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Pharmacy care in older patients

Trial
Results
Comment

We know that many people do not take medicines prescribed for them, and that adherence rates are often low. We also know that older people have problems with their medicines, often because they are prescribed many medicines, to be taken at different times of the day. Finally, we know that major influences on admission to hospital with adverse drug reactions include older age, being a woman, and having lots of tablets to take.

It does not need a brain the size of planet to see that there are some problems here needing to be solved. A trial from the USA [1] suggests that extremely good adherence results can be had from some simple interventions from pharmacists that help older people understand and manage their medicines.

Trial

This is an interesting example of a randomised withdrawal trial design outlined in Figure 1.



Figure 1: Randomised withdrawal design of study of pharmacy care in older patients with multiple health problems





  1. All patients entered a two-month run in period used to ascertain baseline adherence, and measure blood pressure and cholesterol.
  2. After this, all patients entered an intervention phase, during which they received their drugs individualised in blister packs with tablets labelled for time of day. This was supplemented with individualised education visits, and follow up with a pharmacist every two months. These visits taught patients about their drugs, their names and indication, strengths, adverse events and usage instructions.
  3. After six months, patients were randomised to continuing the intervention or usual care.

Adherence, blood pressure, and cholesterol were measured during the run in period and at the end of each six-month period.

Results

Initially 200 patients entered the run in period, and 159 were eventually randomised. Their average age was 78 years (minimum 65 years), 77% were men, 57% had four or more health problems, with an average of nine chronic medications. There were high levels of use of statins and blood pressure medicines.

Results for adherence are shown in Table 1. The pharmacy care programme resulted in a large increase in adherence, with the proportion of patients more than 80% adherent to all medicines increasing from just 5% in the run in period to 99%. After randomisation, the intervention group maintained these high levels of adherence, while return to usual care resulted in a large decrease in adherence, approaching rates seen in the run in period.



Table 1: Median adherence (% of all tablets taken) and percentage of patients taking at least 80% of all medicines



Randomised to
Run in
Intervention
Usual care
Intervention
Month
2
8
14
14
Median adherence (%)
62
99
68
96
>80% adherence to all medicines
5
99
22
97


Increased adherence resulted in large reductions in systolic and diastolic blood pressure during the intervention period; For LDL-cholesterol there useful reductions in both groups maintained after randomisation, with no significant difference between them.

Comment

This is a very important study, which shows that to achieve high adherence in older people with multiple health problems and medications, continuing intervention is needed. The paper, and especially the thoughtful discussion, should be read by anyone wanting to do better.

The benefits of high adherence are potentially large, given the generally low adherence usually seen in these circumstances, and given that low adherence is associated with increased rates of hospital admission. This is not a simple answer to a simple problem, but an indication that with insightful pragmatic action much better outcomes can result.

After all, the pills are better in the patient than in a bottle. If the latter we pay twice, in unused medicine and more healthcare costs. Given the acknowledged size of the problem, the implication is that this is a topic area that requires some sensible research and action.

Reference:

  1. JK Lee et al. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol. A randomized controlled trial. JAMA 2006 296: 2563-2571.

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