Medication Non-Compliance in the Elderly: Implications for Nursing Practice
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 excluded 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 the 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 were 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 were associated with poorer adherence. Regarding the 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 a 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 affected 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 medically 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 of rational thought processes, the existence of depression or anxiety or suicidal ideation should be carried out.