Factors predicting home medication management practices among chronically ill older population of selected districts of Nepal

The demographic shift in the age distribution to an increasingly older population has significant social, health and economic impacts. Health-related issues are challenging among elderly people in terms of prevalence of multiple diseases [1], related medication problems [2] and additional complexity of their changing physiology [3]. Among several medication-related problems, polypharmacy, adverse drug reactions, and the use of potentially inappropriate medications have been commonly reported in the literature [2]. Poor home medication management practice (MMP) also accounts for such problems [4, 5], which is often underestimated in the aged population.

Poor home management of medicines includes poor drug storage practices, lack of medication administration schedule, use of drugs from multiple prescribers, use of discontinued medicines, expired medications or medicines that are no longer needed and the use of over-the-counter medications which are not suitable for their condition [6]. Studies have identified a number of factors associated with these practices including gender, age, confusion between trade and generic names [6], education level [7] and the number of medicines [8]. Particularly with older patients; it has been known that they tend to experience multiple practical problems using their medicines such as difficulty reading and understanding the instruction, handling the packaging, preparation before use, and taking the medicine; all of which have the potential to cause negative impacts on their health [9, 10]. On the other hand, the ageing population is more prone to chronic diseases and is more likely to be prescribed multiple medications [11‐13]. Additionally, inappropriate MMP has been linked with a decline in the cognitive functioning of older patients [14]. But several other factors such as wrong storage condition of prescribed medications, omission of medication dose, wrong time and frequency of administration, wrong route of administration, lack of medication administration schedule, use of discontinued or expired medication are often seen as poor home MMP in the older population [6]. It is therefore crucial to understand about the MMP in older population in order to ensure that drugs maintain their potency through appropriate storage along with drug safety by avoiding a mix-up of drugs and minimizing the possibility of overdosing and wastage of resources [15].

Studies on medication management at homes in Australia revealed that most older individuals keep their medicines in the kitchen, around 4% store them in a bathroom and 8.3% store them in multiple locations [6, 16]. Also, 14% of elderly Australians fail to keep their prescription medications in the original container and 9% of them mix more than one prescription medications in the same container [16]. Another study in the similar setting reported that home MMP of chronically ill patients discharged from acute hospital care was also sub-optimal [17]. Similarly, more than half of the patients (52%) discharged from the hospital in the United States were found to have one or more medication discrepancies at home [18]. In another study in the United States it was found that patients with inadequate literacy skills had higher odds (10 to 18 times) of being unable to identify all of their medications as compared to adequately literate skilled patients [19]. A cross-sectional study as a part of a randomized controlled trial conducted in Australia states that community pharmacists and general practitioners have identified number of medication related risk factors such as poor adherence, expired medications, number of prescribers and dispensers, hoarding, multiple storage, no administration schedule, presence of discontinued medication repeats, and confusion between generic and brand names during their home visit [4]. Although the literature on the status of MMP in developing countries is often rare, a study from Uganda reported inappropriate home MMP among 70% of the participants [5]. One of such developing countries is Nepal, which is having an upsurge of older population aged 60 years and above (6.5% in 2001 to 8.1% in 2011) [20]. But there is a paucity of data on MMP among older population from this country. Therefore, we aimed to determine the current status of MMP and its associated factor(s) among chronically ill older population of selected districts of Nepal.

Appropriate MMP is essential to ensure medication safety, and to minimize the possibility of overdosing and wastage of resources [15, 21]. However, the majority of the participants (80%) in our study had inappropriate home MMP. Our finding may be the indication of inadequate information provided by the healthcare professionals to such individuals in our setting, probably due to their limited knowledge [22, 23]. MMP is not always optimal or appropriate in both developing and developed countries. In Uganda, 70% of the study participants had inappropriate MMP at home [5]. Similarly, the MMP among Australian [4, 6, 17] and American [18] population has also been noted unsatisfactory. Chronically ill individuals face numerous difficulties on a day-to-day basis for the management of their own medications and it is challenging to develop, maintain, and adjust their medication routines [24]. Moreover, a study in a different setting has found low health literacy levels among patients with chronic diseases [25], and inappropriate medication management has been linked with low literacy level since such individuals are unable to read and understand the medication instruction [26]. Nearly three-fifths of participants had never gone to school, therefore, it might also be responsible for comparatively higher inappropriate practice as seen in our study. In addition to this, inadequate pharmaceutical service delivery by hospital pharmacy [27, 28] and delivery of service by unauthorized personnel in the community pharmacy of Nepal [29] might also have contributed to the findings of our study.

In bivariate analysis of our study, the MMP (appropriate or inappropriate) was found to be associated only with duration of disease (p = 0.002), which indicated that chances of inappropriate MMP increases with increase in the duration of disease. However, multivariate analysis showed a significant association between MMP with both the duration of disease and smoking status. This analysis showed that individuals aged ≥60 years with a lesser duration of the disease had higher odds of appropriate MMP but the odds were statistically significant only in participants with disease duration of less than one year and 1–2 years when compared with the duration of more than three years. Alternatively, longer duration of the disease can be considered as a predictor of inappropriate MMP at home. This highlights the importance of assessment of knowledge of older patients on medication management on follow-up visits and continuing education in order to improve their practice and therapeutic outcomes. A study in Uganda depicts that on multivariate analysis longer disease duration is significantly associated with inappropriate home MMP. The likelihood of inappropriate MMP was double among those with more than five years disease duration than those with five or less years [5]. Though this study was not specifically on older patients and undertook patients with treatment for chronic disease for at least two months; it suggested that patients with prolonged diseases may be associated with drug accumulation, visiting multiple prescribers, and perceiving their disease as very severe, thus leading to poor MMP.

Similarly, in our study smokers had two times lesser odds of appropriate home MMP than non-smokers. A possible explanation for this finding is that smoking is found to be a significant risk factor for cognitive decline and dementia among older adults [30‐32]. Therefore, non-smokers might have a good cognition leading to better home MMP in our study. However, the effect of smoking on MMP in people aged above 60 years needs further elaboration. A study from Uganda states that perceived severity of disease, duration of disease of more than five years, and lack of treatment-response assessment by health workers as predictors of inappropriate medication practice [5]. Another study from Australia showed greater number of medication at home as predictor of therapeutic duplication, hoarding and greater severity of illness [6].

It has been known that patients with threshold or sub-threshold health literacy have lower ability to perform simple tasks and actualize the importance of tests or medicines [26]. Therefore, it necessitates the improvement of the level of health literacy of chronically ill older population which could be possible through interventions [33, 34] in order to improve MMP at home. The current status among those with poor literacy levels might also be improved through pictorial and audio-visual demonstrations. Moreover, older age has been known to be associated with decrease in memory power [35‐37]. Furthermore, cognitive impairment has been observed in a number of diseases [38‐42]. These indications emphasize the necessity of continuous education and counselling on aspects of medication management for chronically ill older individuals, though cognitively impaired patients might need dedicated attention.

Our study was a population-based study and we evaluated the medications of our participants at their homes, which signifies its strength. We were able to physically evaluate their medications as they would bring them out on every occasion, though we had to rely on verbal information from the participants about medication storage. However, the direct evaluation enabled us to obtain valid information about their medicines irrespective of their storage place. This highly reduced the recall bias or possibility of misinformation.

The sites of our study were selected on the basis of our convenience due to constraints of finance and manpower. Hence, probability sampling techniques such as stratified or cluster methods can be considered. Study population from rural areas and health services-deprived areas could make this study more inclusive. Additionally, this study could have incorporated more medication-related components such as dose and use of any alternative medicines. Furthermore, we collected information on all medicines that were available, but in the analysis, we excluded OTC and prn medicines. But we recommend considering the issue of self-medication practice of prescription medicine, particularly of antibiotics, in future studies in similar settings, as more recent finding suggests that antibiotics are dispensed without prescription by non-pharmacists from randomly selected community pharmacies in two districts of Nepal [43]. Moreover, whilst storing medicines in a cool and dry place (unless otherwise stated for different storage condition), out of the reach of children or avoiding potentially humid places such as bathrooms or kitchens, is an appropriate MMP, realistically achieving these practice in these group of patients in similar settings is seemingly difficult. However, an effort has to be directed towards improvising such practice. Similarly, consequences of medicine hoarding should be explained to patients and latter should be encouraged to return unused portions of discontinued medication to the pharmacy. This can be best achieved by advising them to bring all of their medications during their visit to the hospital or community pharmacy and by performing medication reconciliation.

The home MMP among chronically ill older population in the selected areas of Nepal was poor. Duration of disease and smoking status were the predictors of medication management by older population at home in our study. It is possible to improve MMP of older patients by early intervention. Healthcare professionals including physicians, pharmacists and nurses should all re-assess and adequately counsel the older patients about MMP at home during their health institutions visits.