The Drug Regimen Unassisted Grading Scale (DRUGS) was associated with relf-reported Medication Management capacity and the Mini Mental State Examination (MMSE). The DRUGS scale measures the ability to take medication independently, in 4 areas: identification, access, dosage, and timing.
While there are many scales that measure the decline of physical function in older adults, the DRUGS scale also measures the psychological, medical, and social factors that contribute to functional status. Medication management requires a defined set of mental and physical tasks.
James Spader likes measuring medication adherence by survey!
Tests the predictive validity of a structured four-item self-reported adherence measure. The surveys address barriers to medication-taking and helps the clinician reinforce positive adherence behaviours
75% of high scorers had blood pressure under control, and only 47% of low-scorers had blood pressure under control. People need to take >80% of their blood pressure medications for it to work.
Major categories of adherence factors:
Referral and appointment process
Disease and patient factors are the most commonly studied because they are the most easy to measure. However, none have been shown to have significant associations with adherence.
"Compliance" means the extent to which a patient follows the physician instructions
Considered a pejorative because the patient is presumed to be uncooperative
Ways to measure adherence:
Pill counts - not feasible in most practice settings, patients can have multiple pharmacies, or combine all their pills into of one type into one container
Prescription filling - not feasible in most practice settings, methodological difficulties
Drug levels or pharmacologic markers - not available for many drugs, interpretation is complicated
Surveys are better! Feasible in all care settings, simple, fast, and valid. Addresses reasons for missing drugs:
Stopping the drug when feeling better
Starting the drug when feeling worse
Take away message
Surveys are a good way of measuring adherence
James Spader likes addressing depression in older people caused by spousal death!
Widows have significantly more symptoms of loneliness, sadness, depression, and appetite loss than their non-widow counterparts. Using that data from the Changing Lives of Older Couples (CLOC) study, they asked the question, "How exactly does spousal bereavement cause depressive symptoms?" They tested two hypotheses:
Traditional latent variable explanation: The effect of spousal loss on depressive symptoms is indirect and operates through the latent variable. Depression is the common cause of depressive symptoms. Bereavement should affect a latent depression factor, which in turn should cause the depressive symptoms.
Novel network explanation: The effects are direct and are propagated through a symptom network. The loss of the spouse triggers specific depressive symptoms which, in turn, activate other symptoms in a causal chain.
Traditional latent vartiable explanation: NOPE! effect of partner loss not mediated by latent variable
Novel network explanation: YES! Bereavement mainly affected loneliness, which in turn activated other depressive symptoms
DSM-5 definition for depression is "the great imposter": There are 1,500 unique symptom profiles for depression, including profiles that do not share a single symptom
Some people are genetically more depressed: Individual depressive symptoms vary with respect to their risk factors and heritibility
Medical cause for depression is really complex: Factors for depression include biological, psychological, and environmental influences
Bad things in life make you sad: specific life events such as failing at an important goal or the death of a loved one are associated with particular depression symptom profiles
Solution: Novel network models are better than the common cause framework becaus depressive symptoms are not passive and interchangeable indicators depression, but as distinct entities with autonomous causal power that influence each other. For example, insomnia or fatigue do not cluster because of a common cause – they cluster because they influence each other across time.
How does spousal bereavement affects depressive symptoms
Losing a spouse is a well-established predictor of developing depression. Is it hypothesis 1 (spousal loss affects depressive symptoms which causes depression) or hypothesis 2 (spousal loss triggers depression directly which causes more depressive symptoms)?
Is bereavement different than depression?
If it is different, then normal sadness over the death of a spouse may be misdiagnosed as pathological depression.
Take away message
James Spader likes short tests of health literacy!
The most precise ways of measuring medication adherence are:
direct observed therapy
Other common but less precise methods are:
electronic patient monitors
But patient self-report measures have been shown to be cheap, brief, acceptable to patients, and valid, reliable, and able to distinguish between different types of adherence. Caveats are that the patients have to understand the items and be willing to disclose information. Here are 7 of the most popular surveys.
The most popular scale is the Medication Adherence Questionnaire (MAQ) by Morisky. It identifies barriers to non-adherence, is the shorest, easiest, and adaptable to various groups of medication.
The Brief Medication Questionnaire (BMQ) is a self-report tool for screening adherence and barriers to adherence. It includes:
5-item regimen screen that asks the patients about the medications that they are currently taking
2-item belief screen that asks patients if they had any difficulty with their medications
2-item recall screen that assesses the difficulty that patients have in recalling and remembering their patients
2-item access screen that evaluates how well patients are able to buy and refill their medications
The Hill-Bone Compliance Scale addresses barriers and self-efficacy, but is less generalizable outside of hypertensive patients. It assesses patient behavior for sodium intake, appointment taking, and medication taking.
The Medication Adherence Rating Scale (MARS) is a derivative of the Morisky Medication Adherence Questionnaire (MAQ) scale.It identifies barriers to adherence in individual cases, but not over a large sample.
The Adherence to Refills and Medications scale (ARMS) is a valid and reliable scale for a chronic disease population, even among those with low literacy.
The Culig scale is a 33-item questionnaire that lists 16 common reasons for non-adherence.
This is just a table of the scales according to the disease they were made with.