Quality of life and compliance in geriatric patients

Background. Older adults often have several comorbid deseases. In most cases, each condition requires constant pharmacotherapy. On average, the clinical examination of patients aged 60 and older reveals at least four or ive different chronic pathological states in various phases and stages. Disease interference changes the classical clinical picture, increases the number of complications and their severity, affects the quality of life and prognosis, as a result complicated medical diagnostic process and reduced compliance. The presence in the elderly bothmental and physical illness signi icantly affects the quality of life. Psychological interventions aimed at a patient’s awareness of the disease and methods of its treatment, the creation of therapeutic alliance and the prevention of self-medication, according to our hypothesis, contributes to compliance and quality of life improvement in polymorbid elderly patients suffering frommental disorders. Methods. In the study took part 325 patients who underwent inpatient treatment at the gerontopsychiatric department and signed provided informed consent. The study had a design of a randomized controlled clinical trial. Patients were randomized to experimental and control groups in a ratio of 3 to 1 based on age and gender. The study group of 238 people received standard treatment and psychological interventions. A comparison group of 87 people had only standard treatment. Patients were evaluated for quality of life with SF-36 scale and compliance with Morisky Medication Adherence Scale. Results. We have seen signi icant intergroup differences on the Morisky Medication Adherence Scale in the baseline period. Consequently, its results were not be taken into account in the inal analysis. Before treatment patients’ quality of life between the study groups did not differ statistically (p = 0.317). After the treatment, a statistically signi icant difference in life quality between experimental and control groups was found (p <0.001). A strong direct correlation was noted between changes in quality of life in SF-36 scale (rs = 0.5; p <0.001) and clinical treatment group, which included the patient. Patients with a younger age demonstrated a more signi icant improvement in their quality of life (r = -0.149; p = 0.007). A greater improvement in life quality was observed in patients with a lower cognitive function de icit in the MMSE score (r = 0.282; p <0.001). Among the self-treated patients, there were signi icant changes in SF-36 score after treatment (rs = 0.119; p = 0.033). The obtained data con irm that psychotherapeutic interventions (psychoeducation, compliance therapy, and pharmacomania prevention training) contribute to the life quality improvement of gerontopsychiatric patients. Conclusion. Usage of the psychotherapeutic program during standard treatment, aimed at the psychoeducation, creation of a therapeutic alliance and the reduction of pharmacomania (especially with regard to self-medication with barbiturates) promoted positive changes in the quality of life in the study sample. Our data con irm the need for interventions designed for improving the quality of life in the polymorbid elderly patients with mental disorders.


Background
Progressive aging of the human population is now the major problem of most countries.WHO has projected that by 2050 the number of elderly will reach 2 billion and will exceed the number of children under 14 years [1], [2].
Older adults often have more than one chronic disease.In most cases, each condition requires constant pharmacotherapy.On average, the clinical examination of patients aged 60 and older reveals at least four or ive different chronic pathological states in various phases and stages [3].It makes polymorbid elderly patients seek medical help and apply to doctors of different specialties.Disease interference changes the classical clinical picture, increases the number of complications and their severity, affects the quality of life and prognosis.As a result -obstruction of the medical diagnostic process, and reduced compliance in relations between doctor and patient [4], [5].
The project ZARADEMP on a representative sample of the elderly population (4803 persons aged ≥ 55 years) has tested the hypothesis of a relationship between somatic and mental diseases [6].Total comorbidity in this study reached 19.9%, and this prevalence was estimated after the exclusion of hypertension from physical illness category.33.5% of patients from the total sample had disease states without comorbidity.Concomitant diseases showed a positive correlation with age, female sex and low levels of education.The incidence of mental disorders was higher among patients with physical illness than among physically healthy.The frequency of somatic morbidity among psychiatric patients was higher than among mentally healthy individuals.This relationship between somatic and mental disorders remained statistically signi icant after adjustment for age, sex and education (odds ratio (OR) = 1,61; con idence interval (CI) = 1,38-1,88).Most physical diseases were associated with the presence of a mental disorder, but after adjusting for demographic and certain systemic diseases, the correlation remained statistically signi icant only for stroke (CVAS) (OR = 1,47; CI = 1,09-1,98) and thyroid disease (OR = 1,67; CI = 1.10-2.54).Authors noted that this was the irst study conclusively con irmed the existence of a positive and statistically signi icant relationship between somatic and psychiatric morbidity in elderly, especially for cerebrovascular and thyroid disease [6].
De inition of similar indicators is important for the Ukrainian older patients' population.According to statistics from Ukrainian Ministry of Health, mental illness is the 7th leading cause of disability in the elderly, 11% of people over age 60 need a quali ied mental health care.Half of all patients receiving long-term psychiatric treatment are over 65 years old.Approximately one-ifth of patients who irst came to the psychiatric hospital are older than 65 years [2].The presence in the elderly both mental and physical illness signi icantly affects the quality of life.In the meta-analysis of studies on the relationship between somatic and psychiatric comorbidity in patients with somatic diseases (metabolic, respiratory, musculoskeletal, cardiovascular, gastrointestinal disorders, cancer, etc.) taking into account quality of life.The systematic review included 481 studies, of which 45 were included in the inal analysis.In total were recorded signi icant negative correlation between comorbidity and quality of life.This is mainly related to somatic and psychiatric comorbidity: 70.3% on the psychosocial aspects of quality of life and 100% on the quality of life in general [7].A similar systematic review (7291 reviewed studies and 65 in the inal analysis) aimed to examine the association between comorbid mental disorders and quality of life in patients with chronic medical states (diabetes, coronary heart disease, asthma, chronic back pain and colorectal cancer).In persons with combined physical illness and mental disorder was noted signi icantly decrease in quality of life in general (d = -1,10; 95% CI = -1.34 to -0.86) and its physical (d = -0,64; 95 % CI = -0.74 to -0.53) and psychosocial component (d = -1,18; 95% CI = -1.42 to -0.95) compared with individuals without mental disorders.This result highlights the importance of identifying and treating mental disorders related in physically ill patients [8].
Elderly patients are among the leading medication consumers.Therefore, one of the most important tasks in geriatrics is the development of an ef icient and safe approach for management of elderly with comorbid diseases and, at the same time, avoidance of polypharmacotherapy whenever possible [9].
According to observations, to achieve suf icient adherence in elderly patients with mental disorders is more complicated task than in young and middle age patients.Elderly patients with mental health problems more often in comparison to others don't have a critical attitude to their state [10].They often perceive an attempts to provided medical assistance as violence and cause active resistance.Moreover, these patients more often are subjects to self-medication, e.g., barbiturates.The reluctance of treatment may be associated with the delusional interpretation of events, such as prescribing a drug, that can be perceived as "poisoning" to obtain property.Depressed elderly patients cannot take medicine not only because of the lack of criticism but also through a severe motor retardation, caused by a mental condition, and age-related changes in the body.In diseases involving the development of dementia (atrophic processes, vascular brain damage, etc.), the possibility of therapeutic collaboration is very low because of impaired memory, reasoning, and reduced criticism [7], [8].
Patients' persuasion to take medications independently during the exacerbation of psychosis or other mental illness is a dif icult task, so treatment is carried out in the hospital.Once improvement of criticism contributes to the formation of the therapeutic alliance, patients begin to take medications on their own and continue treatment as outpatients.However, outpatient therapeutic cooperation can also be short-term.It can be associated with the development of side effects that are particularly dif icult tolerated by elderly patients at home, with fear that prolonged treatment can damage the health [11] .This, as a result, can lead to repeated hospitalizations.
Self-medication and failure to comply with doctor's recommendations by elderly patients contribute to serious health consequences such as lack of therapy ef icacy, multiple drug regimen revision by a physician, side effects of medications, disappointment by the treatment results.Poor adherence is one of the primary risk factor for reduction of therapeutic effects, development of complications, which leads to a decrease in quality of life and increase of treatment cost [12], [9].Psychotherapeutic interventions aimed at a patient's awareness of his disease and its treatment, the creation of therapeutic alliance and the prevention of selfmedication, according to our hypothesis, can help to improve compliance and quality of life in polymorbid elderly patients suffering from mental disorders [12].

Materials and methods
The study sample comprised of 325 patients who underwent inpatient treatment at the Gerontopsychiatric Department of the Mariupol Psychiatric Hospital and signed an informed consent.Most prevalent diagnoses were dementia and schizophrenia.The study had a design of a randomized controlled clinical trial.Randomization was performed by a computer program.Patients were randomized to the experimental and control groups in a ratio of 3 to 1 based on age and gender.Consequently, they are representative of these indicators.
The study group (n=238) received standard treatment and psychological interventions.The program of psychological treatment consisted of three parts: informative, motivating and re lective.It included a combination of psychoeducation, compliance therapy, and pharmacomania prevention training.A comparison group (n=87) received only standard treatment.Patients were evaluated for quality of life with SF-36 scale and compliance level with Morisky Medication Adherence Scale.

Baseline characteristics
Following a randomization, the study group and the comparison group were additionally evaluated for their representativeness by the main features.
As can be seen from Table 1, the overall quality of life in the groups did not differ signi icantly, making possible a conduction of variance analysis to determine the effectiveness of psychological interventions in the improvement of the quality of life for the studied sample.Some differences were observed for certain subscales.Thus, in the main group, the indicators of physical (p <0.001) and role functioning due to the physical condition (p = 0.002) were signi icantly better, and, on the contrary, in the comparison group were noted a signi icantly higher baseline scores on the vitality (p = 0.010), social functioning (p = 0.038) and mental health (p <0.001) (Table.1).But the overall SF-36 score didn't differ signi icantly between groups.
We have seen signi icant intergroup difference on the Morisky Medication Adherence Scale.Consequently, since the scores for this scale are signi icantly different, its results will not be taken into account in the inal analysis (Table 2).

Changes during the study, analysis of variance
We have evaluated overall shifts in the quality of life in geriatric patients during the treatment process, as well as differences between experimental and control groups.
So, when evaluating the mean scores of all patients included in the study, we noted a signi icant improvement in the quality of life.On the SF-36 scale, it was 24.65 points with statistically signi icant difference in comparison to baseline score (p <0.001) (Table 3).Prior to treatment patients' quality of life between the study groups did not differ statistically (p = 0.317).But at the end of the treatment was noted the statistically signi icant difference in the quality of life between the study and control group (63.00 vs. 47.86;p<0.001).During the treatment in control group, overall SF-36 score improved by 14.55, while in psychological interventions group -by 28.35 points with a statistical signi icant intergroup difference (Table 4).
Changes in the quality of life in patients in the control group, who received standard treatment averaged at 14.5 points, and in patients in the main group who received additional psychotherapy -28.35 points.The intergroup difference was highly signi icant (p<0.001), which fully con irms the effectiveness of the psychotherapeutic program, consisting of psychoeducation, compliance therapy, and pharmacomania prevention training, in improving the quality of life (Table 5).

Changes during the study, correlation analysis
We also noticed that changes in quality of life on the SF-36 scale during the treatment were signi icantly correlated with age, but the correlation strength was weak (r = -0.149;p = 0.007).These data mean that patients with a younger age demonstrated a more substantial improvement in the quality of life.In addition, changes in SF-36 score signi icantly directly correlated with the overall score on the MMSE scale; the correlation strength was weak (r = 0.282; p <0.001).It indicates that more improvement in the quality of life was observed in patients who scored more on MMSE and, accordingly, had a lower cognitive de iciency.The number of concomitant illnesses, duration and intensity of smoking, as well as the number of drugs taken daily or periodically by the patient, did not have a signi icant effect on changes in the quality of life during treatment (Table 6).
Also, a strong direct correlation was noted between changes in quality of life on the SF-36 scale (rs = 0.5; p <0.001) and the clinical treatment group in favor of the experimental group.These results were con irmed by the data of the dispersion analysis, where more pronounced improvement was observed in psychotherapeutic interventions group (psychoeducation, compliance therapy, and pharmacomania prevention training).
Despite the fact that the total number of drugs taken daily or periodically by the patient did not have a signi icant effect on quality of life changes during treatment, among patients who self-treated, there were more pronounced changes in quality of life on the SF-36 scale after treatment (rs = 0.119; p = 0.033).

Discussion
Mental disorders among the elderly population are one of the main social problems because of their high frequency of occurrence and high somatic comorbidity.In addition, the prognosis of comorbid diseases usually is poor.Studies indicate that there is a strong and complex relationship between somatic diseases, mental disorders and older age, which makes geriatric medicine more laborious and more expensive than conventional one [12], [9].It is emphasized that mental health is crucial because of the importance of functional independence and a decent quality of life in elderly patients [13], [10].
The data obtained in our study con irm the low quality of life in older adults suffering from comorbid psychiatric and somatic disorders.The most vulnerable components were the overall quality of life, role functioning due to the The practical feasibility of providing thematic psychoeducational and psychotherapeutic programs for elderly patients with mental disorders has been shown in many studies.The authors noted the need for interventions aimed at quality of life improving in elderly patients with mental disorders [4], [11], [7].
In our study, it was shown that changes in the quality of life in the study group (patients treated with standard therapy and psychotherapeutic interventions) were twice higher compared to patients receiving standard treatment (control group) (p <0.001).Intervention ef icacy predictors were younger patient age, lower cognitive functioning and the ten-dency to self-treatment before hospitalization.

Conclusion
Consequently, applying the psychotherapeutic program to gerontopsychiatric patients, aimed at obtaining suf icient information about their diseases and their treatment, creation of a therapeutic alliance and the reduction of pharmacomania (especially with regard to self-medication with barbiturates) was associated with positive changes in the quality of life during treatment.These data con irm the need for interventions intended for improving the quality of life in polymorbid elderly patients with mental disorders.

Table 1 :
Baseline characteristics of quality of life (SF-36) and their differences between groups.

Table 2 :
Initial indicators on Morisky Medication AdherenceScale and their differences between groups

Table 3 :
Total scores on the SF-36 scale in the entire sample and changes during treatment

Table 4 :
Baseline and inal (after treatment) quality of life (SF-36) in the treatment group.

Table 5 :
Changes in the quality of life, the difference between the end of treatment and baseline.Analysis of variance (ANOVA).

Table 6 :
Pearson correlation between changes in quality of life/satisfaction with treatment and various characteristics.

Table 7 :
Spearman correlation between changes SF-36 scores with treatment and various dichotomic characteristics.