Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of elderly patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise medication adherence behavior.
Evidence-based information on how to deal with adherence to medication in patients with dementia is limited, because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behavior in elderly patients, and emerging insights into the relationships between adherence behavior and cognitive capacity, memory, and executive functions. Nevertheless, understanding elderly persons’ strategies for maintaining regular use of even complex drug regimens is still lacking. It can be noted that measures to improve medication adherence consist of combinations of educational interventions and cognitive support, but assessment of participants’ cognitive functions is rare.
The most important step is early detection of cognitive impairment, when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment.
Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs). Patients with impaired executive function, lack of the awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence.
The question is when to switch patient medication self-management to another person’s responsibility if cognitive decline progresses.
More research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use, and medication management. Also, evaluations on the influence of personal support, health status and depression on the memory strategies used are needed.
It is important to assess patients’ attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible.
When providing medication organizers, it is important to observe the patient’s ability to use these devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and tele-monitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects.
This is true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient’s cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy.
To date, no evidence-based recommendations are available. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.
Source: Springer Publications, December 2008, Volume 25, Issue 12