NEW ORLEANS – Adherence with medication regimens is poor among the mentally ill and tends to worsen as those patients age, but there are ways to help patients stick to their regimens, several speakers said at the annual meeting of the American Association for Geriatric Psychiatry.
There are not a lot of data on the elderly mentally ill and drug adherence, but a review of 39 studies published since 1980 that included patients of all ages estimated that the mean rate of nonadherence with antipsychotics was about 50% (J. Clin. Psychiatry 2002;63:892), said Dr. Dilip V. Jeste, distinguished professor of psychiatry and neurosciences at the University of California, San Diego.
While age was not a consistent risk factor for nonadherence, age might still contribute, he said.
Another study looked at adherence to antipsychotics and to medications for hypertension and hyperlipidemia in middle-aged elderly patients with schizophrenia. The authors found that the patients were as nonadherent with antipsychotics as with the medications for medical conditions, with fill rates ranging from 52% to 64% (Psychosom. Med. 2003;65:156). Nonadherence takes many different forms, Dr. Jeste said. A study of Medicaid beneficiaries with schizophrenia found that 41% were fully adherent, 16% were partially adherent, 24% were nonadherent, and 19% were excess fillers (Am. J. Psychiatry 2004;161:692), he said.
Adherence is affected by many factors, including side effects and the cost and complexity of the regimen, said Lawrence D. Cohen, Pharm.D., professor of pharmacotherapy at Washington State University, Spokane.
To get at the root of adherence issues, psychiatrists should assess mood, cognition, vision, mobility, and ability to pay for the prescription, said Dr. George T. Grossberg, director of the division of geriatric psychiatry at St. Louis University.
Adherence can be assessed through patient self-reports, but most overestimate their adherence, Dr. Jeste said. Caregivers may also be a source of information, but most don't observe the patient on a day-to-day basis, he said. Pill counts are not very accurate, because patients can throw the medication away.
He often uses the Brief Evaluation of Medication Influences and Beliefs, which was developed by a colleague (J. Clin. Psychopharmacol. 2004;24:404). The patient self-administers the eight-item test, which can be done in the waiting room in less than 5 minutes. The scores can be correlated with pharmacy refill records and Drug Attitude Inventory Scores, Dr. Jeste said.
To improve adherence, strike an alliance with your patients, Dr. Cohen said. That includes educating patients and families about the medications and emphasizing their value. “Patients have to believe that the medications or treatments we're suggesting are valuable, are worth their costs, even if they have adverse events,” he said.
Dr. Grossberg agreed that collaboration is important. He advocates what he calls “AIDES”–assessment, individualizing the regimen, choosing appropriate documentation, providing ongoing education tailored to the individual's age and needs, and continuing supervision after initiation.
Electronic caps, unit dosing, blister packs, and pillboxes with timers or calendars can also help, Dr. Grossberg said. He also encourages patients to keep a medication list in their purse or wallet. Telephone follow-up reminders from the physician office are very effective, he said.
Dr. Grossberg is a consultant for Bristol-Myers Squibb, Forest Pharmaceuticals, Janssen, Novartis, Organon, Sanofi-Aventis, Sepracor Inc., and Takeda Pharmaceuticals North America Inc. In addition, he receives grants or support from Abbott Laboratories, AstraZeneca, Eunoe Inc., Forest, GlaxoSmithKline, Myriad, Novartis, Ono Pharmaceutical Co., Pfizer Inc., and Wyeth.
Dr. Jeste is a consultant for Bristol-Myers, Janssen, Otsuka America Pharmaceutical, Solvay Pharmaceuticals, and Wyeth, and he receives other financial support from AstraZeneca, Bristol-Myers, Eli Lilly & Co., and Janssen.
Dr. Cohen is a consultant with Eli Lilly, Solvay, and Wyeth and is on the speakers' bureau for AstraZeneca, Eli Lilly, Forest, GlaxoSmithKline, Janssen, and Sepracor.