Medication Adherence in the Elderly

One of the most challenging and difficult parts of my professional day is trying to determine if my patients are actually taking their medications as prescribed. I ask my patients to bring their medications to each visit in the original pill bottles and we count pills. I ask them to bring their medication lists as well and we go through the time consuming practice of reviewing each medication against the prescribing date and amount and reviewing whether the correct amount of medication has been taken and is left in the pill bottles.

Many of our patients inadvertently make medication mistakes routinely. The toughest groups of patients to treat are elderly couples living independently with no local family member support and possessing a strong will for independence and privacy. Often one patient is moderately to severely cognitively impaired and the other partner is nowhere near as sharp as they think they are. There are frequently out of state children who try to provide support by hiring someone to assist their parents. In most cases mom and dad do not allow that hired person to work full time and terminate any strong willed but well-meaning caregiver who actually does what needs to be done.

Out of town family members usually hire an aide to help their relatives. Aides are not permitted by state law to administer medications. It is not in their job description or permitted by law. Well-meaning relatives usually then hire an agency which sends a nurse to fill up a monthly pillbox with the patient’s medications. All the patient has to do is go to the pillbox, recognize the day and date and remove and take the medications set aside in that section of the pillbox for that particular day.

Unfortunately it doesn’t happen the way it should. Unless a nurse stands there and administers the medication and then documents it, there is a strong possibility that the medication will not be taken correctly.

When bringing this up tactfully to the patient, spouse/partner or family member; they act in disbelief that you would make such an absurd statement despite the pill count in the bottles being off and extra medicine remaining in the pill box. This issue was recently studied by Niteesh K. Choudhry, MD, Ph.D. of the Brigham and Women’s Hospital in Boston, Ma. Working with a younger group of insured patients he showed that even with the use of a pillbox, and a digital timer to remind patients it was time to take their medication, adherence was extremely poor. He concluded that patients need additional support to adhere to their medication schedules and needs. His study was published in the Journal of the American Medical Association (JAMA).

Patients, especially the elderly, need hired professionals to administer and document the administration of their medications or else they don’t get it right. This may be inconvenient and expensive but it works.

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