Background Medication nonadherence is a common problem among the elderly. Objective To conduct a systematic review of the published literature describing potential non-financial barriers to medication adherence among the elderly. Methods The PubMed and PsychINFO databases were searched for articles published in English between January 1998 and January 2010 that described “predictors,” “facilitators,” or “determinants” of medication adherence and those articles that examined the “relationship” between a specific barrier and adherence for elderly patients (ie, age ≥ 65 years) in the United States (U.S.). A manual search of the reference lists of identified articles and the authors’ files and recent review articles was conducted. The search included articles that (1) reviewed specific barriers to medication adherence and did not solely describe nonmodifiable predictors of adherence (eg, demographics, marital status); (2) were not interventions designed to address adherence; (3) defined adherence or compliance and specified its method of measurement; (4) involved U.S. participants only. Non-systematic reviews were excluded, as were studies that focused specifically on people who were homeless or substance abusers, or patients with psychotic disorders, tuberculosis, or Human Immunodeficiency Virus (HIV), because of the unique circumstances that surround medication adherence for each of these populations. Results Nine studies met inclusion criteria for this review. Four studies used pharmacy records/claims data to assess adherence, 2 studies used pill count/electronic monitoring, and 3 studies used other methods to assess adherence. Substantial heterogeneity existed among the populations studied as well as among the measures of adherence, barriers addressed, and significant findings. Some potential barriers (ie, factors associated with nonadherence) were identified from the studies, including patient-related factors such as disease-related knowledge, health literacy, and cognitive function, drug-related factors such as adverse effects and polypharmacy, and other factors including the patient-provider relationship and various logistical barriers to obtaining medications. None of the reviewed studies examined primary nonadherence or nonpersistence. Conclusion Medication nonadherence in the elderly is not well described in the literature, despite being a major cause of morbidity, and thus it is difficult to draw a systematic conclusion on potential barriers based on the current literature. Future research should focus on standardizing medication adherence measurements among the elderly in order to gain a better understanding of this important issue.

Objectives To describe the prevalence of unplanned hospitalizations caused by ADRs among older Veterans and examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics. Design Retrospective cohort. Setting Veterans Affairs Medical Centers (VAMC). Participants 678 randomly selected unplanned hospitalizations of older (age ≥ 65 years) Veterans between 10/01/03 and 09/30/06. Measurements Naranjo ADR algorithm, ADR preventability, and polypharmacy (0–4, 5–8, and ≥ 9 scheduled medications). Results Seventy ADRs involving 113 drugs were determined in 68 (10%) older Veterans’ hospitalizations, of which 36.8% (25/68) were preventable. Extrapolating to the population of over 2.4 million older Veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n=6; beta blockers, digoxin), hypoglycemia (n=6; sulfonylureas, insulin), falls (n=6; antidepressants, ACE-inhibitors), and mental status changes (n=6; anticonvulsants, benzodiazepines). Overall, 44.8% of Veterans took ≥ 9 outpatient medications and 35.4% took 5–8. Using multivariable logistic regression and controlling for demographic, health status, and access to care variables, polypharmacy (≥ 9 and 5–8) was associated with an increased risk of ADR-related hospitalization (AOR 3.90, 95% CI 1.43–10.61 and AOR 2.85, 95% CI 1.03–7.85, respectively). Conclusion ADRs determined by a validated causality algorithm are a common cause of unplanned hospitalization among older Veterans, are frequently preventable, and are associated with polypharmacy.

Background Osteoarthritis (OA) is the most common cause of disability in older adults, and while analgesic use can be helpful its use can also result in adverse drug events. Objective To review the recent literature to describe potential adverse drug events (ADEs) associated with analgesics commonly used by older adults with OA. Methods To identify articles for this review, a systematic search of English-language literature (January 2001 – June 2012) was conducted using PubMed, MEDLINE, EBSCO, and the Cochrane Database of Systematic Reviews for publications related to the medical management of osteoarthritis. Searches used a combination of the following search terms: analgesics, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, pharmacokinetics, pharmacodynamics and adverse drug events. We also restricted the search to those papers concerning humans ≥65 years of age. A manual search of the reference lists from identified articles and the authors’ article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that examined analgesic use in older adults. Results There are limited data to suggest that non-frail elders are more likely than their younger counterparts to develop acetaminophen-induced hepatotoxicity. However, decreased hepatic Phase 2 metabolism in frail elders may result in an increased risk of hepatotoxicity. Regarding NSAIDs, it is now well-established that older adults are at higher risk for NSAID-induced gastrointestinal toxicity and renal insufficiency. For opioids, the data suggesting an increased risk of falls/fractures/delirium need to be tempered by the potential risk of inadequately treating severe chronic OA pain. Conclusions Acetaminophen is the mainstay frontline analgesic for OA pain in older adults. NSAIDs should be limited to short-term use only, and for moderate to severe OA pain, opioids may be preferable in those without substance abuse or dependence issues.

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Background Information about the about the prevalence and correlates of self-reported medication nonadherence using multiple measures in older adults with chronic cardiovascular conditions is needed. Objective To examine the prevalence and correlates of self-reported medication nonadherence among community-dwelling elders with chronic cardiovascular conditions. Methods Participants (n=897) included members from the Health, Aging and Body Composition study with coronary heart disease, diabetes mellitus, and/or hypertension at year 10. Self-reported nonadherence was measured by the 4-item Morisky Medication Adherence Scale (MMAS-4) and 2-item cost-related nonadherence (CRN-2) scale at year 11. Factors (demographic, health status, and access to care) were examined for association with the MMAS-4 and then for association with the CRN-2 scale. Results Nonadherence per the MMAS-4 and CRN-2 scale was reported by 40.7% and 7.7% of participants, respectively, with little overlap (3.7%). Multivariable logistic regression analyses found that black race was significantly associated with nonadherence per the MMAS-4 (p=0.002) and the CRN-2 scale (p=0.005). Other correlates of nonadherence per the MMAS-4 (with independent associations) included having cancer (p=0.04), a history of falls (p=0.02), sleep disturbances (p=0.04) and having a hospitalization in the previous 6 months (p=0.005). Conversely, being unmarried (p=0.049), having worse self-reported health (p=0.04) and needs being poorly met by income (p=0.02) showed significant independent associations with nonadherence per the CRN-2 scale. Conclusions Self-reported medication nonadherence was common in older adults with chronic cardiovascular conditions and only one factor – race – was associated with both types. The research implication of this finding is that it highlights the need to measure both types of self-reported nonadherence in older adults. Moreover, the administration of these quick measures in the clinical setting should help identify specific actions such as patient education or greater use of generic medications or pill boxes that may address barriers to medication nonadherence.

Objectives We aimed to assess the prevalence of opioid and benzodiazepine prescription drug misuse in older adults, the risk factors associated with misuse, and age-appropriate interventions. Methods Following PRISMA guidelines, we conducted a literature search for reports on misuse of prescription benzodiazepines and opioids in older adults. We searched PubMed, PsycINFO, and EMBASE for peer reviewed journal articles in English through April 2014 with updates through November 2015. We reviewed relevant publications that included participants ≥ 65 years of age. We also manually searched reference lists of key identified articles and geriatric journals through April 2016. Information on the study design, sample, intervention, comparators, outcome, time frame, and risk of bias were abstracted for each article. Results Of 4932 reviewed reports, 15 were included in this systematic review. Thirteen studies assessed the prevalence of prescription drug misuse and included studies related to opioid shopping behavior, assessment of morbidity and mortality associated with opioid and/or benzodiazepine use, frequency and characteristics of opioid prescribing, frequency of substance use disorders and non-prescription use of pain relievers, and the health conditions and experiences of long-term benzodiazepine users. One study identified risk factors for misuse and one study described the effects of provider education and an electronic support tool as an intervention. Discussion There is a dearth of high quality research on prescription drug misuse in older adults. Existing studies are heterogeneous, making it difficult to draw broad conclusions. We discuss the need for further research specific to prescription drug misuse among older adults.

BACKGROUND: Numerous interventions are available to boost medication adherence, but the targeting of these interventions often relies on crude measures of poor adherence. Group-based trajectory models identify individuals with similar longitudinal prescription filling patterns. Identifying distinct adherence trajectories may be more useful for targeting interventions, although the association between adherence trajectories and clinical outcomes is unknown. OBJECTIVE: To examine the association between adherence trajectories for oral hypoglycemics and subsequent hospitalizations among diabetes patients. DESIGN: Retrospective cohort study. PATIENTS: A total of 16,256 Pennsylvania Medicaid enrollees, non-dually eligible for Medicare, initiating oral hypoglycemics between 2007 and 2009. MAIN MEASURES: We used group-based trajectory models to identify trajectories of oral hypoglycemics in the 12 months post-treatment initiation, using monthly proportion of days covered (PDC) as the adherence measure. Multivariable Cox proportional hazard models were used to examine the association between trajectories and time to first diabetes-related hospitalization/emergency department (ED) visits in the following year. We used the C-index to compare prediction performance between adherence trajectories and dichotomous cutpoints (annual PDC <80 vs. ≥80 %). RESULTS: The mean annual PDC was 0.58 (SD 0.32). Seven trajectories were identified: perfect adherers (9 % of the cohort), nearly perfect adherers (31.4 %), moderate adherers (21.0 %), low adherers (11.0 %), late discontinuers (6.8 %), early discontinuers (9.7 %), and non-adherers with only one fill (11.1 %). Compared to perfect adherers, trajectories of moderate adherers (HR = 1.48, 95 % CI 1.25, 1.75), low adherers (HR = 1.51, 95 % CI 1.25, 1.83), and non-adherers with only one fill (HR = 1.35, 95 % CI 1.09, 1.67) had greater risk of diabetes-related hospitalizations/ED visits. Predictive accuracy was improved using trajectories compared to dichotomized cutpoints (C-index = 0.714 vs. 0.652). CONCLUSIONS: Oral hypoglycemic treatment trajectories were highly variable in this large Medicaid cohort. Low and moderate adherers and those filling only one prescription had a modestly higher risk of hospitalizations/ED visits compared to perfect adherers. Trajectory models may be valuable in identifying specific non-adherence patterns for targeting interventions.

BACKGROUND/OBJECTIVES Guideline‐based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties. DESIGN National cross‐sectional survey. SETTING Ambulatory. PARTICIPANTS Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians. MEASUREMENTS Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases. RESULTS In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists). CONCLUSIONS While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician‐physician and physician‐patient communication. J Am Geriatr Soc 68:78–86, 2019