Fitten L J, Coleman L, Siembieda D W, Yu M, Ganzell S
Department of Psychiatry and Biobehavioral Science, UCLA School of Medicine, USA.
J Am Geriatr Soc. 1995 Apr;43(4):361-7. doi: 10.1111/j.1532-5415.1995.tb05808.x.
To develop an instrument that will facilitate and focus the assessment of a patient's capacity to adhere to a medication regimen before its initiation.
This is a crossectional study that compares medical inpatients and outpatients to an age-matched, community-living, independent and relatively healthy group on their ability to adequately understand and implement hypothetical but realistic medication regimens.
Department of Veterans Affairs Medical Center, Sepulveda, California.
Fifty-five older subjects (65 years or older) were divided into three groups: (1) generally healthy comparisons (standard group) (n = 20); (2) medical outpatients (n = 15); and (3) medical inpatients ready for discharge (n = 20).
Older subjects were first tested on their capacity to comply with a difficult medication regimen presented in scenario form. If scores on the first scenario did not meet a standard group-derived cutoff point, further testing was conducted with a simpler scenario to identify greater levels of impairment.
The outpatient group had significantly lower scenario scores than did the healthy comparison group (P < .03). The simpler scenario also showed a trend toward outpatient impairment (P = .06). In the comparison group, only 5% failed Scenario 1, and none failed Scenario 2. The outpatient group had the most difficulty, with 40% failing Scenario 1 and one-third of those failing Scenario 2. This differed significantly from the comparison groups (Fisher's Exact P < .03). In the inpatient group 20% failed Scenario 1 and 75% of those failing Scenario 2. The sensitivity and specificity of the Folstein Mini-Mental State Examination in identifying scenario-impaired subjects were 73% and 80%, respectively. Question types were analyzed to determine which questions were most frequently missed. Memory and judgment questions were found overall to be the most frequently missed. Healthy controls missed some judgment questions; however, the outpatient group was significantly worse in this category (chi 2 = 5.08; P = .01). All three groups improved their scenario performance significantly with question cueing.
A significant number of medically ill outpatients encountered difficulty in understanding or remembering correctly hypothetical but realistic medication regimens. This suggests that an older medical patient's cognitive and functional capacity to comply with medication regimens of differing complexity can be specifically assessed before the start of the regimen and probably should be assessed in patients whose compliance capacity is in question. The assessment instrument under development in this study may be helpful in detecting those who need assistance with medications, thus identifying the need for intervention before poor compliance can lead to increased morbidity, rehospitalization, and increased medical costs.
开发一种工具，以便在开始用药前促进并聚焦于对患者坚持药物治疗方案能力的评估。
这是一项横断面研究，将内科住院患者和门诊患者与年龄匹配、居住在社区、独立且相对健康的一组人在充分理解和实施假设但现实的药物治疗方案的能力方面进行比较。
加利福尼亚州塞普尔韦达的退伍军人事务部医疗中心。
55名老年受试者（65岁及以上）被分为三组：（1）一般健康的对照组（标准组）（n = 20）；（2）内科门诊患者（n = 15）；（3）准备出院的内科住院患者（n = 20）。
首先对老年受试者进行测试，看他们遵守以情景形式呈现的复杂药物治疗方案的能力。如果第一个情景的得分未达到由标准组得出的截止点，则用更简单的情景进行进一步测试，以确定更高程度的损害。
门诊患者组的情景得分显著低于健康对照组（P < 0.03）。更简单的情景也显示出门诊患者有受损的趋势（P = 0.06）。在对照组中，只有5%的人在情景1中未通过，无人在情景2中未通过。门诊患者组遇到的困难最大，40%的人在情景1中未通过，其中三分之一的人在情景2中未通过。这与对照组有显著差异（费舍尔精确检验P < 0.03）。在住院患者组中，20%的人在情景1中未通过，在情景1中未通过的人中有75%在情景2中未通过。福尔斯坦简易精神状态检查在识别情景受损受试者方面的敏感性和特异性分别为73%和80%。对问题类型进行了分析，以确定哪些问题最常答错。总体上发现记忆和判断问题最常答错。健康对照组答错了一些判断问题；然而，门诊患者组在这方面明显更差（卡方 = 5.08；P = 0.01）。所有三组在问题提示下情景表现都有显著改善。
相当数量的内科疾病门诊患者在理解或正确记住假设但现实的药物治疗方案方面遇到困难。这表明在开始治疗方案之前，可以专门评估老年内科患者遵守不同复杂程度药物治疗方案的认知和功能能力，并且对于那些遵守能力存疑的患者可能应该进行评估。本研究中正在开发的评估工具可能有助于检测那些需要药物治疗帮助的人，从而在依从性差导致发病率增加、再次住院和医疗费用增加之前确定干预的必要性。
