Medication Regimen Self-efficacy
The average MSE scores of a patient measured the patient’s confidence that he/she was managing the regimen correctly (5 = totally confident and 1 = not at all confident). The participants in this sample were highly confident that they were following their regimen correctly. Of the 41 patients, 34 (83%) were very confident (MSE = 4) to totally confident (MSE = 5) that they were following their regimen correctly. Eleven patients (17%) scored 3 or less on the MSE.
Outcome Expectation Scores
There was a small, not significant negative correlation between outcome expectation self-efficacy (OESE) scores and risk scores (r = −0.27, n = 41, P < .095) (Figure 4). The relationship between age and outcome expectation score was investigated using the Pearson product-moment correlation coefficient. Because outcome expectation scores were not normally distributed, a nonparametric correlation was conducted. The test yielded no significant correlation between age and outcome expectation score in the sample measured; however, on average, the outcome expectation score went down as the participant’s age increased. In addition, both the mean and median outcome expectation scores were somewhat lower for men than those for women (male mean, 3.6 [SD, 1.3]; female mean, 4.2 [SD, .85]; male median, 3.8; female median, 4.5).
A total of 21 patients were interviewed to obtain qualitative data. Ten of these participants had low self-efficacy scores, and 11 had high scores. Analysis of the transcripts revealed 3 themes, which were identified as social support, attitudes and beliefs, and formulating coping strategies. All patients told a story of either a positive or negative transition learning to manage their new reality.41 Social support as well as the patient’s own philosophy of life promoted either a positive or negative experience during this transition. Patients often described symptoms within the context of a situation. Those with higher self-efficacy scores related a sense of confidence in their ability to manage daily life; however, patients with lower self-efficacy scores recounted feelings of discouragement. Patients with low HF MSE and OESE presented a narrative of being lost and alone. They were often overwhelmed because of the complexity of routine care. These factors and the themes derived became clearly articulated in the words of patients.
Patients with high self-efficacy scores described support systems and the comfort they provided. Social support included family, friends, neighbors, and peers. Patients who did live alone but who felt they could depend on a family member nearby related more positive self-efficacy scores. Family included spouses, partners, sons and daughters, nephews, and grandchildren. Patients relied on different individuals for assistance, but in all cases, they were aware of how important this support was to their well-being. A woman living with her domestic partner simply stated:
I could not do it without her.
Others told stories of “fantastic neighbors” who would shovel their driveway in the snow. One participant called these friends “angels.” For all participants, social networks were carefully constructed to enhance their ability to continue to function successfully within the confines of their limitations.
We have a good support system through the church. Thursday we are going to XXXX… to see if a pacemaker or defibrillator might help me. A fellow from the church and his wife are going to drive us….
In order to maintain social connections, participants made adjustments to their daily routines and set goals to maintain social connections.
I know on Monday mornings I have to take it easy, because I like to go to tai chi. If I start cleaning up, I will get too tired. I go mostly to see my friends.
A grandmother articulated the concepts of adjustment and goal setting by stating that she stayed home on Fridays, which allowed her to attend her grandchildren’s sports games.
I like to get out with a goal… because I will see my grandchildren in their soccer games.
Patients with lower self-efficacy scores often lived alone, and their story related a sense of discouragement. One gentleman described the effect of being alone on his healthcare practices by saying:
I live alone; my children don’t live near me. I use my medicine box, but I still find that I miss some medications. I don’t remember, the days run together….
A widower apologized for his sense of discouragement:
I am home most of the time; I don’t go anywhere… I am legally blind. I cannot read print. I am sorry I cannot be more positive.
Apologizing for feeling discouraged was not limited to 1 participant. A recovering alcoholic who had been sober for 17 years and lived alone without family support also apologized when he self-rated his health as poor. He was fairly confident he took his medication correctly; most were taken early in the morning, but when asked if he felt they were helping, he stated:
I am not sure… I’ll be honest with you; I am not sure how much good they are… I really don’t know. I am overwhelmed really; I am taking so much stuff.
It is clear that social support improved the self-efficacy and facilitated the transition of the patients interviewed in this study.
Attitudes and Beliefs
The patient’s perspective of life was influenced by his/her own attitudes toward spirituality, life’s purpose, and current quality of life. Patients offered a myriad of thoughts and feelings encountered within the framework of transitioning to their altered daily lives. Attitudes and beliefs, as well as personal characteristics, played a role in the adaptation of patients to living with HF. Confronted with unfamiliar situations, patients drew on inner strength and personal beliefs to successfully live with HF. Patients with high self-efficacy related that one could not expect to feel well every day.
Patients with high OESE believed that their medications were of benefit to them; they believed that they helped them feel better and improved their quality of life. They described positive attitudes and beliefs. One woman stated, “I have a very good attitude toward the whole thing. I think you have to think positively, not dwell on what you think might happen.” Another participant summed up the feeling of many who believed that they had to maintain a positive attitude to maintain their current health status: “I don’t let anything stress me out; I can’t have that in my life.”
In contrast to those who were positive about their situation, patients with low self-efficacy were often ambivalent about their daily routines because of the fatigue that resulted from their daily care. A gentleman articulated this sense of despair when he stated:
It is getting tiresome. I am seeing a psychiatrist once a week. I am 70… I feel beat most of the time.
Formulating Coping Strategies
Patients with high overall self-efficacy scores described behaviors used to adhere to their regimen. A retired army officer related a story of the systematic approach required to successfully maintain a level of wellness, which included daily exercise. Patients related the careful details of charts, pill boxes, and alarms used to remember medications along with anyone who would work with them to ensure the accuracy of the procedure. This confidence was expressed frequently in a very matter-of-fact way.
I have been taking them for such a long time. I know what I am doing.
Another retired officer stated that he knew how to take care of himself. He cooked for himself but confessed he was not a very good housecleaner; cleaning required more energy; it made him too tired. He was a widower and lived alone but expressed that taking his medication was “no problem at all.” He was totally confident that he followed his regimen correctly, but he scored only 2.5 on outcome expectations. He confided that the regimen was restrictive: “I am getting to be a homebody because of the medicine.”
Sadly, this avoidance of activities was described by many patients with low OESE in an attempt to allay the onset of symptoms.
Most patients interviewed in this study described both positive and negative feelings; however, those with positive self-efficacy reported a greater sense of control over variables in their lives. The themes described by patients living with HF seemed to parallel Erikson’s42 final stage of development, integrity versus despair. In brief, patients with higher self-efficacy scores demonstrated integrity; they described support systems, positive attitudes, and confidence in their ability to manage their regimen. As opposed to those with lower self-efficacy whose stories illustrated despair, patients with lower self-efficacy scores described themes of being alone and often overwhelmed with daily life. Despair is marked by persons who fear death and have lost independence and significant others. For the patients in this study who have been living with HF for some time, these descriptives seem to uncover the essence of the patients’ experience.
Patients self-identified cognitive changes and admitted to a myriad of errors and omissions. Higher risk scores were generated when patients described behaviors that added to overall risk or were prescribed medications with potential interactions, such as medications published on the Beers list. Although not statistically significant, patients with lower risk scores tended to be more confident that their medications would improve how they feel, and conversely, patients with higher risk scores tended to have less confidence in their medications’ ability to improve how they feel. These data reveal the complexity of daily life of this aging population.
Implications for Future Research
Patients living with HF find themselves in a complex world. The average age of patients in this study was 81 (SD, 8) years, and they took an average of 12.6 medications, many with multiple dose times. All patients reported at least 5 medications, a burden that increases the risk of adverse drug adverse effects as well as cost.43–45 The average computed ActualMeds risk score of the patients sampled was high, 63 (SD, 31). Most (71%) were prescribed medications not recommended for the gerontologic population.34 Patients recognized cognitive changes, and of the patients reporting AGS (2012)34 Beers list of medications, 17% had fallen within the last year. This 17% of patients carried a high ACB, and 4 of the 5 lived alone. Others reported a myriad of associated symptoms including unsteadiness, memory changes, and urinary incontinence.
More than half of the hospitals in the United States have sustained Medicare’s readmission penalties due to patient readmission within 30 days of discharge.46 Polypharmacy has been implicated in ED visits and hospitalizations in older adults.43 Greater than half of those hospitalized for all cause were older than 80 years. Two medications commonly prescribed in HF were implicated in this hospitalization: warfarin accounted for 33.3%, and oral antiplatelet agents, 13.3%.43
The 2015 revision of the Beers Criteria lists medications that increase fall risk; for patients taking 3 or more central nervous system drugs, reduction of central nervous system drugs’ burden is recommended.47 Patients taking medications on the Beers Criteria list and/or following a medication regimen with a high ACB would benefit from a medication reconciliation and medication therapy review by a nurse, pharmacist, or eligible provider at the time of discharge from the hospital and again during home healthcare treatment. In addition, results from the current study demonstrate that patients living with HF require medication oversight of their regimen following discharge from home health. The Centers for Medicare & Medicaid Services recommends reconciliation during transitions of care, such as upon hospitalization and discharge to home.48 In this study, patients were contacted at least 2 weeks following discharge from home care. Contacting patients within 1 week following discharge would provide the prescribing team (eligible provider, nurse, and pharmacist) a good assessment of changes patients are making to their regimen and be early enough to prevent complications. At that point, the nurse or pharmacist would be able to reinforce rationales for the prescribed regimen. Furthermore, when prescribers discontinue or add new medications, a member of the prescribing team should reconcile the medication regimen.
Despite high levels of confidence in their management of their regimen, patients admitted to a plethora of errors, most often because they did not remember. In addition, patients reported discrepancies with their medication record from the home care agency.
Potential risk factors for cognitive impairment include anticholinergic drug use and age.49 Ancelin et al50 found that the only highly significant predictors of mild cognitive impairment were anticholinergic drug use (P < .001) and age (P < .001) after adjustment for other possible causes.
A stunning 95% of patients surveyed in this study were taking medications with anticholinergic adverse effects and risk of cognitive impairment; severity of score needs to be addressed in order to address the patients at greatest risk. Seventy-eight percent had at least a moderate anticholinergic burden (ACB) score (≥2), and 54% had a high anticholinergic burden score (≥3; range, 3–10). It is recommended that patients be prescribed medications with lower levels of anticholinergic activity; however, patients prescribed multiple medications with lower levels of activity would be at risk of additive effects.38,39 Also, patients prescribed a single medication with higher-level activity would be at risk when self-medicating with over-the-counter medications with anticholinergic activity such as loperamide, ranitidine, cimetidine, diphenhydramine, clemastine, and cetirizine. He and Ball51 used relevant evidence-based guidelines to analyze if reduction of ACB was achievable in elderly populations. They concluded that a reduction from a high ACB of 3 was possible in 85% of cases. Their study did not address OTC medications. Patients with recognized cognitive changes or the greatest ACB or risk scores generated from a system such as ActualMeds need to be targeted to address reduction of burden, and support services should be made available to all patients.
Patients with HF are placed in a difficult situation because the HF medication guidelines1 include medications that carry a mild anticholinergic burden. As seen in this study, patients may be prescribed multiple medications according to these guidelines that engender a large anticholinergic burden. Two of the most commonly prescribed medications for the patients, metoprolol and furosemide, together yield a moderate ACB. If the patient also has atrial fibrillation and is prescribed warfarin, the patient already carries a high burden (ACB = 3). Carvedilol has no associated ACB and would be a better choice than metoprolol for patients with HF.52 Because of the compounding effects of additional medications, the regimen warrants review at times of transition, within 1 week of discharge from the hospital and/or home care, and again at a minimum of every 2 months. These reviews require continuity and should be conducted with ongoing assessment of symptoms and education around the importance of adherence to their regimen and avoidance of adverse self-medication behaviors, particularly with over-the-counter medications on the Beers list. Phone interventions could be warranted more often in patients with high-risk scores and/or high anticholinergic burden34 and should be investigated in future research.
Although there are no Healthcare Effectiveness Data and Information Set (HEDIS) performance measures specific to HF, there are HEDIS measures for use of high-risk medications in the elderly.53 The measures include the percentage of Medicare members, 65 years or older, who were prescribed at least 1 high-risk medication and the percentage of patients who received at least 2 different high-risk medications. For both measures, lower rates represent better performance. The Centers for Medicare & Medicaid Services54 is currently considering changes to HEDIS rules in 2016 that would require medication reconciliation for patients inbound on transitions of care and within 30 days after discharge.
Finally, because HF is a disorder of aging and it has been suggested that older (≥73 years) patients living with HF have a decreased ability to detect and interpret shortness of breath and HF symptoms,55 we should be providing seamless electronic communication among the entire healthcare team. Making identified high risks actionable via automatic medication action plans sent to prescribers, including an audit trail for the healthcare team to be able to monitor provider follow-up, can offer a new model of best practices in care management of older adults with HF.
Programs such as The Care Transitions Program56 present a successful option for patients with fewer support systems. Developed through the Division of Health Care Policy and Research at the University of Colorado School of Medicine, it aims to support patients through transitions and increase skills among healthcare providers by enhancing health information technology and implementing system-level interventions to improve the quality of care. One instrument that might prove beneficial for the population in this study is the Medication Discrepancy Instrument.56 The elements in this instrument include the causes and contributing factors related to adherence across the spectrum: patient level, system level, and resolution level. It has been previously validated and is widely used.
Another interdisciplinary program whose aim is to minimize disparities among vulnerable community-based elder populations is the Transitional Care Model (TCM), a nurse-led, team-based care delivery model that focuses on providing synchronous delivery of care among disciplines.57 It calls for enhanced patient engagement with a focus on barriers to elders along with shared decision making in resolution.58 The Hospital Discharge Screening Criteria for High Risk Older Adults instrument could address the need to establish those at greatest risk at the time of discharge.59 The assessment of this instrument would assist nurses in the identification of those in need and trigger post discharge interventions to insure coordination of care to those at risk after discharge. The TCM responds to the greatest threats to our healthcare system: the increasing numbers of chronically ill elderly patients generating a disproportionate amount of healthcare expenditures.60
Interdiciplinary teams can provide support to patients at greatest risk upon discharge from the hospital. One example is CareLink,61 a model that employes students during transitions to optimize patient outcomes. Interventions to support the patient’s self care including adherence to medication, diet, and monitoring in the home are guided under the oversight of faculty and community partners.
Berner62 describes the need for greater numbers of geriatricians who understand the time required to foster and build confidence in the relationship with the aging patient. Iloabuchi, Deming Mi, Wanzhu, and Counsell63 identified independent risk factors of early readmission to the hospital were living alone and poor communication with the primary care provider. Geriatric nurse practitioners could fill the void in number of geriatricians.
Ultimately, it is evident that medication review cannot be left to a primary care visit with a median time of 21 minutes in duration.64 The average length of the focused interview on medications in this study was 15 minutes.
Improving the transitions of patients living with HF is critical in the effective treatment of the disease. Strategies aimed at facilitating supportive care to those who receive a diagnosis of HF would ultimately improve the quality of life in this population. Research to enhance positive relationships and to allay inhibitors of a successful transition is needed. Barriers to a positive transition cannot be ignored. Patients living alone are at risk, and depression remains underdiagnosed and undertreated. Effective strategies would focus on patient concerns and perhaps require gender specificity. The goals to decrease adverse sequelae from medication interactions and improve how patients feel would be achieved.
What’s New and Important?
- Polypharmacy is pervasive in gerontologic patients living with HF following home care discharge for any cause.
- The medication regimens of patients living with HF are complex and include medications not recommended for the gerontologic population that can contribute to anticholinergic burden and risk of cognitive impairment.
- 95% of patients surveyed in this study were taking medications with anticholinergic adverse effects and risk of cognitive impairment.
The authors thank Anne Marie Biernacki, chief technology officer and cofounder, ActualMeds Corp, for facilitating the authors’ use of the ActualMeds solution for this study. J.G.K. thanks the University of Connecticut for support in research, and Stephen Walsh, ScD, for his assistance in quantitative statistical analysis. The authors also thank Joyce S. Fontana, PhD, RN, for her editorial assistance in qualitative analysis.
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved
anticholinergic burden; geriatrics; health transition; heart failure; medication therapy regimen