Understanding the knowledge, attitudes and beliefs of community-dwelling older adults and their carers about the modification of oral medicines: A qualitative interview study to inform healthcare professional practice
Introduction
Due to age-related pharmacokinetic, pharmacodynamic and physiological changes,1, 2, 3, 4, 5 oral medicine modifications (e.g. splitting tablets to administer lower doses or crushing tablets or opening capsules to overcome swallowing difficulties) are a reality in older patient care. Previous research has highlighted that in geriatric care settings approximately one-third of all patients receive modified medicines.6, 7, 8, 9, 10 Despite the routine occurrence of these modifications, there are concerns about the potential effect on dosing accuracy, drug absorption and release profiles and therefore therapeutic outcomes or adverse events.11, 12, 13, 14 As a result, various interventions, including computerised decision support systems, guidelines on medication crushing, implementation of warning labels and, educational interventions, have sought to reduce the prevalence of medicine modifications.9,15, 16, 17 However, it is clear that in many instances, there are simply no alternatives to modification due to an absence of suitable formulations coupled with a clinical need for the medication.5,6,18,19 Consequently, guidance to healthcare professionals routinely advocates for the use of alternative formulations or routes of administration, with the alteration of solid oral medicines being “reserved as last-resort and practised only after appropriate advice has been sought from a pharmacist and/or Medicines Information Centre”.20
Research investigating the views of healthcare professionals about oral medicine modifications for older adults has shown that the practice is regarded as being routine and necessary.21, 22, 23, 24 Reports have suggested that healthcare professionals lack knowledge about the appropriateness of modifications.23,25,26 Qualitative research has provided further insights, highlighting that whilst healthcare professionals were often cognisant of the potential for therapeutic consequences when modifying oral medicines, they expressed concerns and uncertainty about decision-making in this area.21, 22, 23, 24 However, they negotiate this uncertainty through the involvement of other members of the multidisciplinary team.21, 22, 23, 24 Therefore, for healthcare professionals in these studies, when modifications are deemed necessary, they are considered and reviewed by a variety of healthcare professionals with the goal of ensuring that all modifications are safe and appropriate. Given the acknowledgement that the expertise and input of many different healthcare professionals is often required for decision-making about modifications, this raises concerns about community dwelling older adults and their carers.
The vast majority of older adults in Ireland, 94.7% of those aged ≥65 years and 78.3% of those aged ≥85 years, are resident in private households.27 Therefore, the task of medication management falls to the patient and/or a carer. There are limited data on the prevalence of medicine modifications amongst community dwelling older adults, with previous studies suggesting that approximately 14% of community-dwelling older adults experience difficulty swallowing solid oral medicines.10,28,29 A study conducted in 17 community pharmacies found that, of customers suspected by pharmacists as potentially experiencing difficulty swallowing medication, 60% had difficulty taking a tablet or capsule and of these, 68% modified medications to facilitate administration.30 As regards modifications for fractional dosing, a study conducted amongst a community-dwelling adult population in Germany (mean age 67.3 years), found that 24% of all tablets were split prior to administration.19 It has been reported that patients do not inform healthcare professionals about difficulties they experience when taking oral medicines.30, 31, 32 Therefore, older adults or their carers may be modifying tablets and capsules without appreciating the potential for adverse events and without the input of healthcare professionals. Qualitative research would help to reveal the knowledge, attitudes, beliefs and experiences of community-dwelling older adults and carers around oral medicine modification and administration. Ultimately, the most important stakeholders for any qualitative research on medication formulation suitability are the patients and carers who are administering medications on a daily basis. However, as identified in a previous systematic review of the qualitative literature, research investigating the views of these key stakeholders is limited.21 Of the four qualitative studies involving patients that discussed medicine modification, only one addressed modifications in detail,32 while in the remaining three studies, modifications were briefly mentioned as part of broader discussions around medication related problems or factors that affected adherence.33, 34, 35 No studies have investigated the views of carers in relation to oral medicine modification. Therefore, research is needed to address this gap in the literature. This will be vital to ensure that healthcare professionals, policy makers, regulatory agencies and the pharmaceutical industry are aware of the priorities and needs of patients and carers who are tasked with managing medication in a community setting. This study will provide valuable and novel insights into the issue of oral medicine administration and modification in the community setting, which should help to identify areas for more focused and targeted investigation.
Section snippets
Aim of the study
The aim of this study was to investigate the knowledge, attitudes and beliefs of community-dwelling older adults and carers of community-dwelling older adults about the modification of oral medicines.
Ethical approval
Ethical approval to conduct this study was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals, Cork, Ireland.
Study design
Semi-structured, face-to-face qualitative interviews were conducted with community-dwelling older adults (aged 65 years or older), and carers of community-dwelling older adults, who experience difficulty swallowing oral medicines or who require oral medicines to be modified to meet their needs. Various qualitative research methodologies have been used in
Study sites
Twenty one pharmacists were approached and asked if their pharmacies would be part of the study. Of these, seventeen agreed to participate, one did not respond and three declined to participate (two cited a lack of older patients and one was already involved in an ongoing research project). In four of the seventeen pharmacies that agreed to participate, pharmacists chose to only participate in purposive identification of participants and not convenience sampling by a member of the research
Discussion
This study has examined the views of patients and carers regarding oral medicine modification. Four themes emerged: variation in medical needs and preferences; balancing acceptance and resignation; healthcare professional engagement and; opportunities for optimising formulation suitability. The findings of this study highlight the variability associated with the formulation requirements and preferences of community-dwelling older adults. While both patients and carers tend to be very accepting
Conclusion
From this study, the views of community-dwelling older adults and their carers about oral medicine administration and modification have been elucidated. It is clear that the diverse, community-dwelling older population experience substantial variability in their formulation and modification requirements and preferences. Whilst good relationships with doctors and pharmacists were reported by both patients and carers, there was a sense of acceptance veering towards resignation around medications
Funding
AMG is in receipt of a Government of Ireland Postgraduate Scholarship from the Irish Research Council (grant number GOIPG/2016/1634).
AMG wishes to acknowledge the support of the University College Cork Strategic Research Fund.
AMC is a funded researcher in the Synthesis and Solid State Pharmaceutical Centre (SSPC) supported by Science Foundation Ireland (SFI) under grant number 12/RC/2275.
The funding bodies had no role in the design or conduct of this study, in the data analysis process,
Conflicts of interest
None.
Acknowledgements
The authors wish to express their gratitude to all interviews participants who generously shared their experiences with the research team.
The support and assistance of the pharmacists and pharmacy staff who facilitated the conduct of this study is much appreciated.
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