Medication Nonadherence in Older Adults: Patient Engagement Solutions and Pharmacist Impact

NOVEMBER 06, 2018
Amanie Khairullah, PharmD Candidate, Bryce Platt, PharmD, and Rebecca W. Chater, RPh, MPH, FAPhA
Medication nonadherence is a major cause of morbidity, especially in elderly patients. Approximately 10% of hospitalizations may be a result of medication nonadherence.1 It is not only an individual patient’s health problem, but also contributes up to $300 billion of avoidable healthcare costs in the United States (US) and up to 30% of wasteful spending.1

By 2030, 20% of the US population will be aged 65 years or older.2 Patients over 60 years of age consume 50% of dispensed prescription drugs.3 As the population continues to age, chronic disease becomes more prevalent. This translates to an increase in the volume and complexity of medication regimens, increasing the risk for nonadherence. Other factors increasing the likelihood of nonadherence in the elderly include adverse drug reactions that come with polypharmacy, decreased visibility and motor dexterity, and decreased autonomy.

A study assessing the link between potentially inappropriate medicines and avoidable adverse drug events in patients 65 years or older found 68.9% of hospital admissions were avoidable or potentially avoidable due to inappropriate medications.4

On average, older adults take 6-8 medications, typically due to multiple chronic diseases placing them at increased risk for polypharmacy. One in 5 older adults receives inappropriate medications, while 9% take 2 medications from the same drug class.3 Polypharmacy increases the risk of duplicate therapies, adverse drug reactions, drug-drug interactions, and geriatric 'syndromes,' such as urinary incontinence, falls/fractures, and cognitive impairment, all of which may contribute to and exacerbate poor medication adherence.5

Decreased Visibility and Motor Dexterity
Pharmacy labels contain a lot of information, typically in a small font, making them difficult to read for elderly patients with visual impairment. Inability to read the labels and understand how to take their medications can lead to incorrect administration, adverse reactions, and ultimately poor adherence. Additionally, elderly patients may experience difficulty opening pill bottles, even non-childproof ones, due to reduced motor dexterity or chronic conditions like arthritis.

Decreased Autonomy
Aging patients may be limited in their ability to move, drive, and get to the pharmacy in time to pick up their refills. This can lead to delayed refills, resulting in nonadherence. Additionally, this may limit their ability to speak with a pharmacist regarding a medication-related problem they are having.

Solutions and Pharmacist Impact
Implementing services in community pharmacies that are tailored to the needs of the older adult population is key to combating nonadherence. As one of the most accessible health care providers and medication experts, pharmacists can optimize a patient’s medication regimen in order to minimize polypharmacy and associated adverse drug reactions. Through medication therapy management (MTM), pharmacists can identify duplicate or unnecessary therapies. They can also identify drug-drug interactions and potential side effects, and advise patients on how to alleviate them. MTM provided by pharmacists significantly improves health outcomes, as shown in the recent STOMPP study of diabetes patients receiving MTM where A1C goals were achieved.6

Community pharmacies can provide multimed blister packaging to facilitate medication organization and eliminate the need for pill bottles. This packaging uses symbols or colors to indicate the time of the day for each dose, which can help overcome the decreased visual ability that comes with age. Additionally, using blister packs can combat motor dexterity issues associated with opening vials. In the STOMPP study, patients who received multimed blister cards achieved adherence scores greater than 45% above baseline when compared to pill bottles.6

A pharmacy with medication synchronization that follows the appointment-based model (ABM) is optimal for older adults with limited access to transportation and decreased autonomy. This system reduces frequent trips to the pharmacy, providing one monthly appointment, based on the patient’s preference, to pick up all medications and meet with the pharmacist. This increases convenience and coordination, improving adherence. In a recent study by Harvard Medical School, patients enrolled in a medication synchronization program had 9% lower rates of hospitalizations and emergency department visits compared to those not enrolled, likely due to the associated improved adherence.7

Patient nonadherence to prescribed medications is associated with poor therapeutic outcomes, progression of disease, increased healthcare utilization, and an estimated burden of billions per year in avoidable direct healthcare costs. Medication nonadherence is especially common in older adults. Pharmacies can help overcome this public health concern by providing MTM, multimed packaging, medication synchronization, and utilizing the ABM.

  1. Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy. 2014; 7:35-44.
  2. Vincent GK, Velkoff VA. The Next Four Decades: The Older Population in the United States: 2010 to 2050. US Census Bureau. 2010.
  3. Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician. 2013; 87(5):331-6.
  4. Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011; 171(11):1013-9.
  5. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014; 13(1):57-65.
  6. Pinto S, Simon A, Osundina F, Jordan M, Ching D. Study to Measure the Impact of Pharmacists and Pharmacy Services (STOMPP) on Medication Non-Adherence: Medication Adherence and Clinical Outcomes. Innov Pharm. 2018; 9(1).
  7. Krumme AA, Glynn RJ, Schneeweiss S, et al. Medication Synchronization Programs Improve Adherence to Cardiovascular Medications and Health Care Use. Health Aff (Millwood). 2018; 37(1):125-133.