insel et al., 2013) Comprehension(Lauverjat, et al., 2005) Cognitive performances under time pressure (Logie et al., 2015) Age-related decrease of cognitive capacities

  6. Inadequate patient-provider communication • Different sources and standard (inadequate) documents: • Oral instructions: • Doctor’s instructions • Pharmacist’s instructions • Other sources (e.g., internet, etc.) • Visual instructions: • Doctor’s prescription • Medicationleaflet and package • Annotations written by the pharmacist • Other sources (e.g., internet, etc.) • McCarthy et al.(2012); Serper et al.(2013); Tarn et al. (2008) Wolf et al. (2007, 2009)

  7. Inadequate patient-provider communication • Written or printed « ordonnance » • « prescription » • Patient information leaflet • Package insert • Package information • Annotations written by the • pharmacist Source: http://www.popcenter.org/problems/prescription_fraud/print/ Source: https://www.shop-pharmacie.fr/p/ibufetum-ibuprofene-gel-5-60-g-10002093.html • Too many sources

  8. Inadequate patient-provider communication • « Ordonnance » • « Prescription » Source : http://medicalschoolhq.net/prescription-writing-101/ • Inadequate presentation Source : www.droitpharma.fr/8/ordo_reg.htm

  9. How to improve patient-provider communication? • How to make prescriptions more understandable? … by adopting a multidisciplinary patient-centered approach: • Medical • Technological • Cognitive Morrow et al. (2004); Morrow (2015)

  10. Medical patient-centered approach • Simplifications and visualaids: • Lexical simplification • Visual aids: tables, illustrations (pictograms or photographs), medicationschedules Morrow, Leirer, Andrassy, Hier, & Menard (1998) Chuang, Lin, Wang, & Cham (2010)

  11. Medical patient-centered approach • Table format is often used as an aid to communicate « prescriptions » Hawkins & Firek (2014) Cordasco et al. (2009)

  12. Medical patient-centered approach • Table format: MedtableTM Morrow et al. (2008)

  13. Medical patient-centered approach • Table format advantages: • Integrated presentation of information • Spatialisation of information • More concretethan verbal instructions  bettercomprehension • Isomorph to pillboxfillingtask • Adapted to patients withlowhealthliteracy / lowlevel of education

  14. Technological patient-centered approach • Electronic collaborative tools: Electronic Medical Record (EMR) – integrated tool and Medtable™ Morrow (2015); Morrow et al. (2012)

  15. Technological patient-centered approach • Touchscreens and tablets: Piper & Hollan (2013)

  16. Cognitive patient-centered approach • Cognitive psychology and cognitive neuropsychology: • Concepts:procedural documents, mental model (situationalmodels) • Models:procedural document processing • Methods:experimentalparadigms

  17. Cognitive patient-centered approach / concepts • Procedural documents • Proceduraldocuments = documents designed to communicateprocedures • Procedures= actions to execute to reach a goal • One must distinguish: PRESCRIPTION and «Prescription»: • PRESCRIPTION = procedurethat patients shouldexecute « prescriptions » & « ordonnances » « table medicationschedules » = proceduraldocuments Visual aids • A « prescription » is a specificreification of a PRESCRIPTION

  18. Cognitive patient-centered approach / concepts • PRESCRIBER • PROCEDURAL DOCUMENT(S) • PATIENT • PRESCRIPTION (procedure): • How to take drugs • Instructions given in a particular format • Actions • What is the most adequate presentation format and why?

  19. Cognitive patient-centered approach / concepts • To execute instructions from a procedural document: A complextask • Multiple cognitive processes involved : • Understanding= mental model (Ganier 2004) / situation model (Morrow, 2015) “For medication instructions, the situation model represents how to take the medication, including how much to take, when to take it, and what warnings to keep in mind” (Morrow et al., 1998) • Remembering (episodic and semantic memory) • Planning(prospective memory) • Deciding and monitoring • Acting (procedural memory; motor planning, control and execution)

  20. Cognitive patient-centered approach / models • Presentation format  mental model construction • Illustrations: + • Animations: + - • Table format: + ? A model of procedural document processing Source : Ganier (2004)

  21. The study • Objectives: • To analyze the impact of two presentation formats (table vs. sheet) on prescription comprehension and execution in older and young adults • To control possible biases with an experimental procedure • General procedure: • Procedure adapted from a previous study (Heurley, Vandenbergh, Quaglino, 2013) • Participants were given a tablet and had to: • Study at their own rhythm two fictive prescriptions displayed either in a table or in a sheet format (non tabular format) • Fill a pillbox from memory immediately and after a 30 minute delay.

  22. Method • Prescriptions: • Each prescription = 4 medications / 6 days • One medication per page; • Two formats: table vs. sheet Table format Sheet format

  23. Materials • Medication type: • 2 regular intake medications • 2 irregular intake medications Irregularintake Regular intake

  24. Method • Procedure: Delay: 30 min

  25. Participants • Participants: 32 youngadults / 32 olderadults Table 1. Samplecharacteristics NS = non significant

  26. Variables and design • Independent variables: • Age (A: young vs. older) • Format (F: tabular vs. sheet) • MedicationType (T: regularintake vs. irredularintake) • Pillboxfillingdelay (D: immediate vs. 30 min.) • Design:S32 < A2 > * F2 * T2 * D2

  27. Hypotheses • Main hypotheses: • Hyp 1: Format • Hyp 2: Age • Hyp 3: Age x Format interaction • Secondaryhypotheses*: • Hyp4: Type • Hyp5: Age x Type • Hyp6: Delay • Hyp 7: Age x Delay *As thesehypotheses are beyond the scope of the present communication theywon’tbedetailedlater

  28. Results • Analyses: • Level of significance: 0.05 • Non-parametricstatistics: • Repeatedmeasures: Wilkoxonrank test for relatedsamples • Group analyses: Mann-Whitney U test for independentsamples • Dependent variables: medians and IQRs • Medianstudying time (sec.) • Medianpillboxfilling score (%)

  29. Results / Hypothesis 1: Format * * NS p > .05 * p < .05 * * p < .01

  30. Results / Hypothesis 1: Format * *

  31. Results / Hypothesis 2: Age NS

  32. Results / Hypothesis 2: Age * *

  33. Results / Hypothesis 3: Age x Format * * * *

  34. Results / Hypothesis 3: Age x Format * * *

  35. Discussion • Hypothesis 1 / Format: • Adequate format  better comprehension • Adequate format  better execution • Hypothesis 2 / Age: • No age effect during the prescription studying phase • Age effect on execution • Hypothesis 3 / Age x Format: • Format effect for both ages • Limits of the study

  36. Discussion • A multidimensionalapproachisuseful … • Patient-centeredapproach • Cognitive modelsfrom cognitive psychology • Medical expertise / experience • Interactive electronicdevices … to improve patient-provider communication

  37. References • Baudrant-Boga, M., Lehmann, A., & Allenet, B. (2012). Penser autrement l’observance médicamenteuse : d’une posture injonctive à une alliance thérapeutique entre le patient et le soignant – Concepts et déterminants. Annales Pharmaceutiques Françaises, 70(1), 15–25. http://doi.org/10.1016/j.pharma.2011.10.003 • Chuang, M., Lin, C.-L., Wang, Y.-F., & Cham, T.-M. (2010). Development of Pictographs Depicting medication Use Instructions for Low-Literacy Medical Clinic Ambulatory Patients. Journal of Managed Care Pharmacy, 16(5), 337–345. • Cordasco, K. M., Asch, S. M., Bell, D. S., Guterman, J. J., Gross-Schulman, S., Ramer, L., … Mangione, C. M. (2009). A Low-Literacy Medication Education Tool for Safety-Net Hospital Patients. American Journal of Preventive Medicine, 37(6), S209–S216. http://doi.org/10.1016/j.amepre.2009.08.018 • Ganier, F. (2004). Factors Affecting the Processing of Procedural Instructions: Implications for Document Design. IEEE Transactions on Professional Communication, 47(1), 15–26. http://doi.org/10.1109/TPC.2004.824289 • Hawkins, L. A., & Firek, C. J. (2014). Testing a novel pictorial medication sheet to improve adherence in veterans with heart failure and cognitive impairment. Heart & Lung: The Journal of Acute and Critical Care, 43(6), 486–493. http://doi.org/10.1016/j.hrtlng.2014.05.003 • Heurley, L. (2014). Les documents procéduraux : l’apport de 40 ans de recherche en psychologie cognitive et en ergonomie. Le Discours et La Langue, 5.2, 39–51. • Heinrich, C., & Karner, K. (2011). Ways to optimize understanding health related information: the patients’ perspective. Geriatric Nursing, 32(1), 29–38. http://doi.org/10.1016/j.gerinurse.2010.09.001 • Hughes, C. M., Cadogan, C. A., Patton, D., & Ryan, C. A. (2016). Pharmaceutical strategies towards optimising polypharmacy in older people. International Journal of Pharmaceutics, (2015). http://doi.org/10.1016/j.ijpharm.2016.02.035 • Logie, R. H., Horne, M. J., & Pettit, L. D. (2015). When cognitive performance does not decline across the lifespan. In R. H. Logie & R. G. Morris (Eds.), Working memory and ageing (pp. 21–47). London: Psychology Press. • Malek, N., & Grosset, D. G. (2014). Medication adherence in patients with Parkinson’s disease. CNS Drugs, 29(1), 47–53. http://doi.org/10.1007/s40263-014-0220-0 • McCarthy, D. M., Waite, K. R., Curtis, L. M., Engel, K. G., Baker, D. W., & Wolf, M. S. (2012). What Did the Doctor Say? Health Literacy and Recall of Medical Instructions. Medical Care, 50(4), 277–282. http://doi.org/10.1097/MLR.0b013e318241e8e1 • Morrow, D. G. (2015). Technology-Based Support for Older Adult Communication in Safety-Critical Domains. Psychology of Learning and Motivation - Advances in Research and Theory (Vol. 64). Elsevier Ltd. http://doi.org/10.1016/bs.plm.2015.09.008

  38. References • Morrow, D. G., Conner-Garcia, T., Graumlich, J. F., Wolf, M. S., McKeever, S., Madison, A., … Kaiser, D. (2012). An EMR-basedtool to support collaborative planning for medication use amongadultswithdiabetes: Design of a multi-site randomized control trial. ContemporaryClinical Trials, 33(5), 1023–1032. http://doi.org/10.1016/j.cct.2012.05.010 • Morrow, D. G., Leirer, V. O., Andrassy, J. M., Hier, C. M., & Menard, W. E. (1998). The Influence of List Format and Category Headers on Age Differences in UnderstandingMedication Instructions. ExperimentalAgingResearch, 24(3), 231–256. http://doi.org/10.1080/036107398244238 • Morrow, D. G., Raquel, L., Schriver, A., Redenbo, S., Rozovski, D., & Weiss, G. (2008). External support for collaborative problem solving in a simulated provider/patient medication scheduling task. Journal of Experimental Psychology-Applied, 14(3), 288–297. http://doi.org/10.1037/a0012809 • Morrow, D. G., Weiner, M., Deer, M. M., Young, J. M., Dunn, S., McGuire, P., & Murray, M. D. (2004). Patient-centered instructions for medications prescribed for the treatment of heart failure. The American Journal of Geriatric Pharmacotherapy, 2(1), 44–52. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15555478 • Piper, A. M., & Hollan, J. D. (2013). Supportingmedical communication for older patients with a sharedtouch-screen computer. International Journal of MedicalInformatics, 82(11), e242–e250. http://doi.org/10.1016/j.ijmedinf.2011.03.005 • Serper, M., McCarthy, D. M., Patzer, R. E., King, J. P., Bailey, S. C., Smith, S. G., … Wolf, M. S. (2013). What patients thinkdoctors know: Beliefs about provider knowledge as barriers to safemedication use. Patient Education and Counseling, 93(2), 306–311. http://doi.org/10.1016/j.pec.2013.06.030 • Tandy, C., & Bamford, L. (2010). Medication compliance aids. EuropeanGeriatricMedicine, 1(5), 314–316. http://doi.org/10.1016/j.eurger.2010.07.013 • Tarn, D. M., Paterniti, D. A., Kravitz, R. L., Heritage, J., Liu, H., Kim, S., & Wenger, N. S. (2008). How much time doesittake to prescribe a new medication? Patient Education and Counseling, 72(2), 311–319. http://doi.org/10.1016/j.pec.2008.02.019 • Heurley L, Vandenbergh E, Quaglino V. (2013) Effet sur la compréhension du format de prescriptions médicamenteuses présentées sur tablette multimédia : étude comparative chez des personnes jeunes et âgées saines. In Actes du 55ème congrès de la Société Française de Psychologie (p. 120‑121). Lyon. Retrievedfrom http://www.sfpsy.org/congres2013/2013 Lyon/ActesSFP2013.pdf • Wolf, M. S., Davis, T. C., Shrank, W., Rapp, D. N., Bass, P. F., Connor, U. M., … Parker, R. M. (2007). To errishuman: Patient misinterpretations of prescription drug label instructions. Patient Education and Counseling, 67(3 SPEC. ISS.), 293–300. http://doi.org/10.1016/j.pec.2007.03.024 • Wolf, M. S., Shekelle, P., Choudhry, N. K., Agnew-Blais, J., Parker, R. M., & Shrank, W. H. (2009). Variability in PharmacyInterpretations of Physician Prescriptions. Medical Care, 47(3), 370–373. http://doi.org/10.1097/MLR.0b013e31818af91a

  39. Thank you for your attention

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