Drugs & Aging

, Volume 23, Issue 4, pp 345–356 | Cite as

Medication Nonadherence and Subsequent Risk of Hospitalisation and Mortality among Older Adults

  • Shelly A. Vik
  • David B. Hogan
  • Scott B. Patten
  • Jeffrey A. Johnson
  • Lori Romonko-Slack
  • Colleen J. Maxwell
Original Research Article

Abstract

Background

Despite a higher risk for medication nonadherence among older adults residing in the community, few prospective studies have investigated the health outcomes associated with nonadherence in this population or the possible variations in risk in urban versus rural residents.

Objectives

The primary objective of this study was to examine, in a prospective manner, the risk for hospitalisation (including an emergency department visit) and/or mortality associated with medication nonadherence in older, at-risk adults residing in the community. A secondary objective was to examine differences in the prevalence, determinants and consequences of medication nonadherence between rural and urban home care clients.

Methods

Data were derived from a 1-year prospective study of home care clients aged ≥65 years (n = 319) randomly selected from urban and rural settings in southern Alberta, Canada. Trained nurses conducted in-home assessments including a comprehensive medication review, self-report measures of adherence and the Minimum Data Set for Home Care (MDS-HC) tool. Hospitalisation and mortality data during 12-month follow-up were obtained via linkages with regional administrative and vital statistics databases.

Results

Nonadherent clients showed an increased but nonsignificant risk for an adverse health outcome (hospitalisation, emergency department visit or death) during follow-up (hazard ratio [adjusted for relevant covariates] = 1.24, 95% CI 0.93, 1.65). Subgroup analyses suggested this risk may be higher for unintentional nonadherence (unadjusted hazard ratio = 1.55, 95% CI 0.97, 2.48). The prevalence of nonadherence was similar among rural (38.2%) and urban (38.9%) clients and was associated with the presence of vision problems, a history of smoking, depressive symptoms, a high drug regimen complexity score, residence in a private home (vs assisted-living setting) and absence of assistance with medication administration. In both settings, approximately 20% of clients received one or more inappropriate medications.

Conclusions

Although not associated with rural/urban residence, medication nonadherence was common in our study population, particularly among those with depressive symptoms and complex medication regimens. The absence of a significant association between overall medication nonadherence and health outcomes may reflect study limitations and/or the need to differentiate among types of nonadherent behaviours.

Notes

Acknowledgements

The RAI-HC (Resident Assessment Instrument for Home Care) study/initiative was supported by an unrestricted grant from The Merck Company Foundation, the philanthropic arm of Merck & Co. Inc., Whitehouse Station, NJ, USA to the Institute of Health Economics.

We are most grateful to the four home care nurses (Michelle Copeland and Sue Couchman from the Calgary Health Region and Bonnie Matson and Trudy Harbidge from the Chinook Health Region) for their data collection efforts and clinical input into the RAI-HC study. We wish to also acknowledge Chad Mitchell for his clinical input and assistance with drug coding. Special thanks is also given to the 330 home care clients and their caregivers (formal and informal) who graciously gave of their time to participate in this important study.

Shelly Vik is currently a PhD candidate, funded by the Canadian Institutes of Health Research — Skeletal Health, and Alberta Bone and Joint Training Programs. Dr Maxwell is funded by a New Investigator Award from the Canadian Institutes of Health Research — Institute on Aging and a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research (AHFMR). Dr Hogan is the holder of the Brenda Strafford Foundation Chair in Geriatric Medicine, University of Calgary. The Chair provides financial support to Drs Maxwell and Hogan. Dr Johnson holds a Government of Canada Research Chair in Diabetes Health Outcomes and an AHFMR Health Scholar Award. Dr Patten also holds an AHFMR Health Scholar Award.

Over the past 5 years, Dr Hogan has given presentations, consulted and participated in dementia studies sponsored by the following companies: Janssen-Ortho, Merck, Neurochem, Novartis and Pfizer. The other authors have no conflicts of interest that are directly relevant to the content of this study.

References

  1. 1.
    Bergob M. Drag use among Canadian seniors. Statistics Canada [online]. Available from URL: http://www.statcan.ca/english/ads/11-008-XIE7drugs.htm [Accessed 2005 Jul 6]
  2. 2.
    Stagnitti MN. Statistical Brief #21. Trends in outpatient prescription drag utilization and expenditures: 1997–2000. Medical Expenditure Panel Survey [online]. Available from URL: http://www.meps.ahrq.gov/papers/st21/stat21.pdf [Accessed 2004 Nov 1]
  3. 3.
    Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of medication adherence among seniors. Ann Pharmacother 2004; 38(2): 303–12PubMedGoogle Scholar
  4. 4.
    Horwitz RI, Viscoli CM, Berkman L, et al. Treatment adherence and risk of death after a myocardial infarction. Lancet 1990; 336(8714): 542–5PubMedCrossRefGoogle Scholar
  5. 5.
    Llewellyn-Thomas HA, McGreal MJ, Thiel EC, et al. Patients’ willingness to enter clinical trials: measuring the association with perceived benefit and preference for decision participation. Soc Sci Med 1991; 32(1): 35–42PubMedCrossRefGoogle Scholar
  6. 6.
    Kessenich CR, Guyatt GH, Rosen CJ. Health-related quality of life and participation in osteoporosis clinical trials. Calcif Tissue Int 1998; 62(3): 189–92PubMedCrossRefGoogle Scholar
  7. 7.
    Sociodemographic and clinical predictors of participation in two randomized trials: findings from the Collaborative Ocular Melanoma Study COMS report no. 7. Control Clin Trials 2001; 22(5): 526–37Google Scholar
  8. 8.
    Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 1990; 150(4): 841–5PubMedCrossRefGoogle Scholar
  9. 9.
    Malhotra S, Karan RS, Pandhi P, et al. Drag related medical emergencies in the elderly: role of adverse drug reactions and non-compliance. Postgrad Med J 2001; 77: 703–7PubMedCrossRefGoogle Scholar
  10. 10.
    Grymonpre RE, Mitenko PA, Sitar DS, et al. Drug-associated hospital admissions in older medical patients. J Am Geriatr Soc 1988; 36(12): 1092–8PubMedGoogle Scholar
  11. 11.
    McKenney JM, Harrison WL. Drug-related hospital admissions. Am J Hosp Pharm 1976; 33(8): 792–5PubMedGoogle Scholar
  12. 12.
    Huybrechts KF, Ishak KJ, Caro JJ. Assessment of compliance with osteoporosis treatment and its consequences in a managed care population. Bone 2005. Epub 2005 Dec 1Google Scholar
  13. 13.
    Maronde RF, Chan LS, Larsen FJ, et al. Underutilization of antihypertensive drags and associated hospitalization. Med Care 1989; 27(12): 1159–66PubMedCrossRefGoogle Scholar
  14. 14.
    Sokol MC, McGuigan KA, Verbrugge RR, et al. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care 2005; 43(6): 521–30PubMedCrossRefGoogle Scholar
  15. 15.
    Mojtabai R, Olfson M. Medication costs, adherence, and health outcomes among Medicare beneficiaries. Health Aff (Millwood) 2003; 22(4): 220–9CrossRefGoogle Scholar
  16. 16.
    Billups SJ, Malone DC, Carter BL. The relationship between drug therapy noncompliance and patient characteristics, health-related quality of life, and health care costs. Pharmacotherapy 2000; 20(8): 941–9PubMedCrossRefGoogle Scholar
  17. 17.
    Matuszewski MS, Velayudhan MA, Flint N, et al. Noncompliance with drag therapy for chronic obstructive pulmonary disease: a risk factor for hospitalization? Value Health 1999; 2(6): 446–51PubMedCrossRefGoogle Scholar
  18. 18.
    Garcia-Aymerich J, Monso E, Marrades RM, et al. Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation: EFRAM study. Am J Respir Crit Care Med 2001; 164(6): 1002–7PubMedGoogle Scholar
  19. 19.
    Aparasu RR, Sitzman SJ. Inappropriate prescribing for elderly outpatients. Am J Health Syst Pharm 1999; 56(5): 433–9PubMedGoogle Scholar
  20. 20.
    Innovations in rural and community health: Federal budget information. Ottawa (ON): Health Canada, 1999Google Scholar
  21. 21.
    Government of Alberta. Municipal Government Act, Statutes of Alberta: consolidated to June 9, 1999. Edmonton (AB): Queen’s Printer for Alberta, 1999: M-26, Part 4Google Scholar
  22. 22.
    Ramachandran H, Shastri GS. Movement for medical treatment: a study in contact patterns of rural population. Soc Sci Med 1983; 17(3): 177–87PubMedCrossRefGoogle Scholar
  23. 23.
    Lucas CA, Rosenthal TC. Access to health care in rural western New York State. N Y State J Med 1992; 92: 465–8PubMedGoogle Scholar
  24. 24.
    Hawe P, Higgins G. Can medication education improve the drug compliance of the elderly? Evaluation of an in hospital program. Patient Educ Couns 1990; 16(2): 151–60PubMedCrossRefGoogle Scholar
  25. 25.
    Rich MW, Gray DB, Beckham V, et al. Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure. Am J Med 1996; 101(3): 270–6PubMedCrossRefGoogle Scholar
  26. 26.
    Vik SA, Maxwell CJ, Hogan DB, et al. Determinants and health related outcomes associated with nonadherence to prescribed drug regimens: a comparison of rural and urban home care clients. Institute of Health Economics Working Paper 03-02, Edmonton, AB [online]. Available from URL: http://www.ihe.ca/publications/papers/index.cfm?.year=2003 [Accessed 2003 Jan]
  27. 27.
    Morris JN, Fries BE, Steel K, et al. Comprehensive clinical assessment in community setting: applicability of the MDS-HC. J Am Geriatr Soc 1997; 45(8): 1017–24PubMedGoogle Scholar
  28. 28.
    Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986; 24(1): 67–74PubMedCrossRefGoogle Scholar
  29. 29.
    Vik SA, Maxwell CJ, Hogan DB, et al. Assessing medication adherence among older persons in community settings. Can J Clin Pharmacol 2005; 12(1): e152–64Google Scholar
  30. 30.
    Hirdes JP, Frijters DH, Teare GF. The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people. J Am Geriatr Soc 2003; 51(1): 96–100PubMedCrossRefGoogle Scholar
  31. 31.
    Morris JN, Fries BE, Morris SA. Scaling ADLs within the MDS. J Gerontol A Biol Sci Med Sci 1999; 54(11): M546–53PubMedCrossRefGoogle Scholar
  32. 32.
    Hartmaier SL, Sloane PD, Guess HA, et al. Validation of the Minimum Data Set Cognitive Performance Scale: agreement with the Mini-Mental State Examination. J Gerontol A Biol Sci Med Sci 1995; 50(2): M128–33PubMedCrossRefGoogle Scholar
  33. 33.
    Burrows AB, Morris JN, Simon SE, et al. Development of a Minimum Data Set-based Depression Rating Scale for use in nursing homes. Age Ageing 2000; 29(2): 165–72PubMedCrossRefGoogle Scholar
  34. 34.
    Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003; 163(22): 2716–24PubMedCrossRefGoogle Scholar
  35. 35.
    Conn VS, Taylor SG, Kelley S. Medication regimen complexity and adherence among older adults. Image J Nurs Sch 1991; 23(4): 231–5PubMedCrossRefGoogle Scholar
  36. 36.
    Kroenke K, Pinholt EM. Reducing polypharmacy in the elderly: a controlled trial of physician feedback. J Am Geriatr Soc 1990; 38: 31–6PubMedGoogle Scholar
  37. 37.
    Kleinbaum DG. Evaluating the proportional hazards assumption. In: Dietz K, Gail M, Krickeberg K, et al., editors. Survival analysis: a self-learning text. New York: Springer Verlag, 1996Google Scholar
  38. 38.
    Stata Statistical Software. Release 8.0 ed. College Station (TX): Stata Corporation, 2003Google Scholar
  39. 39.
    Lau HS, de Boer A, Beuning KS, et al. Validation of pharmacy records in drug exposure. J Clin Epidemiol 1997; 21: 294–300Google Scholar
  40. 40.
    Grymonpre RE, Didur CD, Montgomery PR, et al. Pill count, self-report, and pharmacy claims data to measure medication adherence in the elderly. Ann Pharmacother 1998; 32(7–8): 749–54PubMedGoogle Scholar
  41. 41.
    Flaherty JH, Perry III HM, Lynchard GS, et al. Polypharmacy and hospitalization among older home care patients. J Gerontol A Biol Sci Med Sci 2000; 55(10): M554–9PubMedCrossRefGoogle Scholar
  42. 42.
    Weintraub M. Intelligent noncompliance with special emphasis in the elderly. Contemp Pharm Pract 1981; 4(1): 8–11PubMedGoogle Scholar
  43. 43.
    Inui TS, Carter WB, Pecoraro RE. Screening for noncompliance among patients with hypertension: is self-report the best available measure? Med Care 1981; 19(10): 1061–4PubMedCrossRefGoogle Scholar
  44. 44.
    Cargill JM. Medication compliance in elderly people: influencing variables and interventions. J Adv Nurs 1992; 17(4): 422–6PubMedCrossRefGoogle Scholar
  45. 45.
    Raffoul PR, Cooper JK, Love DW. Drug misuse in older people. Gerontologist 1981; 21(2): 146–50PubMedCrossRefGoogle Scholar
  46. 46.
    Monane M, Bohn RL, Gurwitz JH, et al. Noncompliance with congestive heart failure therapy in the elderly. Arch Intern Med 1994; 154(4): 433–7PubMedCrossRefGoogle Scholar
  47. 47.
    Monane M, Bohn RL, Gurwitz JH, et al. The effects of initial drug choice and comorbidity on antihypertensive therapy compliance: results from a population-based study in the elderly. Am J Hypertens 1997; 10 (7 Pt 1): 697–704PubMedCrossRefGoogle Scholar
  48. 48.
    Carney RM, Freedland KE, Eisen SA, et al. Major depression and medication adherence in elderly patients with coronary artery disease. Health Psychology 1995; 14(1): 88–90PubMedCrossRefGoogle Scholar
  49. 49.
    Coons SJ, Sheahan SL, Martin SS, et al. Predictors of medication noncompliance in a sample of older adults. Clin Ther 1994; 16(1): 110–7PubMedGoogle Scholar
  50. 50.
    Spiers MV, Kutzik DM. Self-reported memory of medication use by the elderly. Am J Health Syst Pharm 1995; 52: 985–90PubMedGoogle Scholar
  51. 51.
    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(9): 1107–16PubMedCrossRefGoogle Scholar
  52. 52.
    Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992; 45(10): 1045–51PubMedCrossRefGoogle Scholar
  53. 53.
    Tamblyn RM, McLeod PJ, Abrahamowicz M, et al. Questionable prescribing for elderly patients in Quebec. CMAJ 1994; 150(11): 1801–9PubMedGoogle Scholar
  54. 54.
    Higgins N, Regan C. A systematic review of the effectiveness of interventions to help older people adhere to medication regimes. Age Ageing 2004; 33(3): 224–9PubMedCrossRefGoogle Scholar
  55. 55.
    Metlay JP, Cohen A, Polsky D, et al. Medication safety in older adults: home-based practice patterns. J Am Geriatr Soc 2005; 53(6): 976–82PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  • Shelly A. Vik
    • 1
  • David B. Hogan
    • 1
    • 2
    • 3
  • Scott B. Patten
    • 1
    • 4
    • 5
  • Jeffrey A. Johnson
    • 5
    • 6
  • Lori Romonko-Slack
    • 7
  • Colleen J. Maxwell
    • 1
    • 2
    • 5
  1. 1.Department of Community Health SciencesUniversity of CalgaryCalgaryCanada
  2. 2.Department of MedicineUniversity of CalgaryCalgaryCanada
  3. 3.Department of Clinical NeurosciencesUniversity of CalgaryCalgaryCanada
  4. 4.Department of PsychiatryUniversity of CalgaryCalgaryCanada
  5. 5.Institute of Health EconomicsEdmontonCanada
  6. 6.Department of Public Health SciencesUniversity of AlbertaEdmontonCanada
  7. 7.Calgary Health RegionCalgaryCanada

Personalised recommendations