Medication Management Strategies by Community-Dwelling Older Adults: A Multisite Qualitative Analysis

Abstract

Objectives:

Community-dwelling older adults taking five or more medications are at risk for medication-related harm. Managing multiple medications is a challenging task for patients and caregivers. Community-dwelling older adults self-manage their medications with minimal healthcare professional supervision. Although organizations such as the Food and Drug Administration often issue guidelines to ensure medication safety, how older adults understand and mitigate the risk of harm from medication use in the home environment is poorly understood.

Methods:

We conducted semi-structured interviews with community-dwelling older adults 65 and over who took five or more prescription medications to explore medication safety strategies they use. We also compared two organizations’ medication safety guidelines for areas of concordance and discordance.

Results:

A total of 28 older adults were interviewed. Four overarching themes of medication management strategies emerged: collaborating with prescribers, collaborating with pharmacists, learning about medications, and safe practices at home. Study findings revealed that older adults followed some of the published guidelines by the two government organizations, although there were some areas of discord. Some of the strategies used were unintentionally against the recommended guidelines. For example, older adults tried weaning themselves off their medications without notifying their providers.

Conclusion:

Older adults and their caregivers in our study used strategies different from those recommended by government organizations in managing medications to enhance drug safety. Patient-provider collaboration and positive patient outcomes can be improved by understanding and respecting strategies older adults use at home. Future studies must effectively incorporate older adults’ perspectives when developing medication safety guidelines.

1. Introduction

Community-dwelling older adults are often tasked with complex medication management with little to no professional oversight at home.¹ They may have difficulty understanding the medication’s purpose and managing their prescription timing and refills. In addition, most older adults take over-the-counter medicines that have the potential to interact with their prescribed medications.² Aging and polypharmacy increase the risk of hospitalization for adverse drug events (ADEs)³, which can be prevented in most cases.⁴ ADEs contribute to over 700,000 emergency department (ED) visits annually.⁵ Government organizations such as the Food and Drug Administration (FDA) and the National Institute on Aging (NIA) have developed guidelines to help older adults safely manage their medications at home.^6,7 These guidelines are available online. However, it is unclear how older adults are made aware of these guidelines. The guidelines included recommendations about creating medication lists, not sharing or splitting pills, and learning about potential drug interactions, to name a few.^6,7 Additionally, the NIA outlines questions older adults can ask their providers to avoid polypharmacy and encourage deprescribing.⁷ We conducted a study to better understand the basic strategies older adults already use at home by comparing these strategies with guidelines published by government organizations.

Medication safety guidelines and tools such as the Beers criteria are set to mitigate medication safety issues. Though, we continue to see ADEs in inpatient and outpatient settings. In less than a decade, ED visits for ADEs increased from 25.6% to 34.5%, with older adults having the highest hospitalization rates.⁸ It is essential to learn what older adults do at home to reduce the risk of ADEs, such as whether they follow recommended guidelines or adopt other strategies. Additionally, we must understand the work system older adults use at home when managing their medications. A work system refers to tasks imposed on older adults by their health conditions, such as taking medications.⁹ The Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model was adapted to identify various work systems older adults use to manage their medications at home.⁹ The SEIPS 2.0, a human factor engineering model, offers a holistic view of the sociotechnical components of the medication management work system. It allows us to examine the elements’ interactions and how they may impact healthcare processes and outcomes.

The SEIPS 2.0 model presents a work system structure with six interoperating components: (1) the person(s) located at the center, (2) performing tasks such as managing medications, (3) using tools and technology, (4) with a specific organization structure, (5) within their unique internal and (6) external environment.⁹ The sociotechnical work system interacts to produce processes through adaption feedback loops influencing outcomes.⁹ Researchers have used the model to study how processes and outcomes are affected by interactions between structural components of the various work systems.^10–12 This study aimed to explore the strategies used by older adults to improve medication safety at home and compare those strategies to medication safety guidelines set by the FDA and NIA. We also compared both organizations’ safety guidelines for areas of discordance and concordance.

2. Methods

We conducted semi-structured interviews with community-dwelling older adults to explore medication safety strategies they use at home. After institutional review board approval, we recruited Spanish and English-speaking individuals 65 years of age and over who took five or more prescription medications. Purposive sampling was used to promote inclusion of both English and Spanish-speaking participants, thus providing detailed information about the phenomenon (medication safety strategies). Recruitment occurred at three sites: a retirement community for independent living older adults and two family medicine clinics in an urban area. Older adults from the independent living facility do not receive medication management assistance from the facility. We recruited from the three sites to capture a more in-depth view of the phenomenon across sites. Caregivers were encouraged to join the interview sessions. We also compared the FDA medication safety guidelines to those set by the NIA.^6,7

2.1. Recruitment

A recruitment flyer and a video presentation on the internal cable channel were distributed to the retirement community. Healthcare providers at the two clinics identified older adults who met the inclusion criteria and agreed to participate in this study. In addition to screening for eligibility, we contacted prospective interviewees for written consent and scheduling time preferences.

2.2. Data Collection

A semi-structured interview guide framed by the SEIPS 2.0 model was used with direct questions such as “What do you use to manage your medicines at home?” and “How is your experience with the tools you use?” (See supplemental material for complete guide). Researchers conducted interviews in both English and Spanish and recorded field notes. Each Spanish interview was conducted by a native Spanish-speaking team member who also validated the translation of transcriptions. Upon completion of the interview, participants received a $10 gift card. Interviews ended when no new themes were identified and data saturation was reached. The interviews were transcribed and translated professionally. Transcripts were reviewed for accuracy by the interviewers. After each interview, reflection notes were made by interviewers.

2.3. Data Analysis

Six members iteratively developed a codebook and jointly coded the six initial transcripts. Team members met weekly to compare and revise codes. Two members used the final codebook to code the rest of the transcripts. Braun and Clarke’s (2006) six stages of inductive thematic analysis were utilized to analyze the transcripts.¹³ NVivo Version 12 from QSR International was used to manage data. Interview reflection notes and photographs were referenced to supplement transcript coding. Inductive analysis was used to generate the initial themes. The SEIPS 2.0 framework guided deductive thematic analysis and organized themes within the work processes of the model. Using comparative analysis, we compared our findings with the recommendations from the medication safety guidelines of the two US federal agencies (FDA and NIA).

3. Results

A total of nine residents from the retirement community and 19 patients from two clinics participated in the study. In addition, two participants attended with caregivers. The mean age of older adults in this study was 75 years (SD = 7.5). Most of the participants (67.9%, n=19) were females. The average number of medications taken daily was 7.7 (SD = 2.5). More than half (54%) of the participants had a college degree. All the retirement community residents had at least some college. There were eight Spanish-speaking older adults recruited from both clinics (n=8). Demographic data are provided in Table 1.

Table 1.

Demographics Summary n=28.^a

Demographics	n (%)
Gender (male)	9 (32.1)
Language spoken
English	20 (71.4)
Spanish	8 (28.6)
Education
Master’s Degree	1 (3.6)
Bachelor’s Degree	3 (10.7)
Some College	11 (39.3)
High School	7 (25)
Elementary	2 (7.1)
Unknown	4 (14.3)
Setting
Retirement Community (Independent living)	9 (32.1)
Private Clinic	10 (35.7)
Publicly Funded Healthcare System	9 (32.1)
	Mean (SD)
Age	75.2 (7.5)
Daily medications taken	7.7 (2.5

Notes:

^*SD – Standard Deviation

^aPercentages may not add up to 100 due to rounding.

Thematic analysis revealed four overarching themes: collaborating with prescribers, collaborating with pharmacists, learning about medications, and safe practices at home. For comparison purposes, the guidelines from the two federal agencies were organized into the above four themes in Table 2. Table 3 highlights examples of concordance and discordance of medication safety strategies older adults use at home.

Table 2.

Comparison of The Food and Drug Administration and The National Institute on Aging Medication Safety Guidelines for Older Adults

Themes and Subthemes	Organizations
	FDA	NIA
Collaborating with Prescribers
Inform prescribers about allergies, alcohol, tobacco, or drug use	✓	✓
Notify prescribers of meds from all doctors, OTC, vitamins, and herbal supplements	✓	✓
Ask questions and discuss with provider e.g., med review, cost, alternatives.	✓	X
Review how long to take medications	X	✓
Collaborating with pharmacists
Check meds when picking up e.g., correct med, bottle opens easily?	X	✓
Ask for proper label at pharmacy e.g., larger print	X	✓
Ask about medication use while travelling	X	✓
Ask about drug interactions	✓	X
Learning about medications
Write the name and what it is for	X	✓
Know the side effects and risks	✓	✓
Know what to do for side-effects	✓	✓
Know when and how much to take	✓	✓
Check with provider before stopping	✓	✓
Safe practices at home
Follow instructions & labels.  Do not stop or skip without advice	✓	✓
Use an organizer	✓	✓
Use a reminder	✓	✓
Organize for refills	X	✓
Use fewer pharmacies	X	✓
Store meds safely, away from children	✓	✓
Do not store meds in bathroom	✓	X
Do not take meds not prescribed to you. Do not share	✓	✓
Do not take expired meds	✓	✓

Table 3.

Four Overarching Themes with Sample Quotes on Areas of Guidelines Concordance and Discordance in Medication Safety Strategies by Older Adults

Themes	Areas of Guidelines Concordance	Areas of Guidelines Discordance
Collaborating with prescribers	“I look at the side effects to make sure. You know, if it’s worth taking this medication, I’ll ask the doctor.” OA5 “I also ask them questions about how she’s been doing from the last time she went to the moment that she’s there.” PT5	“I tell the doctor that my back hurts. He says, okay, take this. I say, what’s it for? He says, it helps with the pain. I say, okay, thank you. I take the medicine [ask no further questions].” PT18
Collaborating with pharmacists	“Like when it’s a new medication, I do ask the pharmacist questions.” PT9	“I don’t ever ask the pharmacist.” PT18
Learning about medications	“When I pick up the prescription, I’ll do like any normal person, I’ll read the instructions for taking the medication. When you get the medication, they tell you all about it. They give you a sheet.” PT8	“I have an idea of what each shape is. I know my water pill is a little, pink pill. My blood pressure, is a long blue pill.” PT18 “There are some that are small, others that are bigger. That metformin is white. The losartan is yellow.” PT2
Safe practices at home	“I keep them in the bottle, and I keep them in order. I have them in my drawer in order of how I take them.” PT18	“The ones she takes between 12:00 and 3:00,I wrap them up in aluminum foil, and she knows she has to take those during the day. But the ones she has to take with a glass of milk, I wrap that up with saran wrap, and she takes that one with a glass of milk. And then the ones she takes in the morning, well, she knows she has to take those with a meal.” PT5

3.1. Collaborative Professional-Patient Work

Collaborative work is when providers, pharmacists, and older adults actively engage in medication safety practices. However, results indicate that sometimes older adults overly trusted their providers, which was a barrier to collaboration.

3.1.1. Theme 1: Collaborating with Prescribers

Collaborating with prescribers identifies adhering to the recommended guidelines, such as asking specific medication-related questions, bringing medication lists to visits, and discussing other alternative treatments. Older adults collaborated with prescribers by asking specific questions related to medication use. “I prepared a medicine list, and I listed what I was concerned about health-wise for me [to ask the provider during visits]” OA10. Older adults assessed medications’ risks, benefits, and side effects. Others also asked questions about the efficacy of their drugs. Older adults also engaged providers by asking about switching to affordable medications due to insurance coverage.

“If it something else that I can take that the insurance would cover, and it’s the same medicine, maybe a generic or something, then I will see if they will prescribe that one instead of the one I have to pay out of pocket for that’s more than what I can afford.” (PT16)

Discordance with guidelines

Areas of discordance illustrated the lack of collaboration with providers due to other knowledge sources or trust in the provider. Some older adults were reluctant to ask questions regarding their medications. This lack of participation was attributed to trusting the provider. Some older adults thought the doctor knew it all; therefore, there was no need to ask further questions. “I don’t ask no questions because I figure the doctor knows what he’s doing” (PT4). “I feel very confident in my doctors, OA9.” We also found that some older adults would instead “look it up” because the time between visits was too long.

“If I’m sitting here and I think of something, then I will look it up on the Internet because I don’t see my doctor very often. So rather than write the question down and save it for him for whenever, I just look it up.” (OA3)

3.1.2. Theme 2: Collaborating with Pharmacists

We found that older asks would ask pharmacists questions regarding their medications if it was a new prescription. Older adults also questioned pharmacists about possible drug-to-drug/disease interactions. “I ask them specifically, will this conflict with other medicines that’s on my list? And the local pharmacy has that list, OA1.” Effective collaboration was viewed by older adults as “feel free” to ask any questions they wanted.

“If you feel put off by somebody, you’re not going to feel free to ask questions or ask them to do something for you. But the one, the pharmacy I’m going to now, they are very good about talking to me about my medicines and will answer any question that I might have.” (OA2)

Discordance with guidelines

Discordance was associated with the lack of pharmacy collaboration due to other sources of information to improve medication safety. Older adults mentioned that they did not ask the pharmacist questions because their doctor told them all they needed to know about their medications. “I don’t ever ask the pharmacist. The doctor tells me everything I need to know, (PT18).”

3.2. Patient Work Factors

Patient work involves medication management tasks undertaken by older adults and their caregivers with little to no health professional supervision. As a result, some of these tasks were unintentionally against recommended safety guidelines.

3.2.1. Theme 3: Learning About Medications

This theme identifies the practices of self-education about medications. For example, many stated they learned about drugs from inserts with their prescriptions. Older adults referred to these inserts to learn about possible side effects and other safety measures. “They’ll send an information sheet, and so I read that very thoroughly. If I have any questions about it, I’ll ask my doctor when I see him, (OA5).” Some older adults asked prescribers medication-related questions during visits. One older adult in this study, a retired nurse, voiced using a “PDR” to look up medications.

Discordance with guidelines

Discordance in learning about medication is defined as alternative learning strategies initiated by older adults. We found that older adults learned about their medications by their characteristics, such as color, shape, or smell. If drugs appeared to have similar features, it was perceived as confusing. “I recognize them by smell, color, and shape. There are some that I get confused because they’re all plain white, (PT5).

Older adults used technology such as internet search engines to enhance their knowledge about medication therapy management.

I read about them. I just google them. Any time I get a new medicine, like headache medicine, I google it, and I find out what it does, what you can take with it or what you can’t take with it. (PT10)

3.2.2. Theme 4: Safe Practices at Home

Examples of safe practices at home include the use of tools (pillboxes), technology (phones, alarms), organizing refills, and storing medications safely. Several older adults in our sample used pillboxes to aid with organizing medications. Older adults used strategic reminders such as placing morning medications in the kitchen and evening or bedtime medications in the bedroom or bathroom. The color of medications was often used as a guide to sort medication into the morning or evening slots of pillboxes. Leaving the pillbox open was a strategy used as a reminder of dose intake. “I will get it open and leave it open, and that’s the way I know I’ve taken it, (OA7).” Some older adults used electronic timers during meals to remind them to take their medications. “I have a timer that I set every time I finish my meal. And when that timer dings, then I take my medication, (OA4).” Older adults were also vigilant about securing prescribed controlled substances away from pets and other family members. “My role is to take it regularly and [make sure] she [cat, does not] get into my medicine. I have to keep it out of sight, OA2.”

Discordance with guidelines

Although many older adults followed recommended guidelines, there were unsafe practices that posed a serious risk to medication safety. For example, one older adult was found to cut or omit pills and took a lesser dose than prescribed. This practice was due to the pharmacy being far from home and served as a strategy to prolong the prescription supply until there was a way to get refills. “For a while, I thought I would just cut my pill in half, because I live away from the pharmacist, (OA7).” Some older adults stopped taking medications and practiced self-dosing due to their perceived health importance of the drug.

There are some that I need which are not important enough to keep me alive, well, for erectile dysfunction. Too much for insurance to pay for it, so I do without. You know, 18 pills for 90 days, $64, that’s kind of ridiculous. (PT19)

In an attempt to wean themselves off prescribed medications, one older adult broke their pills but suffered unwanted side effects.

“I want to get off, reduce the Xanax that I’m taking, but that’s for the stress and everything that I’ve just been through. So I haven’t done that because I’ve tried like breaking the pill in half, and my stomach is just rolling. So I take the other half and it settles down. But eventually, I will get off of it.” (OA10)

4. Discussion

The main findings highlight that community-dwelling older adults developed individual medication management strategies. Unfortunately, some of the strategies were unintentionally against the recommended guidelines. For example, older adults were advised not to discontinue medications without telling their providers; instead, some tried to wean themselves off medications. There was an immense agreement between the two organizations’ (FDA & NIA) medication safety guidelines. However, we also found some gaps within those guidelines. For instance, both organizations recommended avoiding taking expired medications. But neither organization discussed recalled drugs, which was a concern of our study participants: “make sure that they’re not giving [me] medicine that has been recalled” (OA9).

Community-dwelling older adults in this study facilitated collaborative work during medication management with their providers by asking questions and bringing medication lists to clinic visits. Some older adults were reluctant to collaborate due to overconfidence in the provider. Older adults preferred asking providers drug-related questions rather than pharmacists. Hence, trusting providers was a barrier to collaborating with pharmacists. The pharmacists were only engaged if the prescription was new.¹⁴ Pharmacists should ask specific drug-related questions to older adults instead of asking open-ended questions.

Similar to the literature, older adults in this study split pills or omit doses for various reasons.^15,16 Identifying medication literacy gaps among community-dwelling older adults is essential to educate them about the implications of self-dosing, which could potentially be severe even if the effects are not recognized immediately. Researchers found that older adults do not often recognize ADEs and are often confused with disease-related symptoms.¹⁷ Providers should continue to educate patients about medication safety even though older adults may feel they are experts in their care due to their experience. Our study also found that older adults emphasized medication characteristics when learning about drugs; therefore, safety guidelines should consider this.

From the SEIPS 2.0 model, medication management strategies could be significantly influenced at home by the person’s knowledge, abilities, and cognitive issues.⁹ Task complexity, such as the number of medications and drug risk, can also impact medication management. In addition, older adults were tasked with learning about their medications. However, they learn the characteristics of pills, which can change and complicate learning.¹⁸ Furthermore, we found that tools such as pillboxes were widely used among community-dwelling older adults. Unfortunately, some of these tools are costly and may fail to serve their purpose due to patients’ physical or mental limitations.¹⁹ Electronic pillboxes increase patient satisfaction and quality of life.²⁰ Pillboxes with reminders could prevent missed doses due to forgetfulness and share pertinent usage data with providers. There is a need to expand treatment options and satisfaction for older adults experiencing polypharmacy. Medicare should pay for tools and technology that promote safety for older adults taking five or more medications.

Home organization, such as living arrangements, work schedules, family roles, and social norms, can influence medication management, such as arranging for refills.⁹ Medication therapy management occurs in an internal environment influenced by noise, light, pets, and storage areas.⁹ Many homes lack appropriate storage areas for medications leading to multiple inappropriate storage places,²¹ sometimes mixed with food items.²² Older adults’ storage strategies could affect the efficacy and stability of medications. For instance, some older adults kept all their medications by the window for easy visibility or in the bathroom for convenience.²³ However, most medications must be kept in a cool, dry, and dark environment.

The external environment relates to insurance coverage. In our study, older adults collaborated with providers to change prescriptions if coverage was an issue. Others skipped taking their medications due to the high cost. “There are some that I need which are not important enough to keep me alive, well, for erectile dysfunction. Too much for insurance to pay for it, so I do without. Eighteen pills for 90 days, $64, that’s ridiculous” (PT19). Providers should encourage older adults to discuss insurance issues to prevent jeopardizing their social life of older adults.

Most older adults will see their providers at least once a year. However, these visits are usually brief, less than 30 minutes. Expanding in-home annual wellness visit programs could identify medication safety gaps and improve patient outcomes. For example, researchers found that patients seen by a pharmacist at home reported more current active medications than those seen by a provider.²⁴ In-home visits could unveil other variables affecting medication safety strategies that this study could not.

This study had some limitations. All interviews were conducted remotely to comply with the COVID-19 social distancing requirements, without some of the benefits of in-person interviews at the homes of older adults. However, we used video as much as possible to see how older adults stored and handled their medications. Virtual Interviewing may have potentially limited engagement with interviewees; future studies should replicate the study using face-to-face interviews. We did not target older adults with cognitive impairment or low health literacy. Older adults with cognitive deficits may face different medication management challenges. As a qualitative study, our results are not measured against the principle of generalizability but rather transferability of our findings. These results are transferrable to similar populations in other settings, as the medication management strategies our participants demonstrated are common issues experienced by older adults with multiple comorbidities. As a strength of this study, participants were recruited from multiple sites to capture diverse perspectives on the medication management strategies of older adults.

5. Conclusion

The older adult population is likely to be consuming multiple medications. In a multi-site sample of 28 community-dwelling study participants in the southwest of the United States, older adults reported various medication management strategies that were in contrast with those medication safety guidelines advocated by governmental and professional organizations. Our analysis indicated a need for further studies on patient perspectives to increase professional-patient collaborative work, such as those using similar methodologies to the current study with larger samples of study participants with varying backgrounds. Strong communication between patients, prescribers, and pharmacists can help answer patients’ queries and concerns. Measures not aligned with approved guidelines can increase the risk of unsafe and unpleasant outcomes. Our findings should encourage health organizations to consider older adults’ medication safety strategies to guide opportunities to improve outcomes. Healthcare providers need to assess the knowledge of their patients regarding the purpose of medications and safety. Current guidelines need to be reviewed with older adults to ensure safe medication usage.