78 Journal of the American Pharmaceutical Association November/December 2002 Vol. 42, No. 6 Clock Drawing Test and Medication Complexity Index as Indicators of Medication Management Capacity: A Pilot Study Karen B. Farris, Michael W. Kelly, and Jennifer Tryon Cognitive impairment short of dementia affects nearly one in four community-dwelling elders and is a major risk factor for dementia. 1 An estimated 5% of adults 65 years of age and older suffer from severe, chronic, irreversible cognitive impairment. Another 5% exhibit moderate degrees of impairment. Cognitive impairment is correlated with advancing age, with an estimated prevalence of 19.2% for seniors age 65–74, 27.6% for those 75– 84, and 38.0% for seniors 85 and older. 2 Cognitive or psychomotor deficits have detrimental effects on medication management, which is considered an instrumental activity of daily living (IADL). Medication management capaci- ty is the ability of an individual to use the set of psychomotor and cognitive activities required to administer medications as pre- scribed or directed. 3 Any deviations from a prescribed regimen are attributable to lack of ability and are unintentional. Thus, medication management capacitydiffers from adherence. Among older adults, medication management capacity is of concern in primary care, as members of this group consume the most medi- cations and have a number of characteristics that place them at risk for reduced capacity to manage their regimens. 4,5 Five performance-based tests for assessing medication man- agement have been reported. 6–10 Most of the tests are skill-based, and administration times must include time for patients and providers to interact. For example, individuals may be asked to set up an adherence aid. 9 Alternatively, individuals may have to demonstrate their abilities to read a prescription label, open and close child-resistant and non–child-resistant vials, remove tablets from a vial, and differentiate tablet colors. 10 Previous research has shown that cognitionis an important pre- dictor of medication management capacity. 6–11 However, Maddigan et al. 12 recently showed that the effect of cognition (assessed with the Mini-Mental Status Exam 13 ) was conditional on the complexity of the regimen. The role of functional capaci- ties, such as the level of independence in managing money (e.g., paying bills, balancing a checkbook) or preparing a balanced meal, in predicting medication management capacity is also unclear. 6,9,11 Pharmacists and other providers in the community may be able to identify individuals with medication management difficulties early and thereby prevent negative outcomes, such as nonadher- ence and adverse effects. If health care providers were to proac- tively offer the appropriate level of assistance, the resulting bene- fits would be substantial. Objective The objective of this study was to determine whether easy-to- assess variables were predictive of difficulties in medicationman- agement. Methods The study was approved by the University of Iowa Institutional Review Board. Design Home visits to clients at high risk for medication problems were conducted by a clinical pharmacist (MWK) to ensure patients and caregivers were using or administering medications properly. During the home visit, the clinical pharmacist obtained a comprehensive medication history, which he used to identify drug therapy issues. He then communicated these issues, along with recommendations for solving them, to the patient’s primary care physician. Data for this study were abstracted from his charts, but no identifiable data about the patients, such as name or address, were collected. Subjects The Heritage Area Agency on Aging Case Management Program for the Frail Elderly in Southeast Iowa identified medication man- agement and cost as concerns of 36 clients receiving 10 or more medications. Individuals are admitted to the Case Management Program if they are 60 years of age or older, need nursing-home level care (e.g., are unable to dress, walk, use the toilet, prepare meals), live in Iowa, and meet income/resource guidelines for Medicaid or can pay sliding-scale fees according to income. “Frail” is a term denoting that an individual has lost inde- pendence in his or her activities of daily living (ADLs) and/or IADLs. ADLs generally require basic levels of physical func- tion and include, for example, bathing, dressing, using the toi- let, mobility, and eating. IADLs combine physical function and social role fulfillment, and examples include shopping, cook- ing, managing money, managing medications, and playing a game of skill. Numerous scales for assessing ADLs and IADLs are available. 14 Data Collection During the home visits, the pharmacist completed a compre- hensive medication history, obtaining the following information: demographics, such as age and sex; prescription and nonprescrip-