Assessing Medication Self-Management by the Elderly

A Comparison of Subjective and Objective Indicators from the ABLYMED Study

Elderly patients are often confronted with the daily intake of drugs in a complex regimen. Problems in self-administration may remain undetected, causing poor adherence and a lower likelihood of achieving the goal of treatment. Previous studies did not assess medication self-management by the elderly objectively and comprehensively for all of the common modes of administration. We therefore analyzed data from the ABLYMED study (“the ability to self-administer medication in non-demented in-hospital patients”) to obtain a valid assessment of subjective and objective problems in medication self-management by elderly patients who are taking multiple drugs with multiple different modes of administration, and to determine how well the subjectively reported and objectively observed problems match. This was a sub-analysis of the ABLYMED study, whose overarching goal is to develop an assessment instrument for medication self-management by the elderly that would be suitable for routine use.

Methods

We analyzed data from the ABLYMED study (ethics committee approval at the Heinrich Heine University Düsseldorf 2021–1435; written consent of the participants is available), in which subjective and objective measures of problems in medication self-management were obtained from 100 patients of the departments of orthopedic and trauma surgery and of vascular and endovascular surgery at the Universitätsklinikum Düsseldorf (≥ 70 years old; ≥ 5 drugs self-administered over the long term) (1). The subjective data were derived from questionnaires on problems with self-management (yes/no) that were filled out by all 100 subjects for each currently prescribed mode of administration of the drugs they were taking at home (the current medication list of each patient was taken from the clinical history) (2). Problems in self-management were defined as recurring difficulties in opening, setting up, and administering the medications as prescribed. Objective determinations were made by means of video documentation of 67 of the 100 subjects: 33 were unable to undergo video recording because of time constraints, health problems, or personal reasons. The self-management of each of five different modes of administration was observed on video (tablets, eye drops, drops, pens and patches) (3, 4). All five modes of administration were tested regardless of the modes of administration of the drugs each patient was currently taking, so that a comprehensive impression of each patient’s ability to manage medication could be obtained. A cellular telephone camera was used to make video recordings (without audio) of the patients in their rooms. The recordings showed the patients’ hands while they self-administered the placebo drugs as instructed. The recordings were assessed in standardized fashion by two evaluators, who stated their overall impression (very good [1], good [2], fair [3], poor [4], very poor [5]) for each mode of administration. The scores assigned by the two evaluators were averaged and rounded up to the next whole number. An overall impression of 4 or 5 was considered to indicate a problem with self-management.

Results

Of the 100 patients included in the study, 67 consented in writing to video recording (age, 78 ± 6 years [mean ± standard deviation]; 33/67 [49%] were women). They were taking an average of 10 ± 3 drugs at home. 23/65 (35%) patients had objective problems with the self-management of tablets, 4/64 (6%) with eyedrops, 11/65 (17%) with drops, 27/61 (44%) with pens, and 21/63 (33%) with patches (Figure). 39/67 (58%) had self-management problems with at least one mode of administration. Depending on the mode of administration, the interrater reliability ranged from moderate to substantial, with the following weighted kappa values [and 95% confidence intervals]: tablets 0.5 [0.4; 0.7], eyedrops 0.5 [0.3; 0.7], drops 0.4 [0.3; 0.5], pens 0.4 [0.3; 0.5], and patches 0.6 [0.5; 0.8]. For each mode of administration, there were patients with objective problems in the video recording who did not report any problems with their home medication on the questionnaire (Table) (opening tablet packaging 2/41 [5%], dividing tablets 4/36 [11%], eyedrops 1/12 [8%], drops 1/ 2 [50%], pens 4/14 [29%], and patches 1/2 [50%]). Conversely, there were also patients who reported subjective problems with self-management (opening tablet packaging 20/24 [83%], dividing tablets 4/4 [100%]), eye drops (6/6 [100%]), and drops (1/1 [100%]) that could not be objectively confirmed (Table).

Figure

Percentage of patients with and without problems in the videos of 5 different modes of administration of placebo

Table

Percentages (numbers) of patients with and without problems on the questionnaire and in the videos

Discussion

In our group of patients who were managing their medications by themselves, more than half (58%) had problems relating to at least one mode of administration. Many of them (35%) had problems handling tablets, the most commonly prescribed mode of administration. The problems that were encountered were often related to the opening mechanism of the packaging, e.g., a child-resistant dropper bottle or pill box. It should be noted that the interrater reliability of the objective scores was only fair to moderate in some cases. One important finding of our study is that patients’ subjective assessment of their ability to self-manage their medications often differs from their objective performance. Inconsistencies in both directions were noted: there were patients who had objective problems while reporting none subjectively, but also, perhaps more surprisingly, patients who reported problems that could not be be objectively confirmed. These patients may conceivably go on to develop objective problems with self-management in the future. A practical assessment of medication self-management, such as we performed in this study with video recordings, can reveal current problems that the patients themselves do not report. As there is no available tool at present that could be used in geriatric clinical practice for the efficient, objective assessment of medication self-management by the elderly, a tool of this type is now being developed as part of the ABLYMED study.

Anneke Luegering, Helmut Frohnhofen, Robert Langner, Stefan Wilm, Thorsten R. Doeppner, Dirk M. Hermann, Joachim Windolf, and Janine Gronewold

Conflict of interest statement

AL received financial support from the Paul-Kuth-Stiftung Wuppertal for leave from work in order to pursue scientific research.

HF is a member of the board of the directors of the Paul-Kuth-Stiftung.

The remaining authors state that they have no conflict of interest.

Manuscript submitted on 19 June 2024, revised version accepted on 30 September 2024.

Translated from the original German by Ethan Taub, M.D.

Cite this as:
Luegering A, Frohnhofen H, Langner R, Wilm S, Doeppner TR, Hermann DM, Windolf J, Gronewold J: Assessing medication self-management by the elderly—a comparison of subjective and objective indicators from the ABLYMED study. Dtsch Arztebl Int 2025; 122: 55–6. DOI: 10.3238/arztebl.m2024.0214

References

1. Maiworm A, et al: BMC Geriatr 2022; 22: 466

2. Luegering A, et al.: Dtsch Arztebl Int 2023; 120: 559–60

3. Luegering A, et al.: Front Med (Lausanne) 2023; 10: 1040528

4. Luegering A, et al.: Front Med (Lausanne) 2024; 11: 1444567

e1. Maiworm A, Langner R, Wilm S, Hermann DM, Frohnhofen H, Gronewold J: Developing a novel tool to assess the ability to self-administer medication in non-demented in-hospital patients: ABLYMED study protocol. BMC Geriatr 2022; 22: 466

e2. Luegering A, Frohnhofen H, Langner R, et al.: Problems in medication self-management by elderly patients—responses to a questionnaire in the ABLYMED study. Dtsch Arztebl Int 2023; 120: 559–60

e3. Luegering A, Langner R, Wilm S, et al.: Developing a novel tool to assess the ability to self-administer medication—a systematic evaluation of patients’ video recordings in the ABLYMED study. Front Med (Lausanne) 2023; 10: 1040528.

e4. Luegering A, Langner R, Wilm S, et al.: Assessing self-administration of medication: video-based evaluation of patient performance in the ABLYMED study. Front Med (Lausanne) 2024; 11: 1444567