In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Voices o Polymedica ed Olde Pa ien s: A Focus
G oup App oach
Ana Isabel Plácido 1, Ma ia Te esa He dei o 2, João Lindo Simões 3, Ode e Ama al 4,
Adol o Figuei as 5,6,7 and Fá ima Roque 1,8,*
1Resea ch Uni o Inland De elopmen , Poly echnic o Gua da (UDI-IPG), 6300-559 Gua da, Po ugal;
[email p o ec ed]
2Ins i u e o Biomedicine (iBiMED) and Depa men o Medical Sciences, Uni e si y o A ei o,
3810-193 A ei o, Po ugal; e esahe dei [email p o ec ed]
3Ins i u e o Biomedicine (iBiMED) and School o Heal h Sciences, Uni e si y o A ei o, 3810-193 A ei o,
Po ugal; [email p o ec ed]
4Heal h Sciences School, Poly echnic o Viseu, 3500–843 Viseu, Po ugal; [email p o ec ed]
5Depa men o P e en i e Medicine and Public Heal h, Facul y o Medicine, Uni e si y o San iago de
Compos ela, 15702 San iago de Compos ela, Spain; [email p o ec ed]
6
Conso ium o Biomedical Resea ch in Epidemiology and Public Heal h (CIBER en Epidemiolog
í
a y Salud
Pública-CIBERESP), 28001 Mad id, Spain
7Ins i u e o Heal h Resea ch o San iago de Compos ela (IDIS), 15706 San iago de Compos ela, Spain
8Heal h Sciences Resea ch Cen e, Uni e si y o Bei a In e io (CICS-UBI), 6200-506 Co ilhã, Po ugal
*Co espondence: [email p o ec ed]; Tel.: +351-271205220
Recei ed: 11 Augus 2020; Accep ed: 2 Sep embe 2020; Published: 4 Sep embe 2020
Abs ac :
Polypha macy in olde adul s is equen ly associa ed wi h inco ec managemen
o medicines, which causes d ug- ela ed p oblems and, subsequen ly, poo heal h ou comes.
Unde s anding why olde adul s inco ec ly manage hei medicines is undamen al o heal h
ou comes, howe e , i is an issue ha emains poo ly explo ed. The aim o his s udy is o examine
olde people’s pe cep ions, a i udes, belie s, and conce ns in he cen al egion o Po ugal. Thi een
ocus g oups wi h six y-one olde adul s aking i e o mo e p esc ip ion medicines we e conduc ed o
explo e olde pa ien s’ pe cep ions and belie s abou and managemen o hei medica ion. Sampling
was conduc ed un il heme sa u a ion had been achie ed. T ansc ip s we e coded and da a we e
ob ained using he NVi o quali a i e da a-analysis so wa e p og amme. Olde adul s ecognise
he impo ance o medicines o ensu ing heal hy ageing. Owing o a lack o li e acy, howe e ,
hey equen ly commi medica ion mis akes and comp omise hei heal h ou comes. P omo ing
he li e acy and empowe men o olde pa ien s, as well as s eng hening he ela ionship be ween
heal h p o essionals and pa ien s, is c ucial when i comes o add essing d ug- ela ed p oblems and
imp o ing heal h ou comes.
Keywo ds: polypha macy; home-dwelling olde pa ien s; medica ion e o s; ocus g oup sessions
1. In oduc ion
In he 21s cen u y, he e olu ion o heal h echnologies has con ibu ed o he imp o emen in
heal h ou comes and o e all heal hca e sys em pe o mance [
1
]. Today, he wo ld popula ion li es
longe , albei no necessa ily be e , wi h g ea e au onomy and independence [
2
]. Ge ing olde is
equen ly associa ed wi h mul iple como bidi ies, polypha macy, and cogni i e impai men , which may
inc ease he likelihood o d ug- ela ed p oblems (DRPs) [3].
In . J. En i on. Res. Public Heal h 2020,17, 6443; doi:10.3390/ije ph17186443 www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2020,17, 6443 2 o 10
When co ec ly handled, medicines a e undamen al echnologies o achie ing be e heal h
ou comes [
4
,
5
]. The inc eased agili y o he olde popula ion can lead hem o su e he consequences
o medica ion e o s in he o m o ad e se d ug e ec s o he apy ailu e, and ul ima ely inc eased
mo bidi y and mo ali y [
3
,
6
]. In olde people, ac o s such as polypha macy, socio-economic condi ions,
and pe cep ions o disease and ea men also seem o be ela ed o DRPs [
7
]. Hence, olde adul s’
a i udes, opinions, and conce ns and how hey manage hei medicines can be c ucial when i comes
o designing s a egies aimed a inc easing ou knowledge o ou ine medicine managemen and
imp o ing he quali y o ca e and heal h ou comes.
Quali a i e ocus g oup s udies could be a key esea ch ool o his pu pose. In con as o
o he me hods (in e iews, ques ionnai es), ocus g oups can iden i y all he dimensions o a p oblem,
e en hose ha a e unexpec ed, while also being ex emely sui able o age s a a wi h low li e acy [
8
].
E en so, we we e unable o loca e any ocus g oup s udy on his subjec . Acco dingly, he designa ed aim
o his s udy was o explo e home-dwelling olde pa ien s’ pe cep ions, a i udes, belie s, and conce ns
abou hei medicines.
2. Ma e ials and Me hods
2.1. E hical App o al
This s udy ob ained he e hical app o al o he Cen al Regional Heal h Adminis a ion
(Adminis aç
ã
o Regional de Sa
ú
de do Cen o IP/ARS-C) ( egis y no. 105/2017) and he au ho isa ion o he
espec i e heal h cen e di ec o s.
2.2. Design
A ocus g oup (FG) app oach was conduc ed o s imula e polymedica ed pa ien s who migh
o he wise no be used o discussing he subjec , in o de o sha e hei opinions and conce ns abou
daily managemen o medica ions. The FG sessions we e mode a ed by a esea che (F.R.), ollowing a
opic guide (see Supplemen a y da a, Supplemen 1) based on a e iew o he li e a u e and d awn up
by a g oup o pha macis s and epidemiological expe s [3].
2.3. Se ing
The FG sessions ook place a 13 public heal h cen es alling unde he Cen al Regional
Heal h Adminis a ion and encompassing a o al o 40,835 egis e ed olde pa ien s (age
≥
65 yea s).
Public heal h cen es a e he ga ekeepe o Po ugal’s Na ional Heal h Se ice (NHS). The NHS is
p edominan ly inanced by axes and some ou -o -pocke paymen s ha include co-paymen o a
wide ange o se ices, hough he e a e income-based exemp ions o ce ain popula ion g oups (and
ce ain medical condi ions) [
9
,
10
]. Olde adul s wi h an a e age sala y 1.5 imes below he alue o he
social suppo index a e exemp om co-paymen o any publicly p o ided se ices [
11
]. Howe e ,
he bulk o co-paymen s a e made o pha maceu ical p oduc s, o which di e en le els ( anging om
15% o 90%) o co-insu ance a e applied acco ding o hei he apeu ic alue [9].
2.4. Holding o Focus G oup Sessions
Po en ial pa icipan s we e home-dwelling pa ien s aged 65 yea s o o e who we e aking i e o
mo e medicines. People wi h men al condi ions ha p ecluded hem om eac ing app op ia ely and
hose who li ed in nu sing homes we e excluded om he s udy.
Pa icipa ion was olun a y, wi hou inducemen s o any kind, and all pa ien s signed an in o med
consen o m be o e aking pa in he mee ing. In o ma ion on each pa icipan ’s p esc ibed medica ion
was p o ided by elec onic eco ds o ob ained ia he pa ien ’s ea men guide.
In . J. En i on. Res. Public Heal h 2020,17, 6443 3 o 10
Thi een FG sessions we e held om May o Oc obe 2018, and las ed o 60–90 min. They we e
ca ied ou un il sa u a ion o in o ma ion was eached on he esea ch ques ions. Be o e he beginning
o each session, he mode a o , an expe ienced esea che in FG s udies, eminded he pa icipan s o
he s udy goals and he ac ha audio eco dings we e being made o he sessions. The mode a o
ensu ed he pa icipan s ha he con en ma e would emain con iden ial a all imes and ha he
da a would be p ocessed wi hou iden i ica ion o pa icipan s.
2.5. Analysis
All he sessions we e ansc ibed and coded wi h a se ial numbe by one esea che (A.I.P.).
To ensu e us wo hiness, one mon h a e he ini ial hea ing, he same esea che eplayed he ape
and e iewed he con en o he ansc ip ion.
To ob ain a hema ic desc ip ion o he da a, an induc i e hema ic analysis wi h open codes
was pe o med, using he NVi o quali a i e da a-analysis so wa e p og amme (QSR In e na ional’s
NVi o e sion 12 quali a i e da a analysis so wa e, om SR In e na ional P y L d. nVi o. Doncas e :
QSR In e na ional P y L d; 2019, Doncas e , England). In a i s s age, A.I.P. and F.R. ead h ough
he FG ansc ip s a numbe o imes o acili a e amilia isa ion wi h he da a. Ini ial codes we e
hen gene a ed and clus e ed o enable a sea ch o be made o hemes. A his poin , hemes we e
e iewed, and ele an da a and in e p e a ion o indings we e discussed by he esea ch eam. Las ly,
he hemes we e named and a epo was made in acco dance wi h he checklis o consolida ed
c i e ia o epo ing quali a i e esea ch (COREQ; see Supplemen a y Da a, Table S1) [
12
]. The lis o
p esc ip ion medicines was con e ed o he co esponding Ana omical The apeu ic Classi ica ion
(ATC) code, using he Wo ld Heal h O ganisa ion (WHO) Collabo a ing Cen e o D ug S a is ics
Me hodology websi e [13].
3. Resul s
A o al o 61 pa icipan s, dis ibu ed ac oss 13 FGs, we e en olled in his s udy. The mean (
±
SE)
age o he pa icipan s was 76.3
±
0.77 yea s, and 47.5% we e women (Table 1). The mean numbe
(
±
SE) o medicines pe pa ien was 8.5 (min 5, max 16). FG pa icipan s’ medica ion p o iles a e shown
in Table 2. The ollowing h ee main hemes eme ged om he FG da a: (i) daily medicine ou ine;
(ii) belie s and a i udes ega ding medicines; and (iii) ela ionship wi h heal h p o essionals (Table 3).
Table 1. Socio-demog aphic cha ac e is ics o pa icipan s.
Pa icipan s (N =61) N (%)
Female 29 (47.5)
Age (mean ±SE) 76.3 ±0.77
65–69 9 (14.8)
70–74 17 (27.9)
75–79 18 (29.5)
80–84 13 (21.3)
85–89 3 (4.9)
≥90 1 (1.6)
FG pa icipan s’ medica ion p o iles a e shown in Table 2.
The ollowing h ee main hemes eme ged om he FG da a: (i) daily medicine ou ine; (ii) belie s
and a i udes ega ding medicines; and (iii) ela ionship wi h heal h p o essionals (Table 3).
In . J. En i on. Res. Public Heal h 2020,17, 6443 4 o 10
Table 2.
Use o medicines in Ana omical The apeu ic Classi ica ion (ATC) pha macological g oups A,
C, and N.
ATC Pha macological G oups N (%) Mean Pe Pa ien
A- ALIMENTARY TRACT AND METABOLISM 119 (20) 2.38
A02B D ugs o pep ic ulce and gas o-oesophageal e lux disease (GORD) 40
A02BA H2- ecep o an agonis s 2
A02BC P o on pump inhibi o s 35
A10B Blood-glucose-lowe ing d ugs, excl. insulins 21
A10BA Biguanides 8
A10BD Combina ions o o al
blood-glucose- lowe ing d ugs 5
C- CARDIOVASCULAR SYSTEM 85 (15.0) 1.7
C03C High-ceiling diu e ics 27
C03CA Sulphonamides, plain 16
C09D Angio ensin II ecep o blocke s (ARBs), combina ions 21
C09DA Angio ensin II ecep o blocke s
(ARBs) and diu e ics 6
C09DB Angio ensin II ecep o blocke s
(ARBs) and calcium channel blocke s 6
C10A Lipid modi ying agen s, plain 34 (16.7)
C10AA HMG CoA educ ase inhibi o s 21
N- NERVOUS SYSTEM 59 (10.3) 1.18
N02B O he analgesics and an ipy e ics 22
N02BA Salicylic acid and de i a i es 7
N02BE Anilides 8
N05B–Anxioly ics 23
N05BA Benzodiazepine de i a i es 19
Table 3. Majo hemes om ocus g oups.
Ca ego y o Themes Ca ego y o Sub hemes Coding Concep s
Daily medicine ou ines
Knowledge o medicines
Iden i ica ion o medicines
Associa ion be ween medicines and
pa hology
Iden i ica ion o di icul ies
Handling medicines and
adminis a ion schedules
Handling abili y
S o age
S a egies
Ba ie s o medica ion adhe ence
Compliance
Medica ion e o s
Lack o knowledge
Sel -medica ion
S a egies o educe d ug- ela ed p oblems
Belie s and a i udes
ega ding medicines
Impo ance o medicines
Li ing wi h medicines
Fea s
In luences
Gene ic medicines
Rela ionship wi h heal h
p o essionals
Impo ance o heal h p o essionals
Communica ion
T us
3.1. Daily Medicine Rou ine
Pa ien s iden i ied medicines as pa o hei daily ou ine. Wi hin his heme, h ee sub hemes
eme ged, ha is, “knowledge o medicines”, “handling medicines and adminis a ion schedules”,
and “ba ie s o medica ion adhe ence”.
In . J. En i on. Res. Public Heal h 2020,17, 6443 5 o 10
3.1.1. Knowledge o Medicines
FG pa icipan s exp essed no doub s abou ecognising hei medicines because hey “ha e been
aking hem o a e y long ime” (FG10P1). Some o hem saw he abili y o ead as being eason
enough o iden i y hei medicines co ec ly: “I can ead” (FG1P2)
. . .
“me oo” (FG1P1). Only a
ew pa icipan s admi ed ha hey expe ienced di icul ies in ecognising hei medicines: “I don’
ecognise hem e y well” (FG3P6). Howe e , he majo i y o hem did no e e o hei medicines by
name, bu ins ead men ioned he medical condi ion associa ed wi h he pills, o example, “I ake 2 o
diabe es, 1 o choles e ol, 1 o he head
. . .
” (FG1P1), o he colou /shape o he pills, o example,
“a yellow pill”
. . .
. “all mo ning pills ha e he same shape
. . .
(FG4P1), and only a small numbe
associa ed he medicine’s name wi h he pa hology o he colou o he medica ion.
3.1.2. Handling Medicines and Adminis a ion Schedules
Mos o he pa icipan s said ha hey could handle hei medicines wi hou help: “I don’
ha e anyone” (FG12P2)
. . .
“me nei he ” (FG12P3). Only a ew pa icipan s admi ed ha hey we e
incapable o managing hei medicines co ec ly, and ha hey had he amily’s help: “We, ha e
ou daugh e ’s help” (FG12P4); “I I didn’ ha e he help o my wi e, I’d ha e p oblems” (FG11P3).
Medicines we e s o ed acco ding o hei daily ou ine: “mo ning pills I pu in he ki chen and nigh
pills I pu in he bed oom” (FG7P3). The majo i y men ioned ha hey had a plas ic bag in which hey
pu all he pillboxes, as well as a box o he speci ic day/week: “
. . .
I ha e a box o he week
. . .
”
(FG 9P5); “
. . .
oh! I don’ wan a box o he week, I ha e a box o he day” (FG 9P1). Pa ien s who
used he medicine box admi ed ha hey emo ed he pill om he blis e and did no ecognise he
medicines inside he box. I was o his eason ha , i hey o go o ake a pill, hey we e hen unable
o iden i y which one hey had o go en o ake: “I I don’ ake i , i s ays he e in he box
. . .
look,
his week I’ e missed wo so a . . . ” (FG10P2).
3.1.3. Ba ie s o Medica ion Adhe ence
Pa icipan s acknowledged he impo ance o medica ion and said ha hey we e complying wi h
hei ea men egimens. Du ing he discussion, howe e , some o hem said, “ins ead o aking i
e e y day, I ake i e e y o he day
. . .
” (FG11P5). Ba ie s o medica ion adhe ence appea o be
ela ed o pe sonal issues associa ed wi h daily li e, o example, pa ien s admi ed ha , i a able
in e e ed wi h hei daily ou ine, hey escheduled hei medica ion, o did no ake i : “
. . .
I we
go ou o lunch
. . .
some imes, i ’s no ha I o ge , bu i ’s because I jus don’ ake i ” (FG11P2).
O he pa icipan s admi ed ha hey knowingly missed medicines, wi h uncom o able e ec s: “
. . .
I
couldn’ go ou ; I was always unning o he ba h oom o pee
. . .
some imes I we mysel ” (FG1P2).
Medica ion adhe ence is also a ec ed by he p ice o medicines: “
. . .
I’ e al eady seen pa ien s who
don’ buy hei p esc ibed medicines because hey’ e oo expensi e” (FG4P2). Some pa icipan s
admi ed ha he e we e imes when hey did no ake medicines o ea o a hypo he ical ad e se
d ug eac ion desc ibed in he d ug p ospec us: “I ead he package lea le , he medicine is ha m ul o
so many hings
. . .
I only ook he pills o wo days” (FG3P6). They also belie e ha hey can adjus
he ea men wi hou hei p ima y ca e physician’s consen , and ha his beha iou does no a ec
hei heal h ou comes: “Some imes I don’ ake he pills
. . .
Today I missed he pills
. . .
Some imes I can
ake a b eak, he e’s no p oblem” (FG8P1). Some pa ien s admi ed ha , some imes, hey missed aking
he pills because hey o go and el ha his was no an issue: “
. . .
some imes I o ge , bu he e’s no
big p oblem . . . ” (FG9P1). They main ain ha hey a e mo e complian wi h ce ain medicines, such
as painkille s, because hey eel he lack o he medica ion’s e ec : “Some imes I o ge bu I eel he
pain, and hen I emembe and I ake i ” (FG8P2). O he wise, pills associa ed wi h painless condi ions
(e.g., choles e ol) a e easily o go en: “... I some imes o ge o ake he choles e ol medicine” (FG8P1).
When i came o s a egies used o dec ease DRPs associa ed wi h medica ion e o s, pa icipan s
said ha hey did no need a s a egy. Ye almos all admi ed o using a pillbox o a oid o ge ing o
In . J. En i on. Res. Public Heal h 2020,17, 6443 6 o 10
ha ing some me hod o scheme o emind hem o ake hei medicine. Pa icipan s also insis ed ha
hey had no di icul y in aking medicines o in dealing wi h mul iple medicines. Howe e , hey o en
ema ked ha hey some imes educed he dosage o a pa icula d ug because hey hough ha hey
we e aking oo many pills: “I hink I’m aking oo many pills and ha my body will explode someday
. . .
./Fo ins ance, I’m aking a p os a e pill, I can’ ake 2 e e y day because I hink ha wo pills a e
oo many . . . /because I also ake pills o diabe es and hea . . . ” (FG8P3).
3.2. Belie s and A i udes abou Medicines
Pa icipan s seem o be o e whelmingly esigned o he need o ake hei medicines, and desc ibed
medicines as pa o hei ou ine, “
. . .
I mean, i ’s al eady become a habi ” (FG3P1), and daily li e, “
. . .
in he mo ning, a e waking up, I ge b eak as eady and ake 3 pills” (FG1P1). They also s a ed
ha a daily ou ine was essen ial o emembe ing o ake hei medicine: “
. . .
I know which pill is
o hype ension,
. . .
I ake i in he mo ning on an emp y s omach
. . .
. This mo ning I didn
´
ake
i
. . .
I o go
. . .
When I go he e, oh! I skipped my hype ension pill” (FG1P2); “
. . .
I
´
m going o
cook my husband’s meal
. . .
oh! I skipped he pill” (FG1P2). Olde pa ien s’ beha iou is in luenced
by hei belie s and by he impo ance ha hey a ach o each medicine. They ha e he pe cep ion
ha medicines a e essen ial o ensu ing hei well-being and p e en ing disease, and eel ha all
medicines a e equally impo an o ensu ing hei well-being. Howe e , pa ien s we e pe cei ed as
managing hei medicines acco ding o he se e i y o he disease, ha is, hey equen ly alk abou
hei hea medicines and hei ca diologis appoin men s: “ he ca diologis said i ’s a p oblem in he
ao a” (FG11P1),” “
. . .
yes, he ca diologis said so” (FG12P3). I was also obse ed ha olde pa ien s
we e in luenced by ele ision comme cials and by hei amily and iends: “ he doc o p esc ibed me
calcium and I ook i o a long ime. Bu hen I saw he ad on he elly, my sis e ook i and el good,
so I s a ed aking i oo, and I’m eeling e y well” (FG9P1). A i udes o medica ion compliance seem
o be in luenced by hei knowledge o he bal p oduc s: “
. . .
my daugh e makes ea wi h 3 oli e
lea es, and isn’ aking any medicine o a e ial p essu e” (FG2P4). Pa icipan s had di icul ies in
admi ing ha hey used he bal p oduc s. They desc ibed he e ec o he bal eas, bu concluded by
saying, “I ne e d ink i ” (FG3P1) o “i ’s a iend o a ela i e ha d inks i , no me” (FG2P1), o “My
b o he ook i e e y day” (FG9P3). The e is one excep ion when pa icipan s alk abou p os a e
disease; hey o en say, wi h some p ide, ha hey eplaced hei p os a e medicine wi h a he bal
p oduc and el be e , “I ne e ook a pill . . . I d ink ea . . . ” (FG2P5).
Some pa icipan s belie e ha gene ic medicines a e equal o e e ence medicines, and ha e
he ad an age o lowe p ices, “Gene ic medicines a e cheape han b anded ones” (FG7P6);
o he pa icipan s did no us gene ic medicines and p e e ed o spend mo e money han ake
a gene ic, “I belie e ha gene ic medicines a e no as good as b anded medicines” (FG4P2), “B anded
medicines a e mo e expensi e bu we do e e y hing o heal h” (FG6P1). Pa icipan s equen ly
e e ed o gene ic medicines as medicines in a di e en box wi h a di e en name, which could cause
some mis akes, such as duplica ion: “I didn’ eel any hing bu he pha macis s old me ha i I was
aking ha pill I couldn’ ake his one
. . .
The names a e di e en , bu hey do he same hing” (FG10P1).
Pa ien s did no ha e he pe cep ion ha medicines should be aken wi h wa e . In many cases,
hey ook hei medicines wi h ood o wi hou any pill-swallowing aids, and a ew admi ed o
occasionally aking hei medicine wi h alcohol. “
. . .
in he mo ning I ake my medicines wi h co ee”
(FG7P2), “
. . .
I’m ha ing soup, so I ake my pills wi h soup” (FG9P2), “
. . .
a lunch I ake my pills
wi h wine” (FG13P1).
3.3. Rela ionship wi h Heal h P o essionals
Pa ien s ha e he pe cep ion ha heal h p o essionals play a suppo i e ole and os e a sense
o us . Pa ien s showed hei us in heal h p o essionals and belie ed ha heal h p o essionals
a e essen ial o ensu ing co ec managemen o medicines and dec easing DRPs: “We do exac ly as
he doc o says” (FG1P2); I can’ ake a pill wi hou going o he doc o ” (FG2P1). “We alk o he
In . J. En i on. Res. Public Heal h 2020,17, 6443 7 o 10
pha macis
. . .
and he w i es down he ins uc ions o he pills on he box” (FG4P1). Du ing he
cou se o he discussion, howe e , pa ien s equen ly s a ed ha hey did no in o m he doc o abou
he in e up ion o medicines, al e a ions o hei p esc ip ion, o he in oduc ion o supplemen s o
he bal p oduc s: “I ne e ell he doc o ha I’m aking his medicine” (FG9P1); “My physician doesn’
ag ee bu I ake i all he same...” (FG11P2); “I in e up one medicine
. . .
/I don’ ell he doc o ”
. . .
I
pu i in he ga bage” (FG 1P1); “Once I ied o educe he dosage o my diabe es pills” (FG6P3).
4. Discussion
To ou knowledge, his is he i s ocus g oup s udy o explo e olde polymedica ed adul s’
pe cep ions, belie s, and a i udes abou he managemen o hei medicines. Olde pa ien s’ desi e o
main ain a good quali y o li e and ha e he pe cep ion ha he p ope use o medicines is essen ial
o achie ing his and enjoying “heal hy ageing”. To his end, hey equen ly de elop s a egies o
dec ease medica ion e o s and p e en possible DRPs. Ne e heless, hei e o s may no be al oge he
success ul because hey do no acknowledge he need o comply wi h he ea men egimen o ensu e
good heal h ou comes.
Al hough he Po uguese heal hca e sys em is anked as he 12 h bes in he wo ld [
14
], only 9% o
olde Po uguese pa ien s a e conside ed heal hy, a wo isome igu e when compa ed wi h Swi ze land,
Ge many, Aus ia, o F ance, whe e he pe cen age o heal hy olde adul s is 51%, 38%, 58%, and 37%,
espec i ely [
15
]. Conside ing ha he majo i y o he olde Po uguese adul s en olled in his s udy
we e unawa e o he alue o complying wi h hei ea men egimens o ensu e good heal h ou comes,
ou esul s a es o he ac ha Po uguese olde adul s’ lack o knowledge could be a majo con ibu o
o hei unheal hy s a us and show ha heal h li e acy is a co ne s one o heal hy ageing.
To educe medica ion e o s, FG pa icipan s de elop ex e nal and/o in e nal memo y
s a egies [
16
]. Ex e nal memo y s a egies end o be e ec i e o new asks and un amilia objec s
and less e ec i e o epe i i e asks when he objec in ques ion becomes mo e amilia [
16
]. In e nal
memo y s a egies, such as associa ing medica ion wi h a speci ic ask, a e highly dependen on he
daily ou ine, and so any change in ha ou ine is eason enough o gi e ise o a medica ion e o [
17
].
Medicine boxes we e e y popula among he FG pa icipan s. I is hus ou conside ed opinion
ha , be o e ecommending he use o such boxes, heal h p o essionals should ensu e ha pa ien s
unde s and he co ec way in which hey should be handled; his opinion is in line wi h a p e ious
s udy [18].
Olde adul FG pa icipan s had he pe cep ion ha he e no doub s abou ecognising hei
medicines because hey had been aking hem o a long ime. Howe e , p e ious s udies [
19
,
20
]
concluded ha he e is no ela ionship be ween he numbe o yea s in ea men and a subjec ’s abili y
o emembe he name, ea men , o p ecau ions o be aken when using medicines. Ou s udy showed
ha , a he han e e ing o he name o he p ecau ions o be aken when handling hei p esc ibed
medica ion, pa icipan s equen ly e e ed o he colou o he pills o he eason o aking hem,
sugges ing a lack o knowledge o hei p esc ip ion medicines; hese obse a ions a e in line wi h
hose o a p e ious s udy [20].
Owing o he lack o s anda disa ion o pill o m/colou and d ug packaging, a change o
pha maceu ical labo a o y is eason enough o olde adul s o commi ea men duplica ion e o s.
This could pose a p oblem in a case whe e a e e ence medicine is eplaced by a gene ic. We obse ed
ha some pa ien s mis us gene ic medicines, an obse a ion co obo a ed by Bulsa a e al. [
21
].
We hus eel ha hese wo weaknesses migh well o se he ad an age o be e adhe ence owing o
he la e ’s lowe p ice. I would hus be ad isable o pill o m and colou o be s anda dised.
Ou s udy showed ha pa ien s equen ly a gue ha hey ake oo many medicines, and hus y
ou medicines and weigh he isks and bene i s. This e a ic beha iou pa e n cu s ac oss all ages and
is e e ed o by some as a “d ug holiday” [
22
]. Pa ien s belie e ha lexibili y in adhe ing o hei
medica ion egimen allows li e o con inue wi hou oo many dis up ions [
22
]. Olde adul s wi h ewe
In . J. En i on. Res. Public Heal h 2020,17, 6443 8 o 10
esou ces we e also obse ed o be less complian and o skip doses in o de o make hei medicines
las longe . This ype o beha iou has also been p e iously desc ibed [23,24].
FG pa icipan s showed ha ea o an ad e se e en is a eason o in e up ing ea men .
This ea seems o be ela ed o a lack o comp ehension o he d ug p ospec us; a inding ha is in line
wi h he li e a u e [25].
Some olde adul s epo ed ha hey egula ly consumed he bal p oduc s and, in some cases,
had qui hei p esc ip ion medicines and we e aking he bal eas, some hing ha can boos d ug–d ug
in e ac ions [
26
]. In ou s udy, he mos equen ly men ioned he bal p oduc s we e ginkgo biloba,
oli e ee in usion, and in usions o dec ease p os a e p oblems.
Ou s udy obse ed ha olde pa ien s a e in luenced by pha maceu ical comme cials and ake
hese p oduc s wi hou discussing he need o use hem wi h a heal h p o essional. Such impulsi e
beha iou may well imply ha pha maceu ical comme cials ha e a nega i e in luence on he
doc o –pa ien ela ionship, he eby p omo ing a p og essi e lack o us by pa ien s in hei p ima y
ca e physician, and ul ima ely comp omising WHO ecommenda ions [
27
]. O e all, FG pa ien s us
in hei heal h p o essionals, bu admi o concealing some beha iou , which can in luence ea men
e icacy. Bea ing in mind ha olde adul s place eno mous alue on us , a good ela ionship be ween
heal h p o essionals and olde adul s can ac as he linchpin o enhancing adhe ence o ea men and
sa is ac ion wi h he heal hca e sys em [28,29].
This s udy has some limi a ions linked o he chosen me hodology. FG pa icipan s we e selec ed
by hei p ima y ca e physician because hese pa ien s’ beha iou could be be e han a e age in e ms
o d ug compliance. To educe his ype o bias, each FG session had a leas some pa ien s selec ed by
di e en p ima y ca e physicians. Despi e he ac ha pa ien s may ollow he gene al end o gi e
simila answe s, g oup discussions may p o e di icul o s ee and con ol, and ele an opics may be
missed; his me hodology’s gene alisabili y is bes judged in e ms o logical in e ence and c edibili y
o analysis [30].
The esul s o his FG s udy a e use ul o designing didac ic ma e ial o add ess he main DRPs
obse ed in olde adul s, demys i y alse belie s, and p omo e co ec managemen o medicines.
5. Conclusions
Olde adul s a ach g ea alue o hei medicines, ye ne e heless ha e posi i e and nega i e
pe cep ions o and a i udes o polypha macy. These a i udes e lec he ambi alence o eeling g a e ul
o he exis ence o medicines ha alle ia e symp oms and imp o e hei li e expec ancy, while being
a aid o ad e se eac ions and ha ing doub s abou he need o use some medicines. P omo ing he
heal h li e acy and empowe men o olde pa ien s and s eng hening he doc o –pa ien ela ionship
a e bo h essen ial o dispelling alse belie s and enhancing heal h ou comes among polymedica ed
olde pa ien s.
Supplemen a y Ma e ials:
The ollowing a e a ailable online a h p://www.mdpi.com/1660-4601/17/18/6443/s1,
Supplemen a y da a S1: FOCUS GROUP GUIDE; Table S1: Checklis Co eq.
Au ho Con ibu ions:
Concep ualiza ion, F.R. and M.T.H.; me hodology, F.R. and A.I.P.; o mal analysis, F.R.,
A.I.P., M.T.H., and A.F.; in es iga ion, A.I.P., F.R., J.L.S., O.A.; esou ces, F.R. and M.T.H.; da a cu a ion, F.R.;
w i ing—o iginal d a p epa a ion, A.I.P.; w i ing— e iew and edi ing, F.R., M.T.H., A.F., and J.L.S.; supe ision,
F.R., O.A., and J.L.S.; p ojec adminis a ion, F.R.; unding acquisi ion, F.R. and M.T.H. All au ho s ha e ead and
ag eed o he published e sion o he manusc ip .
Funding:
This wo k was inancially suppo ed by he MedElde ly p ojec [SAICT-POL/23585/2016], unded by
Po uguese Founda ion o Science and Technology (FCT/MCTES), Po ugal 2020 and Cen o 2020 g an s; and by
he APIMedOlde p ojec [PTDC/MED-FAR/31598/2017], unded by he ope a ional p og amme o compe i i eness
and in e na ionaliza ion (POCI), in i s FEDER/FNR componen POCI-01-0145-FEDER-031598, and he Founda ion
o Science and Technology, in i s s a e budge componen (OE).
Acknowledgmen s:
We should like hank he ollowing: all he p ima y ca e physicians who ook he ime o
selec polymedica ed olde pa ien s; all he pa icipan s o sha ing hei expe iences wi h us; and, las ly, all he
heal h p o essionals om he p ima y heal hca e cen e o hei uns in ing suppo .
In . J. En i on. Res. Public Heal h 2020,17, 6443 9 o 10
Con lic s o In e es :
The au ho s decla e no con lic o in e es . The unde s had no ole in he design o he
s udy; in he collec ion, analyses, o in e p e a ion o da a; in he w i ing o he manusc ip ; o in he decision o
publish he esul s.
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