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Vol. 45, No. 4, 545–552 Copyright 2005 by The Gerontological Society of America
Purpose: We investigated whether patient-centered accurately for the unfamiliar medications, but stan-
instructions for chronic heart failure medications dard instructions were understood more accurately
increase comprehension and memory for medication for the familiar medications. However, the recall
information in older adults diagnosed with chronic measures showed that the advantage of the standard
heart failure. Design and Methods: Patient-centered format for familiar medications was short lived. Im-
instructions for familiar and unfamiliar medications plications: The findings suggest that the patient-
were compared with instructions for the same centered format may improve printed medication
medications from a chain pharmacy (standard instructions available in many pharmacies, which
pharmacy instructions). Thirty-two adults (age, M ¼ should help older adults to better understand how to
63.8) read and answered questions about each take their medications.
instruction, recalled medication information (free
Key Words: Medication instructions, Adherence,
recall), and then answered questions from memory
Memory, Health literacy
(cued recall). Results: Patient-centered instructions
were better recalled and understood more quickly
than the standard instructions. Instructions for the
familiar medications also were better recalled. Chronic heart failure (CHF) is a major health care
Patient-centered instructions were understood more problem that is associated with reduced functional
capacity and quality of life, particularly among older
The research for this article was supported by the National Institutes adults (American Heart Association, 2004). Older
of Health under Grants R01 AG19105 and R01 HL69399. Any opinions, adults with CHF often have multiple medications
findings, and conclusions or recommendations expressed herein are those prescribed to provide symptom relief and slow disease
of the authors and do not necessarily reflect the views of the institute.
Partial findings were reported in Toronto at the annual meeting of the progression (Fonarow, 2001). Such complex regimens
American Psychological Association in August 2003, and in Denver at challenge the ability of these adults to take the
the annual meeting of the Human Factors and Ergonomics Society in
October 2003. medications as prescribed (Ghali, Kadakia, Cooper,
Address correspondence to Daniel G. Morrow, Institute of Aviation, & Ferlinz, 1988; Murray, Darnell, Weinberger, &
Aviation Human Factors Division, Willard Airport–One Airport Road, Martz, 1986). Although older adults’ nonadherence
Q5, MC-394, Savoy, IL 61874. E-mail: dgm@uiuc.edu
1
Institute of Aviation and the Beckman Institute, University of relates to many factors, limited knowledge about
Illinois, Champaign-Urbana.
2
medications is an important contributor (Ascione,
Indiana University School of Medicine and Center for Aging 1994; Botelho & Dudrak, 1992; German, 1988; Lorenc
Research, Indianapolis.
3
Wishard Health Services, Indianapolis, IN. & Branthwaite, 1993; Murray et al., 1986; Park,
4
Department of Psychology, University of Missouri–Columbia. Morrell, Freske, & Kincaid, 1992; Salas et al., 2001).
5
Regenstrief Institute, Indianapolis, IN.
6
Pharmaceutical Policy & Evaluative Sciences Division, University of Limited knowledge may in turn be associated with
North Carolina at Chapel Hill. several factors, including cognitive declines that impair
the sentence set for which participants can reliably and speed measures account for age-related differences
recall all sentence-final words (for details on materials in performance of several verbal reasoning and memory
and scoring, see Salthouse & Babcock, 1990). We tasks (Salthouse & Babcock, 1991).
measured processing speed by using the Letter Com-
parison and Pattern Comparison tasks (Salthouse &
Babcock, 1991). In these timed paper-and-pencil tasks, Plan of Analysis
participants decided as rapidly as possible whether
pairs of letter sets or line patterns were the same or We analyzed recall and comprehension measures by
different (maximum score ¼ 25). The working memory using a randomized block factorial analysis of variance
Model Number
1 2 3
Instruction Recall B Change R2 Effect Size B Change R2 Effect Size B Change R2 Effect Size
Standard pharmacy 30%** 0.43 27%** 1.33 11%* 2.13
Age .57*** .28 .16
Education .22 .22
Health literacy .45*** .25
Processing speed .07
Working memory .36*
Patient-centered pharmacy 18%** 0.23 35%** 1.13 1% 1.17
Age .45*** .12 .08
Education .25 .25
Health literacy .53*** .54***
Processing speed .14
Working memory .16
standard instructions were more accurate for familiar information about taking CHF medications by using
medications (PC ¼ 75%, standard ¼ 82%), F(1, 93) ¼ a patient-centered approach to instruction design.
5.3, p , .05; Format 3Familiarity interaction, F(1, 93) ¼ We previously found that older adults with CHF
11.2, p , .001. Main effects of format and familiarity tend to prefer patient-centered instructions over
were not significant, Fs , 1.0. instructions for the same medications from a chain
pharmacy (Morrow et al., 2004). The present study
shows that older adults also better understand and
Predictors of Medication Information Recall remember these instructions. Although only immediate
recall was measured in our study, there is evidence that
Age accounted for 30% of the variance in recall of level of immediate recall of medication information
standard instructions (Model 1, Table 3). Education predicts later recall at a 1-month test (McGuire, 1996).
and health-related literacy accounted for an additional The patient-centered and standard instructions differ
27% of the variance, and the literacy measure appeared on several dimensions, making it difficult to pinpoint
to eliminate the impact of age on recall (Model 2). why the patient-centered instructions were better
Finally, the working memory and processing speed remembered. For example, larger print reduced input
measures accounted for an additional 11% of the limitations on comprehension, and simpler language
variance. The impact of health literacy on recall was (reflected in better readability scores) addressed literacy
eliminated, primarily when working memory was limitations. The icons may also have reinforced in-
controlled for (Model 3). formation about medication name, dose, and time.
The pattern was somewhat different for patient- Indeed, analysis of instruction format effects for types
centered instruction recall. Age accounted for only 18% of information (Table 2) suggested that icon-relevant
of the variance. As with standard instruction recall, the information was especially likely to be recalled from the
effect of age was eliminated when health literacy was patient-centered instructions. Icons may particularly
controlled for (Model 2). Unlike standard instruction help less literate patients (Houts et al., 1998).
recall, literacy predicted recall even with cognitive Instructions for familiar medications were better
ability controlled, primarily because working memory recalled than those for unfamiliar medications. An
had a weaker relationship to patient-centered than to analysis by type of information suggested this advan-
standard instruction recall (Model 3). tage occurred for general facts that patients likely knew
before the study. Although it is possible that variable
content across instructions contributed to familiarity
Discussion effects, familiar and unfamiliar instructions did not
differ in mean readability scores.
Older adults often receive medication information in Patient-centered instructions were understood more
the form of expanded instructions at pharmacies accurately for the unfamiliar medications, whereas the
(Svarstad & Bultman, 1999). Although these instruc- standard instructions were better understood for the
tions do have advantages over directions on medication familiar medications. Patients may have been familiar
containers (e.g., larger print), more information is with the standard pharmacy format for medications
likely to improve patients’ knowledge and self-care they were already taking, which could mitigate
only if it is easy to understand and remember (Morrow effectiveness of the novel patient-centered format.
& Leirer, 1999). Our goal is to increase memory for However, the standard format advantage did not