Jeannette Y. Wick, RPh, MBA, FASCP
Older patients often find medication adherence difficult, as the use of multiple medications create challenges. Pharmacists can help in a variety of ways to identify the problem and implement corrective action.
Increasing medication use with age is common to address specific symptoms, improve or extend quantity of life, or heal curable conditions. Almost 20% of community-dwelling elders (65 years or older) take 10 or more medications.1
For some elders, underlying conditions require multiple drugs from different classes, but for others this polypharmacy is unnecessary and unfortunate.2
Sadly, multiple medication use creates and contributes to adherence challenges in the aging population.
Identifying Adherence Issues
Approximately one half of elders who take at least 1 medication find adherence challenging. They may be adherent to some of their medications and nonadherent to others.3,4
Average adherence decreases from approximately 80% in patients taking medication once daily to 50% in those taking medications 4 times a day.5,6
Clinicians often fail to identify nonadherence issues in their elderly patients. There are several reasons why. Lack of meaningful communication is a major problem.7
Clinicians have to learn to ask about medication adherence, and do so using nonjudgmental, open-ended questions. Starting with an empathetic statement such as, “Many people find it hard to take all their medications every day,” and progressing to an open-ended question such as, “How often do you miss doses?” can identify patients who are challenged by their regimen.3,8
Most of the time, nonadherent patients will divulge 1 of the reasons listed in Table 1.
Pharmacists have several tools at their disposal to identify problems early and implement corrective action. The traditional “brown bag” review with elders of all their medicines—prescription and over-the-counter medicines, vitamins, supplements, and herbal preparations—is an effective way to start a dialogue. Most pharmacists find it useful to use “show and tell” as they remove items from the bag, shaking tablets or capsules into the cap and saying, “Tell me what this is for and how you take it.” Using pharmacy records—the patient’s profile and refill records—and pill counts in the bottles, pharmacists can develop a fairly accurate idea of the patient’s adherence pattern. 3,8,12
Pharmacists can determine what category the elder’s medication nonadherence falls into (Table 2).
Older patients may perceive the treatment benefit to be small compared with its cost, so clear communication is imperative. Pharmacists should anticipate elders’ conflicting beliefs. Helping patients improve their adherence requires knowledge about their current medication use, reasons for nonadherence, and personal health goals.
Many elders are not interested in increasing their longevity if it detracts from quality of life. Additionally, elders often rely on family members and trusted caregivers to help them identify, refine, and communicate their health goals. The preference for quality of life over longevity may be especially pronounced if the elder has a serious chronic illness or terminal condition. For this reason, hospice providers will often discontinue all medications except those for current problems.15-17
Pharmacists need to ask patients what their expectations are (longer life, reducing symptoms, reducing pill burden, avoiding adverse effects, reducing cost) and correct any misperceptions. Patients may be over-adherent to analgesics, for example, because they want to be pain free. Helping them understand that freedom from all pain is an unrealistic expectation can improve adherence.18
Next, pharmacists can help elders by ensuring that all medications have a current indication. Often, medications languish on the patient’s profile long after a condition or symptom has been addressed and an alternate drug has been added. Some drugs, especially benzodiazepines, antidepressants, and beta-blockers, may need to be tapered. Drugs can usually be tapered down at the same rate at which they are titrated up at the initiation of drug therapy.19
Contacting the prescriber(s) is wise in these cases. A large study of ambulatory older patients found that 26% of drug discontinuations exacerbated the underlying condition and 4% led to physiologic withdrawal reactions. 20
Conversely, some elders may need a potentially beneficial medication (eg, antidepressants, analgesics, or laxatives) and adding these may help them be more adherent.21-23
Dosing frequencies should be questioned, and decreasing the number of doses is a good recommendation. Using long-acting medications and dosing different drugs at the same time is practical, as is using 1 medication to treat 2 conditions when possible.22,23
If an adverse effect (AE) is contributing to nonadherence, the pharmacist can try to determine if the AE is truly associated with the drug the elder attributes it to or something else. Anticholinergic AEs can be particularly troublesome in the elderly. Nonspecific AEs often mimic disease processes. Pharmacists should contact the prescriber with concerns, and suggest that the medication be stopped temporarily to see whether the symptoms improve.24,25
Patients may be embarrassed if cost is a barrier, so pharmacists need to ask gently whether this is the case. Recommending lower cost generic alternatives is helpful when possible.26
While discussing medications with elders, pharmacists should educate the patient or caregiver. Oral counseling is imperative but insufficient. Elders also need written information in a readable font and patient-friendly language, especially if changes are being made. Asking the elder or caregiver to describe the drug’s purpose, its use instructions, and its potential side effects (called “back teaching”) can identify knowledge gaps.27,28
Finally, with increasing age, subjects tend to have compromised physical dexterity, cognitive skill, and memory. The inability to open a child-safety cap or raise the arms above the head is a significant adherence barrier for taking oral or ophthalmic medications.6
As health care reform progresses, the dream is that clinicians will share medication management responsibilities following the patient-centered medical home model of care.29
Using combinations of approaches and augmenting clinical intervention with adherence tools (eg, cues, medication organizers, packaging) will be necessary for most elderly patients. Many patients will need a combination of approaches, and creativity is the order of the day.
1. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 2005;294:716-724.
2. Slone Epidemiology Center at Boston University. Patterns of medication use in the United States, 2006. http://www.bu.edu/slone/SloneSurvey/AnnualRpt/SloneSurveyWebReport2006.pdf. Accessed November 18, 2010.
3. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487-497.
4. Gray SL, Mahoney JE, Blough DK. Medication adherence in elderly patients receiving home health services following hospital discharge. Ann Pharmacother. 2001;35:539-545.
5. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23:1296-1310.
6. Salzman C. Medicine compliance in the elderly. J Clin Psych. 1995;56(suppl 1):18-22.
7. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556-1564.
8. Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of medication adherence among seniors. Ann Pharmacother. 2004;38:303-312.
9. Piette JD, Heisler M, Wagner TH. Problems paying out-of-pocket medications costs among older adults with diabetes. Diabetes Care. 2004;27:384-391.
10. Mojtabai R, Olfson M. Medicine costs, adherence, and health outcomes among Medicare beneficiaries. Health Aff (Millwood). 2003;22:220-229.
11. Horne R, Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res. 1999;47:555-557.
12. Wallsten SM, Sullivan RJ Jr, Hanlon JT, Blazer DG, Tyrey MJ, Westlund R. Medication taking behaviors in the high- and low-functioning elderly. Ann Pharmacother. 1995;29:359-364.
13. Russell CL, Conn VS, Jantarakupt P. Older adult medication compliance. Am J Health Behav. 2006;30:636-650.
14. Mistry SK, Sorrentino AP. Patient nonadherence: the $100 billion problem. Am Druggist. 1999;216:56-57.
15. Walter LC, Covinsky KE. Cancer screening in elderly patients. JAMA. 2001;285:2750-2756.
16. Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166:605-609.
17. Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003;51(5 suppl guidelines):S265-S280.
18. Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166:605-609.
19. Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications. J Am Geriatr Soc. 2008;56:1946-1952.
20. Graves T, Hanlon JT, Schmader KE, et al. Adverse events after discontinuing medications in elderly outpatients. Arch Intern Med. 1997;157:2205-2210.
21. Steinman MA. Polypharmacy and the balance of medication benefits and risks. Am J Geriatr Pharmacother. 2007;5:314-316.
22. Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49:200-209.
23. Lipton HL, Bero LA, Bird JA, McPhee SJ. The impact of clinical pharmacists' consultations on physicians' geriatric drug prescribing. Med Care. 1992;30:646-658.
24. Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications. J Am Geriatr Soc. 2008;56:1946-1952.
25. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people. BMJ. 1997;315:1096-1099.
26. Hsu J, Fung V, Price M, et al. Medicare beneficiaries' knowledge of Part D prescription drug program benefits and responses to drug costs. JAMA. 2008;299:1929-1236.
27. Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions. Arch Intern Med. 2007;167:540-550.
28. Conn VS, Hafdahl AR, Cooper PS, Ruppar TM, Mehr DR, Russell CL. Interventions to improve medication adherence among older adults. Gerontologist. 2009;49:447-462.
29. Feldstein AC, Smith DH, Perrin N, et al. Improved therapeutic monitoring with several interventions. Arch Intern Med. 2006;166:1848-1854.
Ms. Wick is senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Maryland.