Improving Medication Compliance in the Elderly Strategies For the Health Care Provider

Patient noncompliance with therapeutic regimens has been and continues to be a problem in the delivery of health care.¹ The compliance literature includes over 6,000 articles detailing the scope of medication noncompliance, its determinants and approaches to dealing with it. Providers for the most part though, have not integrated the management of the problem into clinical practice. Noncompliance involves patients of all ages; however, the elderly patient is a particular concern to the clinician and health care provider. Noncompliance in the elderly is a special case because of the unique profile involved that frequently may include large quantities of drugs consumed, combined with the effects of aging on the distribution, metabolism, and the patterns of drug usage.² Other considerations such as the impact aging may have on impairment in the patient's vision, cognition, muscle strength, and coordination may contribute to the older person's difficulty in adhering to a medication regimen.³ Unfortunately, recognition of the magnitude of the problem of medication noncompliance and efforts to devise practical means to reduce it have not resulted in significant changes in the way health care providers deal with the compliance of patients in general and with older patients in particular.⁴ In the 1980s 14% of the US population was 65 years of age or older and about 75% of these adults were on at least one prescription drug.⁵ The issues of the elderly patient and their medication-taking compliance is clearly a major concern for the clinician and one that will require increasing attention in the future as the population ages. The importance of practical strategies for the implementation of interventions for dealing with noncompliance in the elderly is underscored by these population demographics.

Both physicians and pharmacists have a role in addressing noncompliance in their interactions with elderly patients. Morrow et al⁶ in this issue of JAGS contribute to the growing body of compliance literature by detailing specific methods for impacting on patient noncompliance. They emphasize the importance of communication between the prescribing physician and patient. The authors also emphasize the positive role that can be played by the pharmacist.

The clinician is frequently the first point of contact for a patient where the doctor can take specific time to outline in very clear language each of the medication regimens for the patient. This includes the purpose of the medication, its dosage, frequency, and duration of administration. The physician can also explain all of the relevant conditions for taking the medication such as the timing of the dosage and their relationship to meals as well as the administration of other medications. He can explain what the patient should do if he misses a dose or runs out of medications, as well as the common side effects of the medications and what to do if these occur. The doctor can also simplify the drug regimen whenever possible. Simplification of the drug regimen has been and continues to be a cardinal consideration in patient noncompliance. A complex regimen, in terms of numbers of medications and frequency of administrations is more likely to result in patient noncompliance.^7–9

In addition to communicating specific drug information to the patient, the physician can consider written instructions as a way of emphasizing and clarifying the oral directives. Most importantly though written instructions can serve to remind the patient about the regimen long after the visit and help answer questions that may arise in their use. The clinician can also avoid “jargon” whenever possible in both written and verbal instructions. He can take sufficient time for these explanations and for the patient to ask questions. The literature has shown that communications of this type can have positive results in patients complying more accurately and fully with their medications.^9,10

While the objective is not to prioritize any one particular intervention over another, each patient will require a tailored set of interventions to address particular noncompliance problems. The physician needs to assess his patients capabilities and limitations that might adversely affect their ability to take their medications as prescribed. Since limitations in motor dexterity may affect an older person's ability to take medications, the physician can ask patients who have such impairments whether they have difficulty opening medication containers, especially those that have been “child proofed”. If necessary the physician may test the patient's dexterity functioning by observing the patient opening and closing a child-resistant container. Vision deficits related to medication-taking may be checked by asking the patient to read a label on a medication container. The physician may also want to check whether the patient can distinguish different medication tablets by color, size, or shape. By linking medication-taking to the physical examination, the physician will likely communicate his special concern for medication-taking that might positively impact on the patient's compliance.

Another equally important provider of care that can impact on patient noncompliance is the pharmacist. Morrow et al consider the pharmacist an important health care professional that can intervene on the patient's behalf. McKenney et al¹¹ in an early article demonstrated that the pharmacist can impact positively on patient noncompliance through use of medication instructions. Morrow et al have advanced this approach by describing specific guidelines for pharmacists in their design of medication instructions for patients. While useful for pharmacists, these rules for constructing medication instructions have relevance for physicians, too. The use of written medication instructions by both physicians and pharmacists is not a new approach. For example, the American Medical Association Patient Medication Instruction (PMI) Program has been in existence for some time.¹² Suggested improvements in the content, format, and physical characteristics of the information included in written instructions will require careful testing and evaluation of their impacts on patient noncompliance. Both the physician and pharmacist should be included in these studies.

The physician, pharmacist, and patient are all part of a triad that ultimately affects the patient's compliance with therapeutic regimens. Both the physician and pharmacist can help elderly patients take their medications more appropriately. Poor compliance in the elderly may very well hinge upon the level of communication between the physician and pharmacist with the patient. Good compliance should begin with more than adequate communication by the providers of care. Verbal communication is the first important step on the road to successful compliance with therapies. Health care providers can begin to anticipate the likely questions and problems that a particular patient will have with specific medications. For this reason information needs to be tailored to the patient and to treatment. The physician and pharmacist can also use written medication instructions that reinforce these verbal instructions. Their use is likely to improve patient compliance and save the physician time during the patient visit. Written instructions should not, however, be a substitute for talking to the patient about medications being prescribed. The integration of specific strategies along these lines into routine patient care should bring the field of medication compliance closer towards realizing its goal, that of improved patient outcome especially in the elderly.