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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR19

Intentional non-adherence in elderly patients: fact or fiction?

By C. J. Lowe and D. K. Raynor

Introduction Non-adherence to medication regimes has been categorised as either unintentional, where patients want to follow the regime and are unable to do so, or intentional, where patients choose not to follow their treatment regime.1
The elderly could be perceived to be less adherent than younger patients, but the consensus is that they are no different to other patient groups.2 However, they have distinct features which can lead to a focus on unintentional non-adherence, eg, sensory and manipulation difficulties, and decreased cognitive function.
Previous work in the United States suggests intentional non-adherence in the elderly is also prevalent.3 Our aim was to investigate this among elderly patients in a United Kingdom general practice population.

Method Patients aged 65 years or older and taking three or more drugs were recruited from a general practice. All patients were visited at home and interviewed about their medicine taking, using a structured questionnaire (as part of a wider study). They were asked which medicines they took, the dose taken and the frequency. Responses were compared with the medical records and patients were questioned on the reasons for any discrepancy.

Focal points

  • The elderly have significant barriers to adherence which relate to unintentional non-adherence (eg, manipulation, sensory difficulties)
  • This can lead to a focus on unintentional non-adherence in elderly patients (who are seen as confused and muddled)
  • This study examined intentional non-adherence in elderly patients in general practice
  • Thirty-four per cent of patients were taking their medicine in a different way to that prescribed as a result of a conscious decision
  • Elderly patients are as likely as younger patients to make reasoned decisions not to adhere to their prescribed medicine regime

Results A random sample of 161 patients was recruited into the study. The mean age of the patients was 76 years (range 65-96). There were 53 men (33 per cent) and 71 (44 per cent) lived alone. The mean number of medicines taken was four.
There was a discrepancy between patient report and practice record in 86 patients (53 per cent). In 28 patients the discrepancy was due to an administrative error, and in a further three patients it was due to patient confusion. However, the remaining 55 patients (34 per cent) had made a reasoned decision to alter their medication. For 30 of these patients there was one discrepancy, for 15 there were two discrepancies and eight patients had between three and five discrepancies. The reasons given for the discrepancies are shown in Table 1.
There were 92 medicines involved in total; 51 were no longer being taken by the patient, and there was an adjustment in the dose in 19 and the frequency in 22 of the medicines.

Table 1

Discussion The stereotypical image of poor adherence in the elderly because they are confused or muddled is inaccurate. The weighing up of perceived costs and benefits of taking a particular medicine within the contexts and constraints of their everyday lives4 appears to apply equally to the elderly. A third of these elderly patients showed such intentional non-adherence. The two most frequent reasons were the experience of side effects and adjustment of the regime in response to symptoms (including drugs for both minor and major illness).
In common with younger adults, these patients had made reasoned decisions to alter their medication, which were rational in the light of the information available to them. Some decisions were rational from the professional perspective and others were not.
It is of concern that the patients did not communicate these changes to their doctor. Adoption of the concordance model of medicine taking5 would allow those decisions to be discussed and documented.

Division of academic pharmacy practice, University of Leeds

References

1. Raynor DK. Patient compliance: the pharmacist's role. Int J Pharm Prac 1992;1:126-35.
2. Ley P. Communicating with patients. London: Croom Helm; 1988.
3. Cooper JK, Love DW, Raffoul R. Intentional prescription non-adherence by the elderly. J Am Ger Soc 1982;30:329-33.
4. Donovan JL. Patient decision making, the missing ingredient in compliance research. Int J Tech Assessment in Healthcare 1995;11:443-55.
5. From compliance to concordance: achieving shared goals. A joint report by the Royal Pharmaceutical Society of Great Britain and Merck Sharp & Dohme. London: Royal Pharmaceutical Society; 1997.