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Introduction
Population aging is a global phenomenon that significantly impacts
health systems and the provision of health care. The increase in
life expectancy leads to a larger number ofolder adults who require
long-term medical therapy to maintain health and quality of life
[1,2]. However, adherence to prescribed therapy in the elderly is
often problematic and may lead to suboptimal treatment results
[2,3]. Adherence to drug therapy, that is, taking drugs by the
prescribed dose and schedule, is vital for achieving the desired
health outcomes [4]. Research shows that older adults often have low
adherence rates, which can result in complications, worsening of the
disease, and increased health care costs [5]. Depending on the study
design, nonadherence rates in the literature range from 16% to 76%
[6,7]. Nonadherence to prescribed drug therapy can have severe
consequences for the health of patients [4,8]. Improper intake or
skipping doses can reduce the effectiveness of the treatment and
lead to insufficient control of the disease [7]. Then, lack of
adherence can lead to worsening symptoms and disease, which can
result in complications or adverse effects and worse outcomes [8].
In this regard, poor adherence to therapy may require additional
medical interventions, a change in medication, or an extension of
the duration of therapy [4]. In addition, healthcare costs may
increase due to the need for additional treatment or hospitalization
[9]. Deteriorating health conditions can affect the patient's
quality of life and ability to perform daily activities. Because of
all the above, it is essential that patients, especially the
elderly, follow their drug therapy according to the doctor's
instructions to achieve optimal disease control and reduce possible
complications [8].
Understanding the factors influencing medication adherence in the
elderly is critical to developing effective interventions to improve
adherence and health outcomes [5,7]. This paper presents the most
important factors influencing adherence to therapy in the elderly
and potential strategies to improve adherence.Definition of
terms
Medication nonadherence is a complex and multidimensional
healthcare problem [5]. Adherence is the degree to which patients
can follow recommendations for prescribed treatments [10].
Compliance, adherence, persistence, and concordance are terms used
in connection with suboptimal taking of prescribed drug therapy [2].
Although often used synonymously, they provide different
perspectives on the patient-healthcare professional relationship and
appropriate medication administration. Compliance is the patient
following the doctor's recommendations, while adherence is
behavioral compliance. Compliance refers to the agreement between
the doctor and the patient about the purpose and use of the drug.
Persistence measures the time between the first and last drug intake
in cases where the patient stops therapy relatively soon after
starting the treatment [2,5].
Awareness of intentional and unintentional non-adherence is crucial
for developing effective interventions to improve drug therapy
adherence [10]. Intentional non-adherence can be considered a
process in which a patient actively chooses not to use treatment or
to follow treatment recommendations [2]. Unintentional non-adherence
refers to unplanned behavior and is less related to beliefs and
level of cognition than intentional non-adherence. Unintentional
adherence can result from forgetting and not knowing the correct way
to use medications [2].
Factors affecting adherence to drug therapy in the elderly
Many factors can affect adherence to drug therapy in olderpeople
[1,5]. They can generally be divided into three broad groups:
patient-related, drug-related, and social and economic factors.
Patient-related factors
Elderly patients, especially those with physical, cognitive, or
sensory limitations, may have difficulty taking medications properly
[1,9, 10]. For example, people with arthritis may have difficulty
opening medication bottles, while people with dementia may forget to
take their medication or take it at the wrong dose [10].
Lack of understanding of the importance of adherence to therapy can
lead to incorrect medication intake, such as skipping doses or
incorrect dosing [11]. Then, a lack of understanding about the
consequences of non-adherence to therapy can lead to an
underestimation of the severity of the disease or a lack of
awareness of potential complications [12]. In addition, the risk of
medication errors may increase, which may reduce the effectiveness
of therapy and lead to poor health outcomes. Older adults who lack
an understanding of the importance of adherence may need additional
education and support from healthcare providers to improve adherence
and achieve better health outcomes [2,7].
Older patients with a higher level of health literacy are usually
better informed about their medications and understand the
importance of proper medication intake and possible side effects
[9]. They can better understand the medication instructions given to
them by a healthcare professional, including the dosage, method of
administration, and time of taking the medication [7]. Next, they
are more likely to ask relevant questions about their medications,
which can improve their understanding and reduce the risk of
medication errors. In addition, they better assess the accuracy of
drug information they find on the Internet or other sources, thereby
reducing the risk of accepting inaccurate or unreliable information
[9]. Considering these factors, improving health literacy among
older adults may be crucial to improving medication adherence and
their health and quality of life [10].
Drug-related factors
The complexity of treatment regimens significantly impacts adherence
in olderpeople for several reasons. First, older people often have
chronic diseases that require multiple drug therapy [1,13]. With the
increase in the number of drugs, the complexity of the therapeutic
regimen also increases, which can make it difficult to follow and
take the prescribed medications in the correct schedule [5]. Second,
the treatment regimen's complexity can manifest through different
ways of administering medications, such as oral tablets, drops,
injections, and patches. The variety of drug administration methods
can further complicate adherence, especially if the patient is
unable to self-administer certain forms of medication or if side
effects occur because of a particular administration method [10].
Third, different medication instructions, such as different dosing
schedules, specific conditions of administration [e.g., before meals
or after meals], or dietary requirements [e.g., drinking more
water], may further complicate adherence to therapy [13]. A
meta-analysis of 76 studies showed that 72% of patients on a
once-daily regimen were adherent, 69% on a twice-daily regimen, 65%
on a three-times-daily regimen, and 51% on a four-times-daily
regimen [14]
The presence of unpleasant side effects of drugs can significantly
affect adherence to drug therapy in olderpeople [7]. Undesirable
side effects of medications can make treatment adherence difficult
for older people, reducing quality of life and motivation to take
medications. Fear of side effects can lead to non-adherence to
therapy, even if they are rare or mild. In addition, they can stop
therapy on theirinitiative if they feel unpleasant side effects,
which can lead to a lack of treatment effectiveness. Elderly
patients with side effects may require the support of healthcare
professionals to continue therapy and treatment effectiveness.
Managing adverse drug reactions and providing support may be vital
in improving adherence in older adults [12].
Social and economic factors
Social factors can have a significant impact on adherence to drug
therapy in older people [5]. People living alone or without the
support of family and friends may feel lonely and depressed, which
may lead to a lack of motivation to adhere to therapy [7]. Limited
access to health services, such as difficulties with transportation
to doctors or pharmacies, can make it difficult for older people to
collect their medications regularly. Also, financial factors can be
an obstacle to taking medicines properly because some drugs can be
expensive or not covered by health insurance [1,15]. High treatment
costs for older people may limit access to specific therapies or
force patients to choose different medications, affecting adherence
[5,15].
INTERVENTIONS AIMED AT IMPROVING ADHERENCE TO MEDICATION THERAPY
Interventions aimed at unintentional non-adherence include
simplifying dosing regimens, reminders, improved patient-physician
communication, an individualized approach to each patient, and
introducing or improving patient counseling [7,14,16–18].
Attempts to increase adherence are increasingly using modern
technologies [2,4,7]. Currently, the Internet and the mobile phone
are often used in interventions to improve adherence [18]. Short
message service [SMS] is increasingly used to remind patients to
take their medication. SMS enables instant delivery of short text
messages to individuals at any time, place, and environment. As
such, SMS reminders are a straightforward method with low
intrusiveness and relatively low cost [2,4].
Communication between patient and doctor is of utmost importance,
especially regarding adherence to therapy [11,16,18]. Healthcare
professionals should never assume a patient is adhering to
treatment[19]. Questioning patients about medication habits is also
recommended [2]. In the study by Van Dulmen and Van Bijnen, GPs were
shown videos of their consultations. Afterward, they were asked why
they did not ask specific questions or why some of the patients'
questions were ignored. GPs often cited lack of time as a reason for
this, but there was also an element of presumption of patient
adherence to therapy [19]. Through clear communication, the
physician can provide detailed information about the importance of
treatment, its goals, dosage, method of administration, and possible
side effects, which can improve patient understanding and motivate
them to adhere to therapy [19]. In addition, effective communication
can help set realistic therapy expectations, reduce frustration, and
increase patient motivation to adhere to treatment[18]. Through
empathic and supportive communication, the physician can provide
emotional support and motivate elderly patients to adhere to
treatment despite side effects or difficulties. In this way, the
doctor allows patients to ask questions and express their concerns
or doubts regarding the therapy, contributing to better
understanding and cooperation [11].
CONCLUSION
Adherence to therapy in older people has a more profound impact
than is commonly assumed. In addition to directly affecting health,
adherence to therapy can significantly impact emotional well-being
and social interaction. Older people who adhere to their treatment
plans often have greater independence and a sense of control over
their lives, which can increase their quality of life. In addition,
adherence to therapy can help maintain stable physical conditions,
prevent complications, and reduce the risk of emergency medical
interventions. This is extremely important in older people, whose
bodies can become increasingly sensitive to changes and deficiencies
in the therapeutic approach. Understanding the importance of
adherence can help older adults maintain a more active and
independent lifestyle, which is critical to their well-being. By
identifying and addressing the specific needs of this population,
healthcare providers can improve patient outcomes, reduce healthcare
costs, and improve the overall quality of life of older adults.
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