Abstract
A range of behavioural, educational and provider-focused strategies have been tested, individually or in combination, for improving medication adherence. The results of various interventions in different patient groups, including the elderly, have been subjected to systematic reviews and meta-analyses, but because most studies have focused on improving adherence to one drug or drug group, they may have limited applicability to the general elderly population who more commonly use multiple medications for multiple co-morbidities.
A systematic review of controlled studies aimed at improving adherence in community-living elderly patients prescribed at least three, or a mean/median of four or more, long-term medications was undertaken. Only studies which included a minimum of 60 patients in each group, followed patients for ≥4 weeks after intervention, and measured adherence to all medications at baseline and at the conclusion of the study were considered for inclusion in the review. Eight studies met the inclusion criteria. All eight studies used verbal and/or written medication information in combination with behavioural strategies with or without provider-focused strategies. Pharmaceutical care was the theoretical framework of the interventions used in the majority of the studies. Only four studies demonstrated a significant improvement in adherence as a result of the interventions. The relative change in adherence in the intervention groups was highly variable, ranging from–13% to +55.5% (mean +11.4%). Regular scheduled patient follow-up along with a multi-compartment dose administration aid was an effective strategy for maintaining adherence in one study, while group education combined with individualized medication cards was successful in another study. Medication review by pharmacists with a focus on regimen simplification was found to be effective in two studies.
Overall, as a result of inconsistent methodology and findings across the eight studies, we were unable to draw firm conclusions in favour of any particular intervention. Innovative strategies for enhancing medication adherence in the elderly and reliable measures of adherence are needed. Until further evidence from single-intervention strategies becomes available, combinations of educational and behavioural strategies should be used to improve medication adherence in the elderly.
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References
Haynes RB, Taylor DW, Sackett DL. Compliance in healthcare. Baltimore (MD): John Hopkins University Press, 1979: 1–7
Marinker M, Blenkinsopp A, Bond C, et al. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain, 1997
Vermeire E, Hearnshaw H, Van Royen P, et al. Patient adherence to treatment: three decades of research: a comprehensive review. J Clin Pharm Ther 2001; 26: 331–42
Dezii CM. Persistence with drug therapy: a practical approach using administrative claims data. Manag Care 2001; 10: 42–5
DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004; 42: 200–9
Stanton LA, Peterson GM, Rumble RH, et al. Drug-related admissions to an Australian hospital. J Clin Pharm Ther 1994; 19: 341–7
Howard RL, Avery AJ, Howard PD, et al. Investigation into the reasons for preventable drug related admissions to a medical admissions unit: observational study. Qual Saf Health Care 2003; 12: 280–5
McKenney JM, Harrison WL. Drug-related hospital admissions. Am J Hosp Pharm 1976; 33: 792–5
Vik SA, Hogan DB, Patten SB, et al. Medication nonadherence and subsequent risk of hospitalisation and mortality among older adults. Drugs Aging 2006; 23: 345–56
Adherence to long-term therapies: evidence for action. Geneva: World Health Organization, 2003
Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of medication adherence among seniors. Ann Pharmacother 2004; 38: 303–12
Jorgensen T, Johansson S, Kennerfalk A, et al. Prescription drug use, diagnoses, and healthcare utilization among the elderly. Ann Pharmacother 2001; 35: 1004–9
Linjakumpu T, Hartikainen S, Klaukka T, et al. Use of medications and polypharmacy are increasing among the elderly. J Clin Epidemiol 2002; 55: 809–17
Veehof L, Stewart R, Haaijer-Ruskamp F, et al. The development of polypharmacy: a longitudinal study. Fam Pract 2000; 17: 261–7
Elliott RA. Problems with medication use in the elderly: an Australian perspective. J Pharm Prac Res 2006; 36: 58–66
George J, Munro K, McCaig DJ, et al. Prescription medications: beliefs, experiences, behavior, and adherence of sheltered housing residents. Ann Pharmacother 2006; 40: 2123–9
Gray SL, Mahoney JE, Blough DK. Medication adherence in elderly patients receiving home health services following hospital discharge. Ann Pharmacother 2001; 35: 539–45
Lau HS, Beuning KS, Postma-Lim E, et al. Non-compliance in elderly people: evaluation of risk factors by longitudinal data analysis. Pharm World Sci 1996; 18: 63–8
Gilbert A, Luszcz M, Owen N. Medication use and its correlates among the elderly. Aust J Public Health 1993; 17: 18–22
Okuno J, Yanagi H, Tomura S, et al. Compliance and medication knowledge among elderly Japanese home-care recipients. Eur J Clin Pharmacol 1999; 55: 145–9
Spagnoli A, Ostino G, Borga AD, et al. Drug compliance and unreported drugs in the elderly. J Am Geriatr Soc 1989; 37: 619–24
Hemminki E, Heikkila. Elderly people’s compliance with prescriptions, and quality of medication. Scand J Soc Med 1975; 3: 87–92
McElnay JC, McCallion CR, al-Deagi F, et al. Self-reported medication non-compliance in the elderly. Eur J Clin Pharmacol 1997; 53: 171–8
Balkrishnan R. Predictors of medication adherence in the elderly. Clin Ther 1998; 20: 764–71
Spiers MV, Kutzik DM. Self-reported memory of medication use by the elderly. Am J Health Syst Pharm 1995; 52: 985–90
DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000; 160: 2101–7
Peterson AM, Takiya L, Finley R. Meta-analysis of trials of interventions to improve medication adherence. Am J Health Syst Pharm 2003; 60: 657–65
Haynes RB, Yao X, Degani A, et al. Interventions to enhance medication adherence. Cochrane Database Syst Rev 2005; (4): CD000011
Krueger KP, Felkey BG, Berger BA. Improving adherence and persistence: a review and assessment of interventions and description of steps toward a national adherence initiative. J Am Pharm Assoc 2003; 43: 668–78; quiz 678–9
Roter DL, Hall JA, Merisca R, et al. Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care 1998; 36: 1138–61
van Eijken M, Tsang S, Wensing M, et al. Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature. Drugs Aging 2003; 20: 229–40
Van Wijk BL, Klungel OH, Heerdink ER, et al. Effectiveness of interventions by community pharmacists to improve patient adherence to chronic medication: a systematic review. Ann Pharmacother 2005; 39: 319–28
Al-Rashed SA, Wright DJ, Roebuck N, et al. The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. Br J Clin Pharmacol 2002; 54: 657–64
Naunton M, Peterson GM. Evaluation of home-based follow-up of high-risk elderly patients discharged from hospital. J Pharm Prac Res 2003; 33: 176–82
Sweeney SJ, Dixon JS, Sutcliffe I. Impact of the clinical pharmacist on compliance in a geriatric population. Pharm J 1989; 242: R4–6
Ware GJ, Holford NH, Davison JG, et al. Unit dose calendar packaging and elderly patient compliance. N Z Med J 1991; 104: 495–7
Begley S, Livingstone C, Hodges N, et al. Impact of domiciliary pharmacy visits on medication management in an elderly population. Int J Pharm Prac 1997; 5: 111–21
Lowe CJ, Raynor DK, Purvis J, et al. Effects of a medicine review and education programme for older people in general practice. Br J Clin Pharmacol 2000; 50: 172–5
Svarstad BL, Chewning BA, Sleath BL, et al. The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence. Patient Educ Couns 1999; 37: 113–24
Kimberlin CL, Berardo DH, Pendergast JF, et al. Effects of an education program for community pharmacists on detecting drug-related problems in elderly patients. Med Care 1993; 31: 451–68
Kogos Jr SC. Support groups and treatment adherence in a geriatric outpatient clinic. J Clin Psychol Med Set 2004; 11: 275–82
Lipton HL, Bird JA. The impact of clinical pharmacists’ consultations on geriatric patients’ compliance and medical care use: a randomized controlled trial. Gerontologist 1994; 34: 307–15
Hanlon JT, Weinberger M, Samsa GP, et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med 1996; 100: 428–37
Nazareth I, Burton A, Shulman S, et al. A pharmacy discharge plan for hospitalized elderly patients: a randomized controlled trial. Age Ageing 2001; 30: 33–40
Cargill JM. Medication compliance in elderly people: influencing variables and interventions. J Adv Nurs 1992; 17: 422–6
Ryan-Woolley BM, Rees JA. Initializing concordance in frail elderly patients via a medicines organizer. Ann Pharmacother 2005; 39: 834–9
Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA 2006; 296: 2563–71
Raynor DK, Booth TG, Blenkinsopp A. Effects of computer generated reminder charts on patients’ compliance with drug regimens. BMJ 1993; 306: 1158–61
Lundin DV, Eros PA, Melloh J, et al. Education of independent elderly in the responsible use of prescription medications. Drug Intell Clin Pharm 1980; 14: 335–42
Sturgess IK, McElnay JC, Hughes CM, et al. Community pharmacy based provision of pharmaceutical care to older patients. Pharm World Sci 2003; 25: 218–26
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: 151–60
Wu JY, Leung WY, Chang S, et al. Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: randomised controlled trial. BMJ 2006; 333: 522–7
Spector R, McGrath P, Uretsky N, et al. Does intervention by a nurse improve medication compliance? Arch Intern Med 1978; 138: 36–40
Leirer VO, Morrow DG, Tanke ED, et al. Elders’ nonadherence: its assessment and medication reminding by voice mail. Gerontologist 1991; 31: 514–20
Lowe CJ, Raynor DK, Courtney EA, et al. Effects of self medication programme on knowledge of drugs and compliance with treatment in elderly patients. BMJ 1995; 310: 1229–31
Wood SI, Calvert RT, Acomb C, et al. Self medication scheme for elderly patients improves compliance with their medication regimens. Int J Pharm Prac 1992; 1: 240–1
Varma S, McElnay JC, Hughes CM, et al. Pharmaceutical care of patients with congestive heart failure: interventions and outcomes. Pharmacotherapy 1999; 19: 860–9
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: 270–6
Johnston B, Wheeler L, Deuser J, et al. Outcomes of the Kaiser Permanente Tele-Home Health Research Project. Arch Fam Med 2000; 9: 40–5
Sidel VW, Beizer JL, Lisi-Fazio D, et al. Controlled study of the impact of educational home visits by pharmacists to high-risk older patients. J Community Health 1990; 15: 163–74
Fulmer TT, Feldman PH, Kim TS, et al. An intervention study to enhance medication compliance in community-dwelling elderly individuals. J Gerontol Nurs 1999; 25: 6–14
Nucifora G, Albanese MC, De Biaggio P, et al. Lack of improvement of clinical outcomes by a low-cost, hospital-based heart failure management programme. J Cardiovasc Med (Hagerstown) 2006; 7: 614–22
Grymonpre RE, Williamson DA, Montgomery PR. Impact of a pharmaceutical care model for non-institutionalised elderly: results of a randomised controlled trial. Int J Pharm Prac 2001; 9: 235–41
Volume CI, Farris KB, Kassam R, et al. Pharmaceutical care research and education project: patient outcomes. J Am Pharm Assoc (Wash) 2001; 41: 411–20
Edworthy SM, Devins GM. Improving medication adherence through patient education distinguishing between appropriate and inappropriate utilization: Patient Education Study Group. J Rheumatol 1999; 26: 1793–801
Coull AJ, Taylor VH, Elton R, et al. A randomised controlled trial of senior Lay Health Mentoring in older people with ischaemic heart disease: the Braveheart Project. Age Ageing 2004; 33: 348–54
Herschorn S, Becker D, Miller E, et al. Impact of a health education intervention in overactive bladder patients. Can J Urol 2004; 11: 2430–7
Weinberger M, Murray MD, Marrero DG, et al. Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial. JAMA 2002; 288: 1594–602
Wandless I, Whitmore J. The effect of counseling by a pharmacist on drug compliance in elderly patients. J Clin Hosp Pharm 1981; 6: 51–6
Goodyer LI, Miskelly F, Milligan P. Does encouraging good compliance improve patients’ clinical condition in heart failure? Br J Clin Pract 1995; 49: 173–6
Joos SK, Hickam DH, Gordon GH, et al. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med 1996; 11: 147–55
Heneghan CJ, Glasziou P, Perera R. Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database Syst Rev 2006; (1): CD005025
Hughes CM. Medication non-adherence in the elderly: how big is the problem? Drugs Aging 2004; 21: 793–811
McDonald HP, Garg AX, Haynes RB. Interventions to enhance patient adherence to medication prescriptions: scientific review. JAMA 2002; 288: 2868–79
Hoffman L, Enders J, Luo J, et al. Impact of an antidepressant management program on medication adherence. Am J Manag Care 2003; 9: 70–80
Kardas P. The DIACOM study (effect of Dosing frequency of oral Antidiabetic agents on the COMpliance and biochemical control of type 2 diabetes). Diabetes Obes Metab 2005; 7: 722–8
McKenney JM, Munroe WP, Wright Jr JT. Impact of an electronic medication compliance aid on long-term blood pressure control. J Clin Pharmacol 1992; 32: 277–83
Motheral BR, Fairman KA. Patient education programs and continuance with estrogen replacement therapy: evaluation of the women’s health exchange. Menopause 1998; 5: 35–42
Bernsten C, Bjorkman I, Caramona M, et al. Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical care: a multicentre study in seven European countries. Drugs Aging 2001; 18: 63–77
Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47: 533–43
Simpson Jr RJ. Challenges for improving medication adherence. JAMA 2006; 296: 2614–6
Atkin PA, Finnegan TP, Ogle SJ, et al. Functional ability of patients to manage medication packaging: a survey of geriatric inpatients. Age Ageing 1994; 23: 113–6
Nunney JM, Raynor DK. How are multi-compartment compliance aids used in primary care? Pharm J 2001; 267: 784–9
Nichol MB, Venturini F, Sung JC. A critical evaluation of the methodology of the literature on medication compliance. Ann Pharmacother 1999; 33: 531–40
Cramer JA. Microelectronic systems for monitoring and enhancing patient compliance with medication regimens. Drugs 1995; 49: 321–7
MacLaughlin EJ, Raehl CL, Treadway AK, et al. Assessing medication adherence in the elderly: which tools to use in clinical practice? Drugs Aging 2005; 22: 231–55
Rand CS, Wise RA, Nides M, et al. Metered-dose inhaler adherence in a clinical trial. Am Rev Respir Dis 1992; 146: 1559–64
Shalansky SJ, Levy AR, Ignaszewski AP. Self-reported Morisky score for identifying nonadherence with cardiovascular medications. Ann Pharmacother 2004; 38: 1363–8
Friedman RH, Kazis LE, Jette A, et al. A telecommunications system for monitoring and counseling patients with hypertension: impact on medication adherence and blood pressure control. Am J Hypertens 1996; 9: 285–92
Kippen S, Fraser M, Ellis J. As time goes by: issues for older people with their medicine use. Australas J Ageing 2005; 24: 103–7
Wroe AL. Intentional and unintentional nonadherence: a study of decision making. J Behav Med 2002; 25: 355–72
Liu GG, Christensen DB. The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc (Wash) 2002; 42: 847–57
Haynes RB, McDonald HP, Garg AX. Helping patients follow prescribed treatment: clinical applications. JAMA 2002; 288: 2880–3
Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes. Cochrane Database Syst Rev 2000; (3): CD000336
Sorensen L, Stokes JA, Purdie DM, et al. Medication reviews in the community: results of a randomized, controlled effectiveness trial. Br J Clin Pharmacol 2004; 58: 648–64
Holland R, Lenaghan E, Harvey I, et al. Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial. BMJ 2005; 330: 293–7
Raynor DK, Nunney JM. Medicine compliance aids are partial solution, not panacea [letter]. BMJ 2002; 324: 1338
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No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.
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George, J., Elliott, R.A. & Stewart, D.C. A Systematic Review of Interventions to Improve Medication Taking in Elderly Patients Prescribed Multiple Medications. Drugs Aging 25, 307–324 (2008). https://doi.org/10.2165/00002512-200825040-00004
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DOI: https://doi.org/10.2165/00002512-200825040-00004