Practical Problems with Eye-drops Among Elderly Ophthalmology Outpatients E. BURNS, G. P. MULLEY
Summary Many elderly patients have eye-drops prescribed. We have examined the abilities in eye drop application of 43 consecutive outpatients aged 75 years or more who completed a questionnaire and demonstrated their technique in eye-drop application. Less than one-third of patients applied drops themselves, the rest relying on others; one-third of this group lived alone. The majority of patients experienced some difficulty with the application of their drops and it was estimated that half of those who usually applied their own treatment were unlikely to succeed in instilling a drop into the conjunctival sac. Few patients had been prescribed aids or appliances to improve their eye-drop application technique.
Introduction Visual problems affect many old people and may necessitate treatment with eye-drops. Yet visual and other physical disabilities may cause difficulties in instilling drops. We have examined the frequency and type of problems encountered by old people. Methods Sixty-two consecutive patients aged 75 years or more attending for review at a general ophthalmology outpatient clinic were assessed. Forty-three patients were using eye-drops and they were interviewed further. Patients were asked what instruction they had received in the application of their eye-drops, whether they usually instilled their drops themselves, and whether they experienced any difficulty in doing so. The patients were then asked to demonstrate their technique of eye-drop instillation. The patients' technique was scored against a recommended method which was described in an eye-drop package insert provided by the hospital pharmacy. One point was awarded for correctly performing each of the following: unscrew bottle lid; tilt back head;
gently pull down lower eye lid; occlude the punctum; aim accurately; do not allow hand to shake; squeeze bottle; do not touch the eye with the bottle; blink gently and slowly.
Results All patients agreed to participate in the study. For one man who suffered from Alzheimer's disease, information was collected from his wife, as she managed his treatment. The mean age of the 43 patients was 82 years (range 7591). Twenty-five patients were receiving treatment for glaucoma; 13 were recovering from cataract extraction and the others were receiving treatment for dendritic ulcer (2) iritis (1), conjunctivitis (1), and chronic dry eyes (1). The duration of treatment varied from 2 weeks to more than 10 years. Twenty-seven patients (63%) said they had been told how to apply eye-drops, 23 by a nurse, three by a pharmacist and one by a doctor. Only 12 of the 43 patients had actually been shown Age and Ageing 1992;21:168-170
PRACTICAL PROBLEMS WITH EYE-DROPS
169
Table. Patients' technique in self-application of eye-drops No. of patients performing correctly Applying All Relying on treatment others themselves patients (n = 31) (n = 12) (n = 43) Unscrew bottle top Tilt head back Pull down lower lid Occlude punctum Aim accurately Don't allow hand to shake Squeeze bottle Don't touch eye with dropper Blink gently
how to apply drops, in all cases by a nurse. Six of these patients had been instructed as well as shown how to apply their drops. No spouse or other carer had been shown or instructed in the application of drops. Only 12 patients (28%) applied their drops themselves, the others relying on relatives, friends, district nurses or home helps. Ten of the remaining 31 patients lived alone, and had been recommended to apply drops up to six times daily. Thirty-six patients reported difficulties in the application of eye-drops: five of the 12 who put in their own drops and all 31 who relied upon others to instil their medication. The problems reported included inability to abduct the shoulder adequately and difficulties in squeezing the bottle because of arthritis, tremor and blinking causing difficulties in aim. The patients' scores in eye-drop application are shown in the Table. The patients who applied drops themselves tended to score better than the patients relying upon others (median scores 5/9 vs 3/9) but this was not significant. In six of the 12 self-administering patients the score was less than 5 suggesting that these patients were unlikely to succeed in instilling a drop in the conjunctival sac. Two of the five patients who reported difficulties were in this group.
23
8 16 0 14 23 29 21 26
11 5 9 0
34 13 25 0
8 9
22 32 39 28 37
10 7 11
The patients who had received instruction in or who had been shown how to apply their drops or who had been both instructed and shown scored no better than those who had not received attention (median scores 5, 5, 6, 5/9, respectively). Only two patients had been prescribed aids or appliances to improve their technique.
Discussion Several previous studies have examined aspects of drug compliance in ophthalmology and have drawn attention to its importance in conditions such as glaucoma which require long-term preventive treatment [1-3]. However, practical problems with compliance have received little attention. One recent study has examined this problem in a mixed age-group sample of ophthalmology in- and out-patients [4]. Although practical problems were reported frequently, the results of our study indicate that such difficulties are commoner among elderly patients. The prevalence of practical problems was 84% in our study, but only 57% in the mixed age group sample. Most elderly patients had some difficulties in the application of eye-drops. Although some recognized this problem, many of those who
170
E. BURNS, G. P. MULLEY
were observed to have difficulty had not reported it. Thus, asking patients about difficulties is probably an insensitive method of monitoring problems with drops. Only by direct observation of patients' technique can the ability to instil eye-drops be assessed. Previous studies which have reported that practical problems are not a significant factor in noncompliance may have underestimated its importance because of reliance on interview alone [2]. One-third of the patients in this study who had recognized that their ability in eye-drop application was inadequate and relied on others to instil their treatment lived alone. As several of these patients had been prescribed regimes requiring treatment up to six times daily, compliance was likely to be incomplete. Several patients in this study had difficulties in applying drops because of inability to abduct the shoulder, a finding which is in keeping with recent reports of the high prevalence of shoulder disorders among elderly people [5]. Few patients who scored poorly on eye-drop application had been offered aids to improve their independence in this respect. Devices designed to facilitate bottle squeezing and to improve aim are available [6, 7], The more widespread use of such appliances combined with better instruction of patients, and where appropriate their carers, in eye-drop usage may allow elderly patients a greater degree of independence, with benefits not only for the patients' self-esteem, but also for patients' relatives, district nursing services and also for more effective compliance with eye-drop treatment regimes.
Acknowledgements We are grateful to Mr R. M. L. Doran, Consultant Ophthalmologist at Leeds General Infirmary for allowing us to interview patients under his care.
References 1. Norell SE, Granstrom PA. Self-medication with pilocarpine amongst outpatients in a glaucoma clinic. Br J Ophthalmol 1980;64:l 37-41. 2. MacKean JM, Elkington AR. Compliance with treatment of patients with chronic open-angle glaucoma. BrJ Ophthalmol 1983;67:46-9. 3. Kass MA, Meltzer DW, Gordon M, Cooper D, Goldberg J. Compliance with topical pilocarpine treatment. Am 3 Ophthalmol 1986;101:515-23. 4. Winfield AJ, Jessiman D, Williams A, Esakowitz L. A study of the causes of non-compliance by patients prescribed eyedrops. Br J Ophthalmol 1990;74:477-80. 5. Chakravarty KK, Webley M. Disorders of the shoulder: an often unrecognized cause of disability in elderly people. Br MedJ 1990;3O0:8489. 6. Williams A, Winfield A. Topical medication for eye patients. Nurs Times 1990;86:42-3. 7. Winfield AJ, Jessiman D, Craig GM, Williams A. Assisting patients with their eye drops. Hosp Pharm Pract May 1990; 17-22. Authors' address Department of Medicine for the Elderly, St James's Hospital, Beckett Street, Leeds LS9 7TF
Received 31 August 1991
Summary Many elderly patients have eye-drops prescribed. We have examined the abilities in eye drop application of 43 consecutive outpatients aged 75 years or more who completed a questionnaire and demonstrated their technique in eye-drop application. Less than one-third of patients applied drops themselves, the rest relying on others; one-third of this group lived alone. The majority of patients experienced some difficulty with the application of their drops and it was estimated that half of those who usually applied their own treatment were unlikely to succeed in instilling a drop into the conjunctival sac. Few patients had been prescribed aids or appliances to improve their eye-drop application technique.
Introduction Visual problems affect many old people and may necessitate treatment with eye-drops. Yet visual and other physical disabilities may cause difficulties in instilling drops. We have examined the frequency and type of problems encountered by old people. Methods Sixty-two consecutive patients aged 75 years or more attending for review at a general ophthalmology outpatient clinic were assessed. Forty-three patients were using eye-drops and they were interviewed further. Patients were asked what instruction they had received in the application of their eye-drops, whether they usually instilled their drops themselves, and whether they experienced any difficulty in doing so. The patients were then asked to demonstrate their technique of eye-drop instillation. The patients' technique was scored against a recommended method which was described in an eye-drop package insert provided by the hospital pharmacy. One point was awarded for correctly performing each of the following: unscrew bottle lid; tilt back head;
gently pull down lower eye lid; occlude the punctum; aim accurately; do not allow hand to shake; squeeze bottle; do not touch the eye with the bottle; blink gently and slowly.
Results All patients agreed to participate in the study. For one man who suffered from Alzheimer's disease, information was collected from his wife, as she managed his treatment. The mean age of the 43 patients was 82 years (range 7591). Twenty-five patients were receiving treatment for glaucoma; 13 were recovering from cataract extraction and the others were receiving treatment for dendritic ulcer (2) iritis (1), conjunctivitis (1), and chronic dry eyes (1). The duration of treatment varied from 2 weeks to more than 10 years. Twenty-seven patients (63%) said they had been told how to apply eye-drops, 23 by a nurse, three by a pharmacist and one by a doctor. Only 12 of the 43 patients had actually been shown Age and Ageing 1992;21:168-170
PRACTICAL PROBLEMS WITH EYE-DROPS
169
Table. Patients' technique in self-application of eye-drops No. of patients performing correctly Applying All Relying on treatment others themselves patients (n = 31) (n = 12) (n = 43) Unscrew bottle top Tilt head back Pull down lower lid Occlude punctum Aim accurately Don't allow hand to shake Squeeze bottle Don't touch eye with dropper Blink gently
how to apply drops, in all cases by a nurse. Six of these patients had been instructed as well as shown how to apply their drops. No spouse or other carer had been shown or instructed in the application of drops. Only 12 patients (28%) applied their drops themselves, the others relying on relatives, friends, district nurses or home helps. Ten of the remaining 31 patients lived alone, and had been recommended to apply drops up to six times daily. Thirty-six patients reported difficulties in the application of eye-drops: five of the 12 who put in their own drops and all 31 who relied upon others to instil their medication. The problems reported included inability to abduct the shoulder adequately and difficulties in squeezing the bottle because of arthritis, tremor and blinking causing difficulties in aim. The patients' scores in eye-drop application are shown in the Table. The patients who applied drops themselves tended to score better than the patients relying upon others (median scores 5/9 vs 3/9) but this was not significant. In six of the 12 self-administering patients the score was less than 5 suggesting that these patients were unlikely to succeed in instilling a drop in the conjunctival sac. Two of the five patients who reported difficulties were in this group.
23
8 16 0 14 23 29 21 26
11 5 9 0
34 13 25 0
8 9
22 32 39 28 37
10 7 11
The patients who had received instruction in or who had been shown how to apply their drops or who had been both instructed and shown scored no better than those who had not received attention (median scores 5, 5, 6, 5/9, respectively). Only two patients had been prescribed aids or appliances to improve their technique.
Discussion Several previous studies have examined aspects of drug compliance in ophthalmology and have drawn attention to its importance in conditions such as glaucoma which require long-term preventive treatment [1-3]. However, practical problems with compliance have received little attention. One recent study has examined this problem in a mixed age-group sample of ophthalmology in- and out-patients [4]. Although practical problems were reported frequently, the results of our study indicate that such difficulties are commoner among elderly patients. The prevalence of practical problems was 84% in our study, but only 57% in the mixed age group sample. Most elderly patients had some difficulties in the application of eye-drops. Although some recognized this problem, many of those who
170
E. BURNS, G. P. MULLEY
were observed to have difficulty had not reported it. Thus, asking patients about difficulties is probably an insensitive method of monitoring problems with drops. Only by direct observation of patients' technique can the ability to instil eye-drops be assessed. Previous studies which have reported that practical problems are not a significant factor in noncompliance may have underestimated its importance because of reliance on interview alone [2]. One-third of the patients in this study who had recognized that their ability in eye-drop application was inadequate and relied on others to instil their treatment lived alone. As several of these patients had been prescribed regimes requiring treatment up to six times daily, compliance was likely to be incomplete. Several patients in this study had difficulties in applying drops because of inability to abduct the shoulder, a finding which is in keeping with recent reports of the high prevalence of shoulder disorders among elderly people [5]. Few patients who scored poorly on eye-drop application had been offered aids to improve their independence in this respect. Devices designed to facilitate bottle squeezing and to improve aim are available [6, 7], The more widespread use of such appliances combined with better instruction of patients, and where appropriate their carers, in eye-drop usage may allow elderly patients a greater degree of independence, with benefits not only for the patients' self-esteem, but also for patients' relatives, district nursing services and also for more effective compliance with eye-drop treatment regimes.
Acknowledgements We are grateful to Mr R. M. L. Doran, Consultant Ophthalmologist at Leeds General Infirmary for allowing us to interview patients under his care.
References 1. Norell SE, Granstrom PA. Self-medication with pilocarpine amongst outpatients in a glaucoma clinic. Br J Ophthalmol 1980;64:l 37-41. 2. MacKean JM, Elkington AR. Compliance with treatment of patients with chronic open-angle glaucoma. BrJ Ophthalmol 1983;67:46-9. 3. Kass MA, Meltzer DW, Gordon M, Cooper D, Goldberg J. Compliance with topical pilocarpine treatment. Am 3 Ophthalmol 1986;101:515-23. 4. Winfield AJ, Jessiman D, Williams A, Esakowitz L. A study of the causes of non-compliance by patients prescribed eyedrops. Br J Ophthalmol 1990;74:477-80. 5. Chakravarty KK, Webley M. Disorders of the shoulder: an often unrecognized cause of disability in elderly people. Br MedJ 1990;3O0:8489. 6. Williams A, Winfield A. Topical medication for eye patients. Nurs Times 1990;86:42-3. 7. Winfield AJ, Jessiman D, Craig GM, Williams A. Assisting patients with their eye drops. Hosp Pharm Pract May 1990; 17-22. Authors' address Department of Medicine for the Elderly, St James's Hospital, Beckett Street, Leeds LS9 7TF
Received 31 August 1991
