40% of the elderly forget to take their medication: here's how to help them

Ages pass, geographic areas change, but there is one fact that remains almost constant in healthcare systems halfway around the world: the poor treatment adherence of the elderly. Approximately 40 per cent of chronic therapies are not taken correctly by patients over 65, a phenomenon that results in adverse clinical outcomes, avoidable hospitalisations and a considerable waste of resources. "A drug taken incorrectly is the equivalent of throwing money away," effectively sums up Elisabetta Poluzzi, professor at the Department of Medical and Surgical Sciences at the University of Bologna and coordinator of the Eldercare - Enabling medication adherence in the elderly project, funded by the European Union to develop concrete strategies against this silent emergency.

The research conducted with the University of Milan, the University of Naples Federico II and the Mario Negri Institute for Pharmacological Research, with the collaboration of patient associations, scientific societies, and the federations of nurses, doctors and pharmacists, Fnopi, Fnomceo and Fofi, for two years collected data and evaluated experiences in Italy and in different countries before arriving at the presentation of results and recommendations for decision-makers. The problem is particularly acute in Italy, where about one fifth of the over-65s take at least ten drugs at the same time. It is not just a matter of forgetfulness: behind the non-adherence lies a complex web of cognitive, organisational, economic and relational factors that the Eldercare project wanted to unravel through a systematic review of the international literature and an extensive field survey among health professionals and patients.

Four well-defined areas for action emerge from the research, as Professor Poluzzi explains. The first, and most complex, concerns healthcare organisation: 'Time and resources should be devoted to having professionals dedicated to supporting adherence,' she stresses. Whether in a community home, in the specialist outpatient clinic or in the general practitioner's office, the chronic patient must be given that extra quarter or half hour that can make the difference between therapeutic success and failure. The second pillar is citizen education: 'We need to make people understand the importance of taking their medication correctly and not being satisfied with the first relief of symptoms,' Poluzzi warns. All too often, patients stop their therapies as soon as they feel better or, on the contrary, when the fear linked to a cardiovascular risk factor discovered during a check-up passes. The third guideline points to the specific training of health professionals, who must learn techniques of communication and patient engagement. "You have to check that the patient has understood and contact them several times to make sure they are following the therapy correctly," clarifies the Bolognese lecturer. It is a matter of building a relationship of trust based on a shared decision on therapy and maintaining direct contact, also to intercept adverse effects or new symptoms in good time. Finally, the fourth chapter opens up to the potential of technology: from simple reminders on smartphones, to electronic pillboxes with beeps and automatic doors, and on to new solutions based on artificial intelligence. "It's an engaging topic and the prospects are there, but if we really look at what is available to patients today, the field narrows. At least I would start with 'zero-cost' technology as a reminder on smartphones, although then you often still need someone to set up the app for the elderly patient, who is often digitally unskilled. AI? For now, more promise than reality,' Poluzzi pragmatically observes. The systematic review published in the Journal of the American Geriatrics Society confirms that technological interventions work when poor adherence stems from the complexity of the treatment regimen, but are ineffective if the problem is distrust in the therapy itself.

If the recommendations point the way, it is the health professionals who must actually follow it. And here the crucial role of the pharmacist, a figure present in more than a third of the interventions examined by the international review, emerges strongly. "The pharmacy open to the public is probably the most available resource and the closest to chronic patients," Poluzzi reasons. Services such as deblistering - the unpacking of the drug from its packaging - or the preparation of customised weekly pillboxes, already offered by entities such as Farmacap, the network of municipal pharmacies in Rome, represent concrete and immediate solutions. "It would probably be the key solution, and would cover many of the current difficulties of individual patients," she argues convincingly, while acknowledging that the issue of the economic sustainability of these additional services, which are often offered for a fee, remains open. In other countries, especially those with private insurance systems, the cost of deblistering is already covered by health insurance policies. Nurses represent the other mainstay: their presence is documented in almost one fifth of the studies analysed, distributed across hospitals, community homes, home care and residences for the elderly. Their operational flexibility and ability to follow the patient throughout the care pathway make them strategic figures, especially for interventions requiring relational and motivational skills. No less important, of course, is the direct involvement of doctors, but this is often limited by time and resource constraints. A novelty to be carefully analysed in this respect is the recent introduction of prescriptions valid for up to 12 months for certain chronic diseases. "This does not have to correspond to the doctor handing out a 12-month prescription without reviewing the patient in this time frame," Poluzzi admits, "but if it is accompanied by constant alerts from pharmacies, when the patient does not pick up the prescribed drugs, and by monitoring technologies and interaction with the electronic medical record, it could be really useful.