Understanding medication management in older adults: experiences of Turkish community pharmacists

Abstract

Background

Examining the experiences of community pharmacists working with older adults can contribute to improving practices related to geriatric pharmacotherapy management and to better understanding pharmacists’ roles in medication management. The growing burden of chronic non-communicable diseases contributes to the widespread use of multiple medications in later life, and polypharmacy is associated with adverse outcomes such as falls, hospitalizations, and increased healthcare utilization. This study aimed to explore community pharmacists’ experiences regarding medication management in older adults and the situations they encountered during this process.

Methods

This study was conducted within an interpretive qualitative framework. Semi-structured interviews were conducted with 11 community pharmacists working in two regional cities in Türkiye to obtain an in-depth understanding of their perspectives and professional practices regarding medication management in older adults. Data were analyzed using a reflexive thematic analysis.

Results

The interview data were organized into three main themes: perceptions of professional competence, pharmacist intervention practices, and barriers encountered in practice. Participants described medication management in older adults as a complex process shaped by polypharmacy, multimorbidity, fragmented prescribing, limited health literacy, and constraints in interprofessional communication.

Conclusion

The findings indicate that community pharmacists play an important but constrained role in supporting medication management in older adults through counselling, communication-based adherence support, and coordination with physicians. Strengthening pharmacist-led medication review, improving formal communication channels with prescribers and providing system-level support for cognitive services may enhance medication safety and promote more rational medication use among older adults.

Key points

What is already known

• Older adults frequently experience complex medication regimens due to multimorbidity and polypharmacy, increasing the risk of medication-related problems.

• Community pharmacists play an important role in supporting safe medication use among older adults through medication counselling, medication review, and monitoring of therapy.

• Previous studies have examined medication-related problems in older adults; however, most research has focused on clinical outcomes or quantitative assessments rather than pharmacists’ day-to-day experiences in managing medication use.

What this study adds

• This study provides qualitative insights into how community pharmacists experience and manage medication use among older adults in their routine practice.

• The findings highlight the practical challenges encountered by pharmacists, including complex medication regimens, patient-related factors, and health system–related barriers to medication management.

• Understanding pharmacists’ experiences may inform strategies to improve medication safety and support community pharmacists in managing medication use in older adults.

Introduction

Older adults often live with multiple chronic conditions that significantly affect their functional abilities and require complex pharmacotherapies [1]. According to United Nations data, the number and proportion of older adults in the global population are increasing rapidly and are expected to continue to rise in the coming decades [2]. The growing burden of chronic non-communicable diseases contributes to the use of multiple medications in later life, and polypharmacy is associated with adverse outcomes such as falls, hospitalizations, and increased healthcare utilization [3, 4]. Physiological changes associated with aging, decreased cognitive function, memory problems, and complex treatment regimens increase the risk of non-adherence, adverse medication events, and inappropriate prescribing in this population, creating a serious public health concern [5]. The World Health Organization (WHO) emphasizes that polypharmacy is a major patient safety issue among older adults and that medication-related problems are more frequent in this group [6]. Although there is still no consensus on the definition of polypharmacy, recent studies suggest that it should not be understood solely in terms of a specific number of medicines but also in relation to treatment appropriateness, potential harms, and clinical outcomes [7]. Polypharmacy in older adults is associated with drug–drug interactions, adverse drug reactions, and potentially inappropriate medication use [8]. However, the complexity of medication management in later life cannot be explained solely by the number of medications used. Age-related pharmacokinetic and pharmacodynamic changes, multimorbidity, regimen complexity, cognitive decline, and adherence problems all contribute to making medication management more challenging [9]. Recent scoping reviews indicate that polypharmacy management in older adults requires structured and multi‑component approaches, including medication review, deprescribing, and interprofessional collaboration, and that no single gold‑standard strategy exists [3, 10].

Community pharmacies are among the most accessible healthcare points within many health systems, and community pharmacists often have regular and continuous contact with older adults [11]. This position enables pharmacists to detect medication‑related problems early and provide direct counselling to patients and caregivers. By conducting comprehensive medication reviews, assessing prescriptions, counselling on correct medicine use, supporting treatment adherence and identifying potential medication‑related problems, community pharmacists can make meaningful contributions to medication management in older adults [12]. Systematic review evidence indicates that community pharmacist involvement in medication review for older adults is most consistently associated with reductions in actual or potential medication‑related problems and improvements in adherence, even if effects on hard clinical outcomes are more limited [13, 14].

International organisations such as the International Pharmaceutical Federation and the Organisation for Economic Co‑operation and Development highlight pharmacists as key healthcare professionals in improving medication safety and reducing risks associated with polypharmacy in health systems [5, 15]. Medication management in older adults is not solely a matter of clinical or pharmacological assessment. Patient healthcare use behaviors, their tendency to seek prescriptions from multiple physicians, their expectations and beliefs about treatment, and their social and economic circumstances can all influence how medicines are used in daily life [16]. This makes medication management in older adults a multidimensional process situated at the intersection of health system dynamics, patient behavior, and professional practice. Community pharmacists occupy a unique position in this multidimensional process. Because community pharmacies are highly accessible, pharmacists can observe not only the technical aspects of prescribing and dispensing but also older adults’ everyday experiences with medicines, adherence patterns, and navigation of fragmented care pathways. Qualitative and ethnographic studies have shown that trusted community pharmacists can act as key mediators of medication safety for older adults with frailty, multimorbidity, and polypharmacy; however, this perspective remains underexplored in many health systems [17–20].

Numerous quantitative studies have examined the effects of community pharmacists’ medication review and clinical interventions for older adults, often focusing on clinical outcomes or quantitative assessments of medication‑related problems [21, 22]. However, few studies have explored the day-to-day situations community pharmacists encounter when managing medication use among older adults and the professional strategies they develop in response to these challenges, particularly in the Turkish context [23]. Qualitative research offers an important methodological approach to understanding how healthcare professionals interpret their roles, manage complex clinical realities, and negotiate system constraints in routine practice [24]. Therefore, examining the experiences of community pharmacists working with older adults can contribute to improving practices related to medication management and clarifying the role of pharmacists within this process [25]. The aim of this study was to explore community pharmacists’ experiences regarding their perceived competence, professional roles, intervention practices and the challenges they encounter in medication management for older adults, using a qualitative design and reflexive thematic analysis.

Methods

Study design and approach

This qualitative study examined the experiences of community pharmacists regarding medication management in older adults, within an interpretivist qualitative framework. To gain an in-depth understanding of the participants' viewpoints and professional practices, individual semi-structured interviews were conducted — seven in person and four by telephone — depending on the participants' preferences and availability. The study was designed and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32‑item checklist [26] (Appendix 1).

Study setting

This study was conducted in community pharmacies located in two cities in Türkiye: Rize and Erzurum. These cities are important regional centers in the Black Sea and Eastern Anatolia regions, where community pharmacists frequently encounter older adults with chronic diseases and polypharmacy in their daily practice. According to recent statistics from the Turkish Statistical Institute, the population of older adults (≥ 65 years) is 76,676 in Erzurum (approximately 10.4% of the total population) and 54,659 in Rize (approximately 15.8% of the total population) [27], indicating a sizeable older population that frequently uses community pharmacies. Including pharmacies from these two cities, which comprise both urban and semi‑urban areas and have a high density of community pharmacies, was intended to capture some variation in the practice context while remaining within broadly comparable community pharmacy settings.

Study instrument

Data were collected using a semi-structured interview guide and a descriptive information form prepared by the researchers based on relevant literature [21, 28]. The descriptive form collected sociodemographic and professional information, such as age, gender, and years of professional experience. The semi-structured interview guide included open-ended questions about pharmacists’ experiences, perceived competence, intervention practices, communication with physicians, and barriers related to medication management in older adults (Appendix 2). The interview guide was piloted with two community pharmacists to improve the clarity, flow, and relevance of the questions before the main interviews were conducted.

Sampling and recruitment

A purposive convenience sampling strategy complemented by passive snowball sampling was used to recruit participants. Community pharmacists who were licensed, had at least one year of active professional experience in community pharmacy, and were involved in medication management for older adults were eligible for inclusion. Pharmacists who had not actively worked in community pharmacies during the previous 12 months or whose current roles did not involve direct patient care and medication management for older adults were excluded. Potential participants were identified through the researchers’ professional networks and acquaintances and invited to participate voluntarily. In addition, participating pharmacists were asked to inform suitable colleagues about the study, which enabled passive snowball recruitment [29]. The initial sample size was planned to be approximately 20–25 participants, based on previous qualitative studies suggesting that this range is often sufficient to achieve data saturation [29].

Data collection

Semi-structured interviews were conducted in Turkish by a single female researcher (C. C.), who holds a pharmacy degree and has prior experience in qualitative research, between June and September 2025. The researcher had no prior relationship with the participants before the study commenced. Prior to each interview, participants were informed about the study's aims and the researcher's academic background, and written informed consent — including permission to audio-record the interview — was obtained. The researcher's professional background in pharmacy may have facilitated rapport with participants; however, efforts were made to minimise potential bias by using a standardised interview guide and adopting a non-directive interviewing approach. Interviews continued until inductive thematic saturation was reached, that is, until no new codes relevant to the research question were identified [30]. When participants did not fully understand a question, it was repeated or rephrased, and when responses were brief or unclear, follow-up and probing questions were used to elicit more detailed explanations. Field notes were taken by the interviewer during and, when necessary, immediately after the interviews to capture the contextual observations and reflexive impressions. All interviews were audio-recorded using a digital recorder and subsequently transferred to a secure, password-protected computer system for transcription and analysis. The participants did not receive any financial compensation for participating in the study. To ensure accuracy, the research team (E. U. D., C. C.) reviewed the interview transcripts against the audio recordings. When necessary, minor clarifications were made; however, the substantive content of the interviews was not altered.

Data analysis

An accredited third-party consultant independent of the research team transcribed the anonymized interviews verbatim. The transcripts were checked for accuracy by two researchers (E.U.D. and C.C.). The data were imported into the MAXQDA software for systematic data management and analysis. Data analysis followed the reflexive thematic analysis approach described by Braun and Clarke [31, 32]. This approach allowed for the systematic identification, examination, and interpretation of patterns of meaning across the dataset and was particularly suited to exploring how pharmacists make sense of their roles and practices in routine community pharmacy settings. In the first stage, the two researchers read all the transcripts several times to become familiar with the data, and initial codes were generated inductively and applied across the dataset. Thematic ideas were discussed on a subset of transcripts, and differences in coding were resolved through discussion. Codes that captured similar ideas were then grouped into candidate subthemes and themes, which were iteratively reviewed and refined by examining the patterns of meaning and semantic relationships across the dataset. For example, codes relating to multiple prescribers, duplicate therapies, and patients’ difficulties in managing complex regimens were grouped into a subtheme on medication complexity and fragmented care, which later formed part of a broader theme on barriers to medication management. Researcher reflexivity was maintained throughout the analysis process. The researchers kept reflexive notes on their professional backgrounds and assumptions and regularly discussed how these might influence data collection, coding, and interpretation. This process enhanced the transparency of the analytic decisions and supported a reflexive, rather than purely procedural, use of thematic analysis.

Ethics and data management

This study was approved by the Ethics Committee of Atatürk University, Faculty of Pharmacy, Department of Pharmaceutical Management (Approval No: 2500137727, Date: April 28, 2025). Written informed consent was obtained from all participants before data collection. This study was conducted in accordance with the principles of the Declaration of Helsinki.

Audio files and transcripts were stored on password-protected devices and secure institutional servers accessible only to the research team. All transcripts were anonymized before analysis, and identifying information was removed.. Data were used solely for research purposes and will be retained and destroyed according to institutional and ethical guidelines.

Trustworthiness

In this qualitative study, quality criteria were addressed using strategies to enhance credibility, dependability, confirmability, and transferability [32, 33]. Credibility was supported by obtaining data from all interviews, independent review of transcripts and codes by two researchers (E.U.D., C.C.), and regular discussion of the coding and theme development process. Dependability and confirmability were strengthened through the maintenance of an audit trail, comparison of coding across researchers, and reflexive consideration of potential biases that might influence data collection and analysis. Transferability was supported by providing a detailed description of the study setting, participants, data collection, and analysis procedures, enabling readers to assess the applicability of the findings to other contexts. Reflexivity was integrated throughout the research process to ensure that the researchers’ experiences and perspectives did not dominate data interpretation.

Results

Demographics of study participants

Data saturation was considered to have been reached after 11 interviews when no substantially new codes relevant to the research question were identified. The duration of the interviews ranged from 10 to 30 min, with a mean duration of approximately 23 min. The gender distribution of the participants was balanced. Participants’ ages ranged from 28 to 47 years, reflecting variations in their professional stages. The largest age groups were 30–34 and 35–39 years, each representing 27.3% of the participants. The detailed demographic characteristics of the participants are presented in Table 1.

Table 1.

Demographic and professional characteristics of community pharmacist participants (n = 11)

Participant ID	Gender	Years of Professional Experience	City
P1	Female	5	Erzurum
P2	Male	7	Rize
P3	Male	9	Rize
P4	Female	11	Rize
P5	Male	23	Rize
P6	Male	11	Erzurum
P7	Female	5	Erzurum
P8	Female	8	Erzurum
P9	Male	9	Rize
P10	Male	3	Rize
P11	Female	6	Rize

Gender: 5 females (45.5%) and 6 males (54.5%); city: 4 participants (36.4%) from Erzurum and 7 (63.6%) from Rize

Thematic overview

Three main themes were identified from the analysis: perceptions of professional competence, pharmacist intervention practices, and barriers encountered in practice (Fig. 1).

Fig. 1.

Thematic map of community pharmacists’ experiences in medication management for older adults, illustrating three overarching themes (perceptions of professional competence, pharmacist intervention practice, and barriers encountered in practice) and their related subthemes

Theme 1: perceptions of professional competence

Participants did not position themselves as completely incompetent in the treatment management of older patients; however, owing to the breadth of their knowledge base, the variety of medications, and the complexity of polypharmacy, they often defined their professional competence as having limitations. In the interviews, the perception of competence was established between a growing self-confidence gained with experience and an awareness that "it is impossible to know everything."

Perceived professional competence

Some participants stated that they possessed the knowledge to answer older patients’ questions and provide the necessary guidance. This competence was generally defined in terms of the capacity to answer specific questions asked by the patient and provide counseling regarding medication use.

“I honestly don’t think I’m incompetent, but I don’t have that much experience either… I think I’m competent enough to answer a patient’s question and convince them.” (P2).

"Older patients are really challenging… they use 8–10 medicines at the same time, and honestly, keeping track of all interactions is not always easy for us." (P3).

Similarly, some participants indicated that they considered themselves to be moderately competent. “Partially. I don’t think I have completely sufficient knowledge and skills… Let’s say moderate.” (P5).

Perceived areas of insufficiency

Some participants stated that they occasionally felt inadequate because of the vastness of the field of knowledge, particularly on topics such as polypharmacy and drug interactions.

“Honestly, I think I am lacking… I have nine years of experience, but I still think I am lacking… I'm looking at the literature, you know.” (P6).

“Pharmacology is a very broad field… drugs interact with each other a lot.” (P9).

Need for continuing professional education

Most participants stated that access to up-to-date information is important for managing medication use in older adults and that continuous professional development is necessary. Scientific publications, professional training, and conferences were specifically mentioned as important components of this process.

“If I’m not sure, I open a source with the patient.” (P1).

Some participants particularly emphasized individual reading and repetition:

“It’s necessary to always be researching, reading, reading a lot… I still sometimes open my school lecture notes and read them.” (P2).

"When an older patient comes in with a bag full of medicines, I sometimes feel I need to know much more than I do." (P9).

The need for professional development to be supported by training and seminars was also mentioned:

“Seminars could be organized… face-to-face training could be provided.” (P4).

“Our chamber provides seminars, we try to attend them.” (P9).

Theme 2: pharmacist ıntervention practice

Participants did not identify a single intervention model for the management of older patients. The form of intervention varies depending on the type of medication, perceived risk level, and physician's role. Two related patterns were particularly visible in participants’ accounts: a cautious approach to changing long-term prescribed therapies and a more active counselling role in situations perceived as high risk, such as potential drug–drug interactions, unnecessary analgesic use, or incorrect timing of medicines. In addition, efforts to maintain treatment adherence through communication emerged as an important component of intervention.

Cautious management and physician referral

A significant number of participants stated that they avoided directly stopping or changing medications in chronic medication treatments. This approach was associated with respecting the physician's treatment plan and maintaining professional boundaries.

“Of course, we don't interfere too much with chronic medications.” (P1).

"Especially with older patients, I am very careful… they have heart disease, diabetes, everything at once… I don't want to change anything without the physician." (P10).

“I don't think it's right to say that a medication prescribed by a physician is ‘unnecessary’.” (P2).

“Since it's a physician’s referral, I don't want to interfere too much.” (P4).

This cautious approach often involves referring the patient back to the physician:

“I definitely warn the patient… you can talk to your physician again reminding them of this.” (P1).

“I recommend a referral.” (P1).

“I have it removed from the prescription… I contact the physician.” (P5).

“We refer them to the physician… to change their medication.” (P7).

Active counseling in high-risk situations

Some participants stated that they intervened more directly in situations such as the risk of interaction, unnecessary analgesic use, or incorrect timing. These interventions included regulating the frequency of medication use, suggesting alternatives, and adjusting the time interval between medications.

“I intervene in situations like painkillers and antacids… I try to suggest alternatives.” — (P1).

"Older patients come and ask for a painkiller without a prescription… I try to be very careful because they may already be on blood thinners or have kidney problems." (P7).

“I usually stop that medication… or tell them to reduce the frequency… I try to suggest a different, less risky group.” — (P3).

Some participants emphasized the importance of timing adjustments, especially when using medications together:

“Using thyroid medications and antacids together… there needs to be a certain amount of time between them… we play a role.” — (P9).

These statements show that pharmacists can take a more active and guiding position in situations where risk perceptions are high.

Communication-based adherence support

Some participants stated that a significant part of treatment management in older patients was conducted through communication. Repeating the same information, simplifying usage instructions, and involving family members when necessary were identified as intervention practices.

“You patiently explain the same thing to the patient three or four times.” (P3).

“We call a relative and talk to them.” (P7).

Some participants also stated that they indirectly organized the information the patient needed to convey to the physician:

“I tell the patient… tell them this and that when they go to the physician.” (P3).

Theme 3: barriers encountered in practice

Participants did not consider the difficulties encountered in the medication management of older patients to be limited only to the large number of medications. In the interviews, patterns of medication use, difficulties in understanding and application, and limitations related to the health system were mentioned together. The presence of these elements together creates a structure that makes it difficult to carry out the treatment process and safely use medications.

Inappropriate medication use behaviors

Some participants stated that polypharmacy in older patients is related not only to the number of prescribed medications but also to problems arising from how medications are used. In particular, behaviors such as consulting different physicians, reusing the same active ingredient, taking medications together, and changing treatment on one's own decision were frequently mentioned. Some participants stated that multiple physician visits increased their medication burden:

“They go to one, are not satisfied, go to another… it can become an unnecessary pile of medications.” (P1).

Some participants stated that the same active ingredient was reused in different boxes:

“Another box of the same medication… they also use the old medication. Sometimes they use two cholesterol medications.” (P7).

Participants also reported that some older patients took multiple medications simultaneously without considering the dosing schedules:

“I empty them all into my hand, there are 10 pills, and I swallow them.” (P6; describing a patient).

It was stated that some patients changed their treatment according to their own assessments:

“They stop using what they used to use on their own.” (P6).

Cognitive and health literacy challenges in patients

A significant number of participants stated that older adults experienced difficulties in understanding the purpose of medications, following the timing instructions, and distinguishing between medications. These difficulties were described as factors that made it difficult to apply the information provided by the pharmacist.

Some participants pointed to direct comprehension and hearing problems:

“Most of them do not understand. Some don't hear.” (P3).

It was stated that some patients mixed up medications:

“They don't know very well what medication it is… I have patients who mix them up and use them incorrectly.” (P4).

It was also stated that timing instructions could not be maintained:

“Take it in the morning, take it in the evening… they can’t adapt.” (P10).

Some participants emphasized that the same information had to be explained more than once:

“I patiently explains it 3 or 4 times.” (P3).

Systemic and socioeconomic barriers

Participants stated that the factors that make treatment management difficult are not limited to patient behavior; some limitations related to the health system and working conditions also affect the process.

It was stated that direct communication with the physician was not always possible:

“It is very difficult for us to reach the physician directly.” (P1).

Some participants stated that patients trust the physician more than the pharmacist, which can complicate the intervention process:

“Patients trust the physician much more than the pharmacist these days.” (P10).

Work intensity was also mentioned as a limitation:

“We struggle because our time with the patient is short.” (P8).

In addition, some participants stated that living alone and financial difficulties could affect treatment follow-up:

“There are also 80-year-old patients living alone.” (P1).

“We generally have financial difficulties with the older patients.” (P2).

Discussion

This study examined the experiences of community pharmacists in Türkiye regarding medication management in older adults, revealing their roles, intervention practices, and challenges in this process. Participants varied in their years of professional experience and practice contexts, contributing to a diverse range of viewpoints regarding medication management in older adults. The findings were structured around three main themes: perceived of professional competence, pharmacist intervention practice, and barriers encountered in practice. When these themes are considered together, it is seen that community pharmacists undertake an important counseling and monitoring role in geriatric pharmacotherapy; however, this role is significantly shaped by patient behaviors, professional limitations, and structural factors related to the health system. This finding is consistent with studies in the literature showing that community pharmacists have an important position in the safe management of medication therapy in older adults, but this role is often carried out within the framework of systemic and professional limitations [20, 34].

The first theme, perceptions of professional competence, showed that participants evaluated their professional knowledge and skills regarding the management of medication in older adults as "adequate but limited.” Participants particularly emphasized that polypharmacy, drug interactions, and multiple disease states complicate geriatric pharmacotherapies. This reflects the broader literature describing medication use in older adults as inherently complex due to multimorbidity, multiple prescribers, and overlapping treatment regimens [7, 8, 35]. Indeed, polypharmacy is common in older populations, and the use of multiple medications is considered a significant risk factor for adverse drug reactions, drug interactions, and non-adherence [8]. Therefore, geriatric pharmacotherapy is defined as a field that requires not only knowledge of medications but also clinical evaluation and monitoring of medication combinations.

Participants frequently emphasized the need to keep knowledge up-to-date and refer to resources when necessary, indicating that medication management in older adults is perceived as a dynamic and evolving field of knowledge. In Türkiye, community pharmacists routinely use electronic prescription systems and integrated drug interaction modules in their daily practice, which support medication safety monitoring and patient counselling [36]. International pharmaceutical organizations state that the role of pharmacists in geriatric pharmacotherapy is not limited to medicine supply; it also includes responsibilities such as medication review, supporting adherence, and monitoring medication safety [6]. In this context, the participants’ emphasis on professional development is consistent with studies highlighting the importance of continuing professional education in the medication management of older adults [5].

Studies conducted in Türkiye also show that community pharmacists are positioned as important health consultants for older adults. For example, previous research has reported that community pharmacists play an important role for older patients, especially in counselling on medication use, identifying medication-related problems and supporting treatment adherence [37]. Taken together, these findings suggest that community pharmacists’ perceived competence in medication management for older adults is shaped by continuous learning, clinical experience, and access to appropriate information resources.

The second theme, pharmacist intervention practice, showed that community pharmacists play an active but cautious role in the medication management of older adults. Participants stated that they provided active counseling, especially in situations perceived as high-risk, such as drug interactions, misuse, or unnecessary medication use. This finding is consistent with studies showing that pharmacists play an important role in identifying and resolving medication-related problems in older adults. In particular, medication review services have been shown to reduce medication-related problems and increase treatment safety in older patients [13]. Studies have also shown that pharmacist interventions can improve treatment adherence and reduce medication-use errors [21, 38, 39].

However, another finding of the study was the pharmacists’ tendency to avoid direct intervention, especially in chronic treatments. Participants reported that they often preferred to refer patients to a physician rather than changing the treatment themselves. This indicates that pharmacists carefully evaluate their professional responsibilities and consider formal treatment decisions to be the responsibility of physicians. Furthermore, participants highlighted that direct communication with physicians is not always feasible in practice, which may, in some cases, result in patient-mediated communications. This represents a systemic challenge with potential implications for patient safety and interprofessional collaboration in the Turkish healthcare system. The literature also emphasizes that physician-pharmacist collaboration should be strengthened so that pharmacists can play a more effective role in clinical interventions [40]. Studies examining communication between community pharmacists and physicians show that limited or informal communication between these professional groups can create a significant barrier to medication management [41, 42]. In this context, the present findings highlight the need for structured communication channels and clear agreements about roles and responsibilities to support pharmacists’ contributions to medication management in older adults [43, 44].

The third theme, barriers encountered in practice, showed that medication management in older adults is too multifaceted to be explained solely by pharmacological knowledge alone. Participants specifically stated that inappropriate medication use behaviors, cognitive difficulties, and systemic limitations complicate the treatment process. Certain age-related geriatric syndromes, particularly cognitive impairment, significantly reduce the capacity of older adults to participate in healthcare [45]. The findings show that polypharmacy is not only about using a large number of medications; it is also associated with behaviors such as taking medications at the wrong times, using medications prescribed by different physicians together, and changing treatment regimens based on personal judgement. This pattern resembles “real-life polypharmacy” described in the literature, in which overlapping prescriptions, multiple prescribers, and patient-led regimen changes create complex and sometimes unsafe medication use trajectories [8, 46].

Cognitive and practical difficulties also emerged as a significant barrier. Participants stated that older patients may have difficulty understanding medication instructions, confuse the timing of doses, or not remember the indication for which medications are used. These findings are consistent with those of studies showing that health literacy significantly impacts treatment adherence in older adults [47]. Low health literacy can make it difficult to follow medication instructions correctly and increase the risk of medication errors [48].

Finally, this study showed that structural and systemic limitations significantly affected pharmacist interventions. Participants reported that direct communication with physicians was often difficult, that patients frequently trusted physicians more than pharmacists, and that pharmacy workloads limited the time available for counselling older adults. Similar barriers have been reported in other settings, where community pharmacists’ ability to provide cognitive services is constrained by reimbursement structures, staffing levels, and regulatory frameworks [49]. This suggests that for pharmacists to play a more effective role in medication management in older adults, not only individual training but also structural arrangements that strengthen interdisciplinary communication and support pharmacist-led services are necessary. More effective integration of community pharmacists into multidisciplinary care teams can provide important gains in terms of medication safety and treatment adherence [20, 21, 40, 42].

The quality of this study was strengthened by several interrelated strategies. The consistency of themes across participants from two geographically distinct cities — Rize and Erzurum — supports the credibility of the findings, as similar patterns regarding pharmacists' roles, barriers, and intervention practices emerged independently across different practice contexts. Transferability is further facilitated by the detailed description of the study setting, participant characteristics, and health-system context provided throughout the manuscript, enabling readers to assess the relevance of the findings to other community pharmacy settings. Reflexivity was particularly salient in this study, given that the interviewer (C.C.) had a professional background in pharmacy. A continuous critical examination of how this background may have shaped the interpretation of pharmacists' accounts of their limitations and intervention boundaries was maintained throughout the data collection and analysis. Together, these strategies — grounded in the COREQ-32 reporting framework — reflect a coherent approach to ensuring rigor in a qualitative single-case design.

Study limitations

The findings of this study should be interpreted in light of its limitations. First, the study was designed as qualitative research and was based on semi-structured interviews conducted with a limited number of community pharmacists from two cities. Therefore, the findings cannot be generalized to all community pharmacists; however, the aim of qualitative research is not statistical generalization but to provide in-depth insight into participants’ experiences and the underlying patterns of meaning. Second, the study was conducted in community pharmacies located in two medium-sized cities in Türkiye, within a health system where the clinical role of community pharmacists in geriatric medication management is still evolving, and opportunities for structured collaboration and continuing professional education are limited. These context‑specific characteristics, together with the sociodemographic profile of the local older population (including constrained financial resources and variable health literacy), may have influenced pharmacists’ perceptions of their professional competence, the types of interventions they described, and the barriers they emphasized; therefore, experiences of community pharmacists working in other regions or health‑system contexts may differ. Future qualitative and mixed-methods studies conducted in different cities or socioeconomic contexts could contribute to a broader understanding of experiences related to medication management in older adults. Third, this study focused only on the perspectives of community pharmacists. Since medication management in older adults is a multidisciplinary process, studies that include the perspectives of other stakeholders, such as physicians, nurses, older adults, and family caregivers, may contribute to a more comprehensive understanding of this process. Additionally, the reasons for missed doses reported by older adults, as described by the pharmacist participants, were not directly verified with the patients themselves. Pharmacists' accounts reflect their observations and perceptions rather than patients' self-reported experiences, which is a recognized limitation in studies relying on proxy reports of medication behavior [50].

Implications for practice and policies

The findings of this study demonstrate that community pharmacists can play a significant role in the safe and effective management of medications in older adults. The participants' accounts show that pharmacists can make important contributions, particularly in evaluating potential drug interactions, explaining medication use, and supporting adherence. Strengthening the advisory role of community pharmacists in older adult care, for example, through structured medication review services, may improve the quality and safety of healthcare [51].

Simultaneously, the findings show that pharmacists’ intervention capacity is often limited by systemic constraints. Factors such as communication difficulties with physicians and high workloads can limit the duration of counselling for older adults. Therefore, developing communication mechanisms that support pharmacist-physician collaboration, such as formal consultation pathways or shared documentation systems, may significantly improve medication management in older adults [52]. Considering the complexity of geriatric pharmacotherapy, continuing professional education programs for community pharmacists are warranted. Structured training on polypharmacy management, drug–drug interactions, and communication with older adults could directly address the competency gaps identified in this study. To overcome systemic barriers, such as limited pharmacist–physician communication, the establishment of structured referral pathways and regular case-based communication channels between pharmacists and prescribers would be a practical step. Regarding workload constraints, the integration of brief structured medication review tools into routine dispensing practice could allow pharmacists to identify high-risk older patients more efficiently without requiring extended consultation times. Finally, to address health literacy and medication-use challenges in older adults, pharmacists could adopt simplified written instructions, visual or color-coded labelling, and routinely involve family members or caregivers in medication counselling [53].

Conclusion

Community pharmacists in Türkiye play an important but constrained role in the medication management of older adults. They support medication safety by recognizing potential drug–drug interactions, reinforcing adherence, and counselling older adults about medication use; however, their contribution is shaped by patient behaviors, professional limits, and structural conditions in the health system. The findings indicate that medication management in older adults cannot be explained solely by the number or pharmacological properties of the prescribed medications. Participants highlighted inappropriate medication-use behaviors, timing errors, cognitive and practical difficulties, low health literacy, communication problems with physicians, and workload-related constraints as key barriers. Medication management in older adults thus emerges as a multidimensional field that requires not only pharmacological knowledge but also communication, education, monitoring, and coordination. Pharmacists' interventions were described as situational: they provided more active counselling in high-risk situations, such as potential interactions, misuse, or risky medication choices, but tended to avoid directly changing chronic treatments and instead referred patients back to physicians. This suggests that community pharmacists maintain an important clinical awareness and observation role, which is often expressed through counselling and guidance rather than direct modification of therapy. To strengthen the role of community pharmacists in the care of older adults, it is crucial to expand continuous professional training in polypharmacy management, geriatric pharmacotherapy, and communication with older adults, and to develop structural mechanisms that facilitate pharmacist–physician communication. In the context of a rapidly aging population and increasingly complex medication use patterns, supporting professional practices and collaborative care models that enhance community pharmacists' involvement in geriatric pharmacotherapy may promote safer and more rational medication use among older adults.

Appendix 1

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist. Developed from: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349 – 357.

Item No	Guide Questions/Description	Reported on Page #
Domain 1: Research team and reflexivity
Personal istics
1. Interviewer/ facilitator	Which author/s conducted the interview or focus group?	Pg 9
2. Credentials	What were the researcher’s credentials? E.g., PhD, MD	Pg 9
3. Occupation	What was their occupation at the time of the study?	Pg 9
4. Gender	Was the researcher male or female?	Pg 9
5. Experience and training	What experience or training did the researcher have?	Pg 9
Relationship with participants
6. Relationship established	Was a relationship established prior to study commencement?	Pg 9
7. Participant knowledge of the interviewer	What did the participants know about the researcher? e.g. personal goals, reasons for doing the research?	Pg 9
8. Interviewer characteristics	What characteristics were reported about the interviewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic	Pg 9
Domain 2: study design
Theoretical framework
9. Methodological orientation and Theory	What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis	Pg 7-8
Participant selection
10. Sampling	How were participants selected? e.g., purposive, convenience, consecutive, snowball	Pg 9
11. Method of approach	How were participants approached? e.g., face-to-face, telephone, mail, email	Pg 8
12. Sample size	How many participants were in the study?	Pg 12
13. Non-participation Setting	How many people refused to participate or dropped out? Reasons?	N/A
14. Setting of data collection	Where was the data collected? e.g., home, clinic, workplace	Pg 8
15. Presence of nonparticipants	Was anyone else present besides the participants and researchers?	N/A
16. Description of sample	What are the important characteristics of the sample? e.g. demographic data, date	Pg 12, 34
Data collection
17. Interview guide	Were questions, prompts, and guides provided by the authors? Was it pilot tested?	Pg 8-9
18. Repeat interviews	Were repeat interviews carried out? If yes, how many?	N/A
19. Audio/visual recording	Did the research use audio or visual recording to collect the data?	Pg 10
20. Field notes	Were field notes made during and/or after the interview or focus group?	Pg.10
21. Duration	What was the duration of the interviews or focus group?	Pg 12
22. Data saturation	Was data saturation discussed?	Pg 9-10, Pg 12
23. Transcripts returned	Were transcripts returned to participants for comment and/or correction?	N/A
Domain 3: analysis and findings
Data analysis
24. Number of data coders	How many data coders coded the data?	Pg 10-11
25. Description of the coding tree	Did the authors provide a description of the coding tree?	Pg 10-11
26. Derivation of themes	Were themes identified in advance or derived from the data?	Pg 10-11
27. Software	What software, if applicable, was used to manage the data?	Pg 10
28. Participant checking	Did participants provide feedback on the findings?	N/A
Reporting
29. Quotations presented	Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g., participant number	Pg 12-18
30. Data and findings consistent	Was there consistency between the data presented and the findings?	Pg 12-18
31. Clarity of major themes	Were major themes clearly presented in the findings?	Pg 12-18, 35
32. Clarity of minor themes	Is there a description of diverse cases or a discussion of minor themes?	Pg 12-18, 35

Appendix 2

Interview questions

1. What is your age?

2. How often do you encounter older adults in your daily practice? (To determine the frequency of access to services for older adults)

3. What kinds of situations do you encounter regarding polypharmacy in older adults? (To understand your observations regarding polypharmacy)

4. What kinds of negative effects do you encounter due to the use of multiple medications? (Health risks, interactions, drug side effects)

5. How do you intervene when you encounter unnecessary medication use? (To determine application strategies)

6. Have you ever contacted a physician? How did the process work? (To examine interdisciplinary communication)

7. How do you act in situations where you have a disagreement with a physician? (To evaluate ethical dilemmas and professional boundaries)

8. Have you ever faced ethical challenges when intervening in polypharmacy? (Ethical evaluation within the triangle of patient autonomy, physician decisions, and patient safety)

9. What difficulties do you encounter when communicating with older adults? (Health literacy, cognitive impairments, communication barriers)

10. Do you think you have sufficient knowledge and skills regarding polypharmacy? (Education needs and professional competency assessment)

11. Do you have any suggestions for professional development in this area? (For policy, training, and guideline suggestions)

12. Do you have any other experiences or opinions you would like to add?

Authors’ contributions

EUD conceived and designed the study, developed the interview guide, conducted the interviews, and performed the initial data analysis. CC contributed to data analysis and interpretation and assisted in refining the themes. Both authors contributed to drafting the manuscript, critically revised the manuscript for important intellectual content, and approved the final version of the manuscript.

Funding

This research did not receive any specific grants from any funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the qualitative nature of the data and the need to protect participants’ confidentiality but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Atatürk University Clinical Research Ethics Committee (Approval No: [2500137727], Date: [28 April 2025]). All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee and the principles of the Declaration of Helsinki. Informed consent was obtained from all participants prior to their participation in the study.

Informed consent was obtained from all participants before data collection.

Competing interests

The authors declare no competing interests.