Adverse drug reactions (ADRs) are common in older adults, with falls, orthostatic hypotension, delirium, renal failure, gastrointestinal and intracranial bleeding being amongst the most common clinical manifestations. ADR risk increases with age-related changes in pharmacokinetics and pharmacodynamics, increasing burden of comorbidity, polypharmacy, inappropriate prescribing and suboptimal monitoring of drugs. ADRs are a preventable cause of harm to patients and an unnecessary waste of healthcare resources. Several ADR risk tools exist but none has sufficient predictive value for clinical practice. Good clinical practice for detecting and predicting ADRs in vulnerable patients includes detailed documentation and regular review of prescribed and over-the-counter medications through standardized medication reconciliation. New medications should be prescribed cautiously with clear therapeutic goals and recognition of the impact a drug can have on multiple organ systems. Prescribers should regularly review medication efficacy and be vigilant for ADRs and their contributory risk factors. Deprescribing should occur at an individual level when drugs are no longer efficacious or beneficial or when safer alternatives exist. Inappropriate prescribing and unnecessary polypharmacy should be minimized. Comprehensive geriatric assessment and the use of explicit prescribing criteria can be useful in this regard.

Adherence with prescription medications among elderly patients with cardiac conditions is poor. Mechanisms underlying adherence behavior have not been fully investigated. The purpose of this study was to develop a substantive model that describes medication-taking behavior in elderly individuals with chronic diseases. The study was exploratory using grounded theory. Purposive sampling was used to recruit 19 elderly cardiac patients. Four major themes were delineated from the data to describe readiness to adhere: perceived effectiveness, perceived partnership, perceived reality, and interpersonal influences. To convert perceptions into actions, 2 influencing factors, facilitating and inhibiting factors, played pivotal roles. This model could provide a useful framework for health professionals to design valid interventions for elderly patients to increase medication adherence.

Approximately 50% of patients across all age groups with varied types of medical conditions do not adhere to their prescribed medication regimens. Medication nonadherence is common in older adults who are often prescribed medications for age-related chronic disorders. The purpose of this paper is to investigate the effect of personal and cultural beliefs on older adults' medication adherence through a review of research studies published in journals across different disciplines. A systematic literature search using ten databases found 14 articles meeting the inclusion criteria. Belief-laden variables including self-efficacy (i.e. the belief that one can perform a specific behaviour under differing conditions), medication efficacy, confidence in the physician's knowledge, perceptions about natural products and home remedies, beliefs of control (over one's health), and illness perceptions were found to be significantly related to medication adherence among older adults. However, several measurement, design and sampling problems were identified in this review. The majority of the studies in the review evaluated older adults' medication adherence by self-report and used cross-sectional designs and convenience samples. Future studies should utilise prospective longitudinal designs and a more objective measure of medication adherence, such as electronic event monitoring, when examining factors related to older adults' medication adherence. Future research should also evaluate belief-related variables in larger and more ethnically diverse samples of older adults. Implications for assessment and intervention are evident from this literature review of the effect of personal and cultural beliefs on medication adherence in older adults.

To evaluate medication adherence, pharmacokinetics and exposure versus response relationships in patients with myelodysplastic syndromes (MDS).

Ninety adult patients with MDS received oral topotecan (1.2 mg/m2) either once a day for 10 days or twice a day for 5 days every 21 days for up to six cycles. Dosing histories were collected using electronic monitoring devices fitted to medication vials. Topotecan plasma concentrations were measured, and exposure was determined by a sparse sampling approach and Bayesian estimation methods. Relationships between exposure and clinical response and toxicity were evaluated using logistic regression.

Overall adherence was excellent with 90% of patients taking the prescribed number of doses in cycle 1. Adherence did not differ between the two regimens. Topotecan pharmacokinetics were described using a one compartment open model with first order absorption and elimination. Pharmacokinetic parameter estimates did not differ between the once a day and twice a day dosing groups. While topotecan exposure was greater in the twice a day arm compared to the once a day arm due to drug accumulation, exposure did not correlate with clinical response. However, the probability of needing a platelet transfusion in the twice a day arm was significantly increased (by 35%) as a result of greater steady-state plasma topotecan concentrations.

Adherence is high in patients with MDS receiving oral topotecan, whether the drug is prescribed once or twice daily. The optimal schedule cannot be determined from this study, as there was no evident relationship between any pharmacokinetic parameter and clinical response.

Patients' willingness to take a newly prescribed medication is an important, but little studied, part of the medication process. The authors studied the impact of patient age on the perceived importance and interaction of three factors known to influence young people: severity of their medical condition, extent of possible medication side effects, and level of trust in their physician. A convenience sample of 170 French adults aged 18 to 93 rated their likelihood of taking a medication intended to alleviate physical suffering in 27 scenarios in which three levels (low, moderate, and high) of each of the above three factors were combined in an orthogonal factorial design. Among younger participants, high trust in the physician was not considered a sufficient reason for high acceptance of a new medication; it had to be accompanied by low side effects. Among very elderly participants, high trust led to high acceptance almost irrespective of the severity of possible side effects. Among the middle aged, trust and side effects had largely independent effects. To promote patients' acceptance of newly prescribed medications, physicians need to establish trust, but not abuse its power in elderly patients.

Noncompliance affects all age groups, but older patients have specific barriers against effective medication use and can be more vulnerable to the incorrect use of medication. Some age-related barriers are vision loss and cognitive impairment. In people aged 60 years or older, noncompliance with medication regimens varies from 26-59%. In this article we review randomised controlled trials (RCTs) on interventions aimed to improve compliance with medication regimens in older patients living in the community. It is known from other reviews that multifaceted interventions, a combination of interventions, are more often effective than single-focus interventions, probably because these address a wider range of barriers. Also, an individual approach with specifically tailored interventions is effective at improving compliance. In this review the following two hypotheses are evaluated: i) multifaceted interventions improve compliance more successfully than single interventions; and ii) interventions that are tailored to patients improve compliance more successfully than generalised interventions. A systematic literature search in four databases produced 14 suitable RCTs with 23 interventions that we categorised as single or multifaceted, and generalised or tailored. Differences in medication compliance between the intervention group and the control group were in less than half of the comparisons in favour of the intervention group. Telephone-linked reminder systems achieved the most striking effect, looking at differences between the intervention and control group, and deserve further attention. Overall, multifaceted interventions and tailored interventions seemed to result more often in differences in compliance rates in older adults in favour of the intervention group compared with a control group than single and generalised interventions.

The quality of written prescriptions has not been examined in a psychiatric setting. The aim of this study was to examine the quality of drug prescribing by medical staff for elderly patients hospitalized with dementia in comparison with the quality of prescribing for elderly patients hospitalized for functional psychiatric illness (depression, anxiety and psychosis). We studied a cohort of 112 elderly psychiatric inpatients in two hospitals over a seven-year period. A standardized assessment sheet was used to assess 320 prescriptions of psychotropic drugs, using medical notes and drug charts. Patients with dementia and functional illness were defined by ICD-9 or ICD-10 criteria. Severity of illness was measured by the presence or absence of symptoms in six discrete symptom clusters. Two raters examined prescription quality. Twenty percent of prescriptions for patients with dementia were illegible, significantly higher than in functional illness. In both groups, among prescriptions of regular medication, one third contained missing information on either, dose, intended frequency, or, indications for use. Among prescriptions for as-required medication, two-thirds of prescriptions contained this missing information. Prescriptions were legible and free of all errors in only 20 of 112 cases (18%). Quality of as-required medication prescribing was inferior to the prescription of regular medication, particularly for dementia patients. In addition, prescribing for patients with dementia carried significantly more errors in notation of dose than prescribing for patients with functional illness. We conclude that errors are common in prescribing for elderly psychiatric patients, particularly for as-required medication and for patients with dementia.

Medication compliance; the role of a portable Medical Summary Card as a compliance aid; and the role of a medical practice-based clinical pharmacist in identifying medication-related problems in a rural general practice setting is evaluated. A clinical pharmacist checked the medications of 50 predominantly aged patients against their medical summary and noted inconsistencies and potential medication problems. From this information the general practitioner (GP) assessed patient compliance with prescribed medications and transcribed the correct medication regimen and medical problems onto a Medical Summary Card for the patient to carry. Forty per cent of the patients were non-compliant. A Medical Summary Card alone was unable to improve compliance. Issues noted by the clinical pharmacist warranted a change in therapy for 8% of patients. Eighteen per cent of patients provided medical information to the clinical pharmacist of which the GP was unaware. Non-compliance with prescribed medications is common. A portable Medical Summary Card may not rectify this problem. Patients' withholding medical information from their medical practitioner is of particular concern.

Humalog Mix75/25 (Mix75/25) is a novel premixed insulin containing 75% neutral protamine lispro (an intermediate-acting insulin) and 25% insulin lispro.

The purpose of this study was to compare glycemic control and hypoglycemia rates with Mix75/25 versus glyburide, and with preprandial versus postprandial Mix75/25, in patients aged 60 to 80 years with type 2 diabetes mellitus and persistent hyperglycemia on sulfonylurea therapy.

In this open-label, 16-week, parallel-group study, patients were randomized to 1 of 2 treatments: glyburide 15 mg/d (or up to the maximum daily dose) or Mix75/25. The Mix75/25 group was randomly subdivided into preprandial (immediately before breakfast and dinner) and postprandial (within 15 minutes after the start of breakfast and dinner) injection subgroups. The primary outcomes were glycemic control and rate of hypoglycemia.

A total of 143 patients were randomized; 127 completed the study. The change in glycosylated hemoglobin (HbA(1c)) from baseline to end point was significantly greater with Mix75/25 than with glyburide (mean +/- SEM, -1.14% +/- 0.18% vs -0.36% +/- 0.15%, P = 0.001). HbA(1c) changes with preprandial and postprandial Mix75/25 were not significantly different (-1.20% +/- 0.26% vs -1.08% +/- 0.26%, P = 0.748). Fasting blood glucose (BG), 2-hour postprandial BG, and mean daily BG reductions were greater with Mix75/25 than with glyburide (P < 0.001); preprandial and postprandial Mix75/25 administration did not differ significantly with respect to any of these BG variables. The hypoglycemia rate increased with Mix75/25 by 0.17 +/- 0.02 episodes per patient per 30 days, but there was no change with glyburide (P = 0.077). Body weight increased by 1.02 +/- 0.35 kg with Mix75/25 and decreased by 0.85 +/- 0.18 kg with glyburide (P < 0.001).

Compared with glyburide, Mix75/25 significantly improved glycemic control in older patients with type 2 diabetes mellitus, could be administered after meals without compromising glycemic control, and was well tolerated.

To characterize the degree of disparity between physicians' perceptions of older patients' medication regimen and patients' perceptions of their regimen.

Prospective observational. Physicians and patients were blinded at index visit; after, trained medical students made home visits, collecting information about medications that was compared with physician questionnaires.

Community family medicine residency program.

Patients age 65 and older presenting for routine visit, taking at least four prescription medications, and seen by index physician three or more times in the past year. Physicians were family medicine faculty and second- and third-year residents.

Fifty physician-patient pairs were analyzed. Average age was 75 (standard deviation (SD) +/-5.5); patients averaged 7.0 prescription medications (range 3-17, SD +/-2.89). Three hundred seventy-five prescription medications were identified; the most commonly prescribed were antihypertensives (134/375; 36%).

Congruence, defined as agreement between physician and patient regarding all prescription medications, dosages, and frequency, averaged 70% for faculty (range 53-89%) and 58% for residents (range 41-81%) (P = .08). Fourteen percent (7/50) demonstrated complete congruence; 74% (37/50) had at least one medication that either the physician was unaware the patient was taking or the physician thought the patient was taking but that was not part of the patient's regimen; 12% (6/50) had dose and/or frequency discrepancies.

This study demonstrates significant disparity in a population where it is crucial for healthcare providers and patients to be in close agreement about intended medication regimens.

Documented evidence indicates that medication non-compliance for the older person is a common and poorly understood problem. This paper reports on a pilot study, which used a focus group interview to explore carers' attitudes, experiences and perceptions regarding medication compliance for their older depressed relative. It aimed to understand the problems and challenges encountered by carers in respect of their relative being non-compliant, and provide material to develop a comprehensive educational and support package to promote antidepressant compliance. A convenience sample of seven carers participated in the focus group and a qualitative analysis of the interview identified a number of key issues. Carers had little knowledge of depression, they were not well informed regarding antidepressant medication and they took an active role to ensure compliance. The focus group highlighted the need for health care professionals to promote and encourage carers to be part of the older individuals treatment programme and provide concise and unambiguous educational information in relation to antidepressants and the importance of compliance.