Medication Non-Compliance in the Elderly: Implications for Nursing Practice
Medication Non-Compliance in Older Adults: The Problem
Due to better medical care, improved technology and new treatments, people are now living longer than ever before. This means that often people survive with worsening health and medical conditions requiring increasing nursing care and treatment with numerous medications. Recent studies have determined that those between the ages of 64 to 70 years old are prescribed on average 14 medication a year while those between the ages of 70 and 85 are prescribed on average 18 medications a year (Comaty, 2015).
While newer medications help older adults live healthier and happier lives, they must be taken as prescribed to be effective. Non-compliance in the elderly with medication instructions is a common problem. Since medications may be prescribed long term to treat chronic conditions and short term for curable conditions, changes in medication regimens in the elderly is common and contributes to the problem of non-compliance. It has been estimated that at least 20 percent of those over the age of 64 years that are still living in the community take at least 10 medications. The use of multiple medications in older, community based populations create a series of adherence issues which should be monitored and addressed by the health care community. However, research regarding the efficacy of possible interventions are limited and barriers to proper medication used restricts the implications that could inform nursing care for this group.
Issues in Geriatric Medicine: Medication Compliance
The State of the Research and Implications for Nursing Care
There are many types of interventions that have been examined to improve medication compliance in older adults. These include behavioral, educational and provider-focused treatments. While these interventions have been examined in multiple patient groups including the elderly in order to get clean results they were limited to one medication or medication class. It was suggested that this limitation restricted how generalizable the results were for older adults who tend to be taking multiple medications from multiple medication classes.
In a review conducted by George, Elliott, and Stewart (2008), the authors studied treatments intended to improve medication compliance in older populations who were taking multiple medications. In this review, studies considered included those in which participants were taking at least three medications or the mean or median of long-term medications reported for the entire sample was at least four. Additionally each included study was required to include at least 24 weeks of follow-up and medication adherence was required to be measured for all medications participants were taking. Eight studies were included in the review. In the studies included, verbal and/or written prescription information was provided along with a variety of behavioral strategies that were utilized with or without provider focused strategies. Results indicated that participants in half of the studies reviewed showed a significant improvement in medication compliance. Changes in adherence in the studies were extremely varied ranging from -13 percent to +55.5 percent. Some of the strategies found to be effective at improving medication adherence included regularly scheduled follow-up combined with a multi-compartment dose administration pill box, group education combined with personal medication cards and pharmacist prescription review combined with simplifying the medication regimen.
While this review seems to suggest that combining information provision with behavioral strategies with or without provider focused techniques, there were numerous limitations that restricted the implications that could be gleaned from the study. First, the inclusion criteria were slightly different for different studies. Second, there was no indication that the studies controlled for complexity of treatment or severity of the conditions the participants were taking the medications for. Nor was there any control for the types of medications taken or side effects. Third, the study does not detail what constituted compliance. In some studies patients might be required to take their medication as prescribed 100 percent of the time to be rated as compliant while in others they may have been required to be compliant less than 100 percent of the time. Fourth, the variety in changes in compliance encompassed an array of values ranging from negatives to positives. This suggests that in some studies compliance in the intervention group decreased while in others it increased making the distribution of finding bimodal indicating a potential interaction or confounding effect. Finally, the variety of strategies and combinations of strategies differed for each study making comparison difficult and preventing use of meta-analytical techniques due to the lack of homogeneity of method.
This study indicates the need for further research conducted in a more rigorous manner as it isn’t possible to conclude with conviction from the findings which strategies are the most effective. the However, the study does seem to at least suggest that combinations of information provision, education for example, helping to increase awareness of the benefits of therapy and consequences of non-compliance, and behavioral techniques such as helping seniors to utilize monitoring devices and reminder techniques might be used when improved compliance is desired, until further findings indicate the efficacy of specific interventions. These are simple therapeutic strategies which could regularly be incorporated into nursing practice regardless of compliance status to improve adherence to medication for all older adult patients or for all patients of any age taking multiple medications. These strategies would then become second nature for nurses to use providing an automatic component in their practice as a means of combating non-compliance. This could also help address potential compliance issues from the very beginning in the hopes of preventing it from occurring or in it's earliest stages such that it would be easier to eliminate as it would not be habitual.
Medication Reminder and Automatic Pill Box
Barriers to Medication Compliance in Seniors
When considering compliance in a population it is not enough to try to determine if an intervention is effective or not. Often research takes place in a neutral laboratory setting which makes it easier to observe the behavior in question and record it. This also helps by removing barriers as efficacy is irrelevant if there are barriers to becoming adherent. Thus, it is crucial to determine what barriers may exist preventing compliance and address them before trying to administer an intervention to improve compliance. Sometimes an intervention may not be necessary if existing barriers are focused on. If barriers exist any intervention attempted may not seem effective when without the barriers in place it might have a significant positive effect. While financial factors have strong support in the literature as they relate to medication compliance in the elderly, findings regarding other potential barriers to adherence have been mixed, not clearly described, or summarized data which included individuals younger than 65 years old.
Elliott, & Stewart (2008), reviewed the literature in an attempt to elucidate the finding regarding non-financial barriers to medication adherence in the elderly. Studies were selected for the review which included specific barriers to medication compliance that were modifiable, were not intervention studies, clearly defined the construct of adherence or compliance, identified its method of measurement and included only U.S. participants. Studies focusing only on individuals who were homeless or substance abusers, or those with schizophrenia or other psychotic disorders, tuberculosis, or Human Immunodeficiency Virus (HIV), were exclude from the review due to the specific conditions related to medication compliance in each population..
Nine articles were identified that met criteria for inclusion. Four of these studies used pharmacy records or claims data to evaluate compliance, two studies utilized pill count or electronic monitoring of medication, and three studies used other specified methods to assess adherence. The articles selected for inclusion differed in method of analysis, population, and barriers and measures of compliance. Due to this heterogeneity the researchers did not combine the results using meta-analytic methods. Despite this variety in the studies, three categories of barriers were identified which included patient related factors, medication related factors and other factors. Patient related factors included co-morbidities, cognitive ability, knowledge and health beliefs. Specifically, lack of knowledge about diseases in general along with knowledge about the patient’s disease was related to medication adherence. Thus, it may be possible to improve adherence in older adults by altering health beliefs through knowledge provision such that they are aware of the consequence of non-compliance regarding their disease process. Becoming more knowledgeable and realistic about health in general may lead to increased motivation to remain compliant. The relationship found was not robust, however which may be due in part to using prescription refills as the outcome variable. It is possible that knowledge would have a stronger relationship with actually taking medication rather than just refilling prescriptions. Cognitive factors such as memory was also found to be a barrier to adherence in older adults. Those who relied solely on themselves to remember to take their medication evidenced poorer adherence than those who used additional methods of remembering to take their medication.
In terms of medication related factors, side effects was associated with poorer adherence. Regarding number of medications taken, these results were mixed with four studies showing a negative relationship between this potential barrier and adherence, and one study showing a positive relationship. While not included here, regimen complexity might be a more worthwhile variable to study since it includes number of medications taken among other variables such as dosing and method of administration.
Regarding other factors that could play a role in adherence in older adults, this review found that the patient –provider relationship was important. The ability for a patient to be able to communicate with their provider is crucial. This means the provider listens to their concerns and addresses them to the best of their ability and answers all questions that may arise. The provider must do their best to meet the senior’s needs within the boundaries of the medical regimen, find ways to help them cope with the regimen or modify the regimen if possible. In this study those participants who found it a lower priority to discussing their medical status with their provider were less compliant with medications than those who found such communication to be a high priority. Logistical barriers such as lacking transportation to a pharmacy also effected adherence.
There has been much research on patient provider communication and adherence in older adults. In a recent study Fung et al., (2016), examined how patient–provider communication impacted adherence to therapy. The way older adults communicated with their providers, preferences for communication, and beliefs about communication characteristics and decision aid attributes were examined through the use of focus groups. One factor reported by several of those participating was the belief they had not received sufficient information about their diagnosis and different treatment options. Many elders want to decrease the number and frequency of their medication regimen. They can become extremely frustrated when they don’t feel they understand the need for the different medications.
In this study, the majority of participants stated that it would help them to have treatment information provided that was specific to their condition and needs. When asking for additional specially tailored information they included information on negative consequences related to their treatment specifically focusing on comfort, convenience and overall quality of life. Most participants were also concerned about common barriers to adherence and wanted information about this topic including a list of strategies for overcoming these barriers if they were faced with them. Participants were also asked to provide a list of characteristics they found desirable in terms of an aid aimed at helping them make decisions about medical related behaviors.
These findings have implications for nursing care regarding how to design useful decision aids for seniors. Focusing on the patient provider relationships is one of the keys to enhancing medical compliance in older adults as it leads to trust when decisions must be made. This also means respecting the individual’s decision although an assessment for rational thought processes, the existence of depression or anxiety or suicidal ideation should be carried out.
Assessment For Predicting Which Seniors Are at Risk for Medication Non-Compliance
- Study characterizes older adults who may need help managing medications - Medical News Today
An analysis of 4,000 older adults yields a list of characteristics for identifying which elderly patients are likely to need help managing medication.
Patient Perspectives on Barriers to and Facilitators of Adherence in Older Adults
Researchers have attempted to integrate information on the variety of barriers to and facilitators of medication adherence in seniors based on patient reports (e.g. Holt et al., 2014). These can be broken down into levels, specifically the individual, relationship, health care system, and environmental or policy levels. Each of these levels is important in their own right yet they also are inter-related in important ways.
At the individual level, memory and forgetfulness have repeatedly been demonstrated to be important barriers to compliance. Many older adults have trouble remembering to take their medications. Patients have stated that medication reminder routines such as taking medications at the same time daily, keeping checklists of medication on the refrigerator and using pillboxes to organize and keep track of medications are the most useful strategies to overcome memory related problems. Reminder phone calls have been suggested as an intervention for forgetfulness. Patients interviewed found this acceptable for those with serious memory problems but felt it would be irritating for others. It was also deemed more acceptable if the calls came from family or friends instead of medical professionals.
Other important individual level barriers that have been identified include patients' knowledge, attitudes, and beliefs. One factor, in particular, that has been demonstrated as an important barrier in this population is the lack of immediate consequences resulting from missing doses. When physical symptoms result from a missed medication dose it serves as a reminder. However, many medications don’t result in any short term symptoms when a dose is missed. When a patient feels as good after missing a few doses as they did before, they may not see the necessity of complete compliance.
Many patients have stated that regular adherence depends on one's personal attitudes, and that compliance must be a personal decision or lifestyle choice. Others state that education and gaining knowledge about the positive of taking the medication changed their attitude toward compliance while discovering the consequences of not taking it helped them make behavioral changes. Beliefs have also shown to function as a barrier to medication adherence in seniors. For example, the belief that all medications are addictive if taken for over time led some to resist taking their medication daily.
These factors may led to elders making health related decisions without all the facts, further putting their long term well-being at risk. Patients have stressed the importance of education and referral to follow-up programs as effective interventions for barriers involving knowledge, attitudes, and beliefs. Furthermore, Increasing patients' knowledge could infuse them with the self-confidence they need to create a goal focused mind-set.
At the relationship level, social support and regular contact with others has been shown to be a critical facilitator of medication adherence in older adults. Interpersonal support has been shown to predict adherence and many patients feel that regular participation in groups with other seniors such friendship circles or activity related outings can improve mood which they have noticed is linked to memory and hope in the future. Both of these factors have also been demonstrated to relate to medication adherence in this population. Some, however, stated that increasing social support would not be an effective strategy for improving medication adherence. This was related to the position that taking medication was a personal decision unrelated to how other believed or other benefits from increasing social support.
At the policy level, many seniors have identified cost as a crucial barrier to medication adherence, stating that cost can lead to them being forced to skip or decrease doses to make medication last longer. One intervention which may prove helpful in this situation is working with providers to obtain free samples, prescriptions for generics or switching to a different, lower cost medication. Access to pharmacies was also identified as a significant barrier for those without transportation. Education about alternative prescription filling services such as mail order prescriptions of multi-month prescriptions was a potential strategy identified by seniors for helping with this barrier.
The research on medication adherence in seniors pinpoints important issues for nurses to be aware of and provides indications for addressing barriers and establishing facilitating factors Studies show the importance of understanding the diverse characteristics and the individual nature of barriers and facilitators. As some barriers may not be modifiable it is all the more important to determine specific barriers for individual patients and work towards modifying those. Assessing potential barriers that have been supported in the literature such as health literacy, methods of remembering to take medication, side effects, and ability to travel to a pharmacy can provide information on modifiable factors. Nurses should be aware of the importance of the patient – provider relationship for good adherence in this population and work to determine what improves their relationship on an individual patient basis. Nurses are in the perfect position to carry out observational research in their daily practice. They are also ideal for helping to determine what additional factors should be investigated in the area of elderly medication compliance and how to insure these investigations provide the most useful implications for the widest segment of the senior population possible.
Patient perceptions on interventions that are useful for helping them maintain medication compliance should also inform nursing practice and research, in particular those related to social support, knowledge, attitudes and beliefs, and medication cost. It is clear from the diverse nature of patients’ experiences and perceptions that interventions for mediation adherence in seniors must be, at the same time, multi-faceted and individually tailored. The amount of time nurses spend with patients presents the opportunity to identify potential areas of research that will provide a clearer picture of which types of intervention strategies are effective for different patient characteristics in seniors.
Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 294:716-724.
Comaty, J. E. (2015). Geriatric Pharmacotherapy. The Tablet, 27.
Fung, C. H., Alessi, C., Truong, C., Josephson, K., Hays, R. D., Col, N. & Martin, J. L. (2016). Patient-Provider Communication With Older Adults About Sleep Apnea Diagnosis and Treatment. Behavioral sleep medicine, 1-15.
Gellad, W. F., Grenard, J. L., & Marcum, Z. A. (2011). A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity. The American journal of geriatric pharmacotherapy, 9(1), 11-23.
George, J., Elliott, R. A., & Stewart, D. C. (2008). A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications. Drugs & aging, 25(4), 307-324.
Holt, E. W., Rung, A. L., Leon, K. A., Firestein, C., & Krousel-Wood, M. (2014). Medication adherence in older adults: a qualitative study. Educational gerontology, 40(3), 198-211.
Workshop for Medical Providers on Medication Adherence in Seniors
© 2016 Natalie Frank