Views of older adults on patient participation in medication-related decision making

  • Vernee N. Belcher
  • Terri R. Fried
  • Joseph V. Agostini
  • Mary E. TinettiEmail author
Original Articles


BACKGROUND: Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients’ views of involvement in medication decision making.

OBJECTIVE: To explore the views of older adults regarding participation in medication decision making.

DESIGN: Qualitative study.

PARTICIPANTS: Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians’ offices.

APPROACH: One-on-one interviews were conducted to uncover participants’ perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis.

RESULTS: The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making.

CONCLUSIONS: While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.

Key words

medication prescribing patient participation in decision making older adults 


  1. 1.
    Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States. The slone survey. JAMA. 2002;287:337–44.CrossRefPubMedGoogle Scholar
  2. 2.
    Linjakumpu T, Hartikainen S, Klaukka T, Veijola J, Kivela SL, Isoaho R. Use of medications and polypharmacy are increasing among the elderly. J Clin Epidemiol. 2002;55:809–17.CrossRefPubMedGoogle Scholar
  3. 3.
    Balkrishanan R. Predictors of medication adherence in the elderly [Review]. Clin Ther. 1998;20:764–7.CrossRefGoogle Scholar
  4. 4.
    Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556–64.CrossRefPubMedGoogle Scholar
  5. 5.
    Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107–16.CrossRefPubMedGoogle Scholar
  6. 6.
    Tinetti ME, Bogardus ST, Agostini JV. Potential pitfalls in disease guidelines for patients with multiple conditions. N Engl J Med. 2004;351:2870–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Lewis DK, Robinson J, Wilkinson E. Factors involved in deciding to start preventive treatment: qualitative study of clinicians’ and lay people’s attitudes. BMJ. 2003;327:841–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Townsend A, Hunt K, Wyke S. Managing multiple morbidity in mid-life: a qualitative study of attitudes to drug use. BMJ. 2003;327:837–41.CrossRefPubMedGoogle Scholar
  9. 9.
    Britten N, Stevenson FA, Barry CA, Barber N, Bradley CP. Misunderstandings in prescribing decisions in general practice: qualitative study. BMJ. 2000;320:484–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Berry DC, Michas IC, Gillie T, Forster M. What do patients want to know about their medicines and what do doctors want to tell them? A comparative study. Psychol Health. 1997;12:467–80.CrossRefGoogle Scholar
  11. 11.
    Dickinson D, Raynor DK. What information do patients need about medicines? Ask the patients—they may want to know more than you think. BMJ. 2003;327:861–4.CrossRefPubMedGoogle Scholar
  12. 12.
    Wyn G, Edwards A, Britten N. What information do patients need about medications? Doing prescribing: how doctors can be more effective. BMJ. 2003;327:864–7.CrossRefGoogle Scholar
  13. 13.
    Tsevat J, Dawson NV, Wu AW, et al. Health values of hospitalized patients 80 years or older. JAMA. 1998;279:371–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346:1061–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA. 2004;291:2359–66.CrossRefPubMedGoogle Scholar
  16. 16.
    Schneider JK, Mion LC, Frengley JD. Adverse drug reactions in an elderly outpatient population. Am J Hosp Pharm. 1992;49:90–6.PubMedGoogle Scholar
  17. 17.
    Chaudhry SI, Krumholz HM, Foody JM. Systolic hypertension in older persons. JAMA. 2004;292:1074–80.CrossRefPubMedGoogle Scholar
  18. 18.
    Dahlof B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in old patients with hypertension (STOP-Hypertension). Lancet. 1991;338:1281–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Mulrow CD, Cornell JA, Herrera CR, et al. Hypertension in the elderly. Implications and generalizability of randomized trials. JAMA. 1994;272:1932–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Systolic Hypertension in the Elderly Program Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA. 1991;265:3255–64.CrossRefGoogle Scholar
  21. 21.
    Gueyffier F, Bulpitt C, Boissel J-P, et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomized controlled trials. Lancet. 1999;353:793–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Gross CP, Mallory R, Heiat A, et al. Reporting the recruitment process in clinical trials: who are these patients and how did they get there? Ann Intern Med. 2002;137:10–6.PubMedGoogle Scholar
  23. 23.
    Whitney SN, McGuire AL, McCullough LB. Typology of shared decision making, informed consent, and simple consent. Ann Intern Med. 2003;140:54–9.Google Scholar
  24. 24.
    Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44:681–92.CrossRefPubMedGoogle Scholar
  25. 25.
    Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49:651–61.CrossRefPubMedGoogle Scholar
  26. 26.
    Arora NK, McHorney CA. Patient preferences for medical decision making: who really wants to participate? Med Care. 2000;38:335–41.CrossRefPubMedGoogle Scholar
  27. 27.
    Flood AB, Wennberg JE, Nease RF Jr., Fowler FJ Jr., Ding J, Hynes LM. The importance of patient preference in the decision to screen for prostate cancer. Prostate Patient Outcomes Research Team. J Gen Intern Med. 1996;11:342–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Beaver K, Luker KA, Owens RG, Leinster SJ, Degner LF, Sloan JA. Treatment decision-making in women newly diagnosed with breast cancer. Cancer Nursing. 1996;19:8–19.CrossRefPubMedGoogle Scholar
  29. 29.
    Degner LF, Sloan JA. Decision making during serious illness: what role do patients really want to play? J Clin Epidemiol. 1992;45:941–50.CrossRefPubMedGoogle Scholar
  30. 30.
    Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med. 1996;156:1414–20.CrossRefPubMedGoogle Scholar
  31. 31.
    Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to paticipate in decision making. A national study of public preferences. J Gen Intern Med. 2005;20:531–5.CrossRefPubMedGoogle Scholar
  32. 32.
    Roccaforte WH, Burke WJ, Bayer BL, Wengel SP. Validation of a telephone version of the mini-mental state examination. J Am Geriatr Soc. 1992;40:697–702.PubMedGoogle Scholar
  33. 33.
    Cornoni-Huntley J, Brock DB, Ostfeld AM. Established Populations for the Epidemiologic Studies of the Elderly: Resource Data Book. US Department of Health and Human Services Publication NIH-86-2443. Washington, DC: National Institute on Aging; 1986.Google Scholar
  34. 34.
    Glaser PG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Hawthorne, NY: Aldine Publishing Co.; 1967.Google Scholar
  35. 35.
    Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd edn. Thousand Oaks, CA: Sage Publications; 1998.Google Scholar
  36. 36.
    Crabtree B, Miller W, eds. Clinical Research a Multimethod Typology and Roadmap. Doing Qualitative Research. 2nd edn. Thousand Oaks, CA: Sage Publications; 1999.Google Scholar
  37. 37.
    Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267:2221–6.CrossRefPubMedGoogle Scholar
  38. 38.
    Torke AM, Corbie-Smith GM, Branch WT. African American patients’ perspectives on medical decision making. Arch Intern Med. 2004;164:525–30.CrossRefPubMedGoogle Scholar
  39. 39.
    Elywn G, Edwards A, Kinnersley P. Shared decision-making in primary care: the neglected second half of the consultation. Br J Gen Prac. 1999;49:477–82.Google Scholar
  40. 40.
    Institute of Medicine. Crossing the quality chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.Google Scholar
  41. 41.
    National Committee for Quality Assurance. The state of health care Quality: 2003. Washington, DC: National Committee for Quality Assurance; 2003.Google Scholar

Copyright information

© Society of General Internal Medicine 2006

Authors and Affiliations

  • Vernee N. Belcher
    • 1
  • Terri R. Fried
    • 1
    • 2
  • Joseph V. Agostini
    • 1
    • 2
  • Mary E. Tinetti
    • 1
    • 3
    Email author
  1. 1.Department of Internal MedicineYale School of MedicineNew HavenUSA
  2. 2.Clinical Epidemiology Research CenterVA Connecticut Healthcare SystemNew HavenUSA
  3. 3.Department of Epidemiology and Public HealthYale School of MedicineNew HavenUSA

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