“I came up with a scheme where I keep the medicines on one side of my microwave … When I take it, I put it on the other side,” said one participant in an interview study, when asked to describe her daily medication routine.
“I have what I call my staging area, which is an area between my kitchen and my dining room. [My medication] stays in the [staging area] and since I take that medication right after dinner, it’s right there,” said another.
These two responses highlight a striking finding from our recent interview study aimed at investigating home medication management among older adults: medication management routines of older adults are highly varied, and more complex than you might expect.
Older adults are the most likely age group to take prescription medication. The CDC found that 67.1% of U.S. adults ages 45–64 take prescription drugs, a percentage that rises to 88.5% in people ages 65 years and older. However, medication adherence—taking medication as prescribed—is estimated at about 50% in the United States.
Medication nonadherence contributes to more than 125,000 preventable deaths each year, in addition to 33%–69% of hospital admissions. In our study we sought to understand the factors contributing to nonadherence in home medication management, specifically focusing on how older adults manage their medication in their homes.
For this purpose, we conducted in-depth interviews via Zoom with 22 older adults, asking them to walk us through their day from the perspective of taking their medication. From storage to refilling to reminders to take medication, participants varied considerably in methods for remembering.
Almost All Interviewees Used Pill Cases
A typical 7-day compartment pill case was the most common tool used to store medication, however, the day of the week and frequency of refilling the pill cases varied significantly. Because the typical pill case has “Sunday” as the first slot, we had assumed people would refill on the weekend, but this was not the case, and many people didn’t even refill the case on a consistent day each week. For instance, one participant said:
“When I get to the point where something is empty, and I say, ‘Oh, time to refill.’ It should be every 7 days, but sometimes I might forget. Or I don't know why. But it doesn’t always work out to be every 7 days. But anyway, whenever they’re empty, then they need to be refilled.”
‘One participant had a strict refilling routine each Sunday, and even had a second pill case to use once her first had run out.’
In contrast, another participant had a strict refilling routine each Sunday, and even had a second pill case to use once his first had run out:
“I have two different sets [of pill cases]. So, I always have one in reserve in the closet with the bottles of the pills. I can easily take [the medication] on Sunday. I don’t have to wait ‘til I fill them in order to take pills [because] I already have a set ready. Usually after breakfast or when I have a chance during the day on Sunday, I'll go ahead and fill the one that I’ve just emptied in the previous week and put it in the closet.”
Routines Were Unique
As apparent in the two anecdotes at the start of this article, which involved moving medication to different sides of the microwave or having a “staging area” for medication, participants had different strategies to remember to take their medicine. Interestingly, lots of routines revolved around mealtimes, such storing the pill box on the kitchen counter and using it as a visual cue to take the medication at breakfast or dinner. Other visual cues included keeping the medication on the bathroom counter or nightstand, to prompt them to take the medication when waking up or going to bed.
These visual cues highlight an important point: routine-based reminders are preferred to time-based reminders, as not many people wake up or eat a meal at the exact same time every day. Only three study participants used some form of time-based reminder, such as a phone alarm or Alexa device and none used the variety of smart medication containers and dispensers that are designed specifically to assist with adherence.
However, the reliance upon routines has its limitations, and a disruption in routine appears to be one of the key contributors to medication nonadherence.
Routine Disruptions and Forgetting to Take Medication
Forgetting medication while at home typically happened because of a disruption such as a poor night’s sleep or an early morning phone call.
For example, one participant recalled: “If I have to go somewhere first thing in the morning, that’s a typical time when I forget. Because sometimes I don’t even have time for breakfast or for one reason or another didn’t get around to it.”
Travel frequently came up as an issue for medication adherence, understandably, given the change in routine and in location.
“I have occasionally forgotten. Frankly, it’s when I'm on vacation; even though I have them in the [weekly pill case], my routine is different on vacation. It [the pill case is] not in my kitchen on vacation.”
One participant forgot to pack his medication on his vacation.
Perceptions of Medication
The medication adherence literature we reviewed prior to our interviews focused on prescription medication, but we quickly learned that people in our study thought about their medication as what their doctor prescribed, what their doctor recommended (like vitamin D), and what they had learned about on their own or from a friend, such as turmeric. Study participants developed routines around everything they took, prescribed or not.
‘A disruption in routine appears to be one of the key contributors to medication nonadherence.’
We asked people how they described their medication, and more subjects used the chemical name, followed by those who used appearance, purpose, or generic name. While not a significant point as part of our investigation into medication management, it may be confusing when changes occur, such as doses, or a changed name to a generic version of the same drug.
What We Learned
Through our interview study, we learned about the medication management routines among 22 older adults. Much of what we learned may be applicable to other older adults, or to other medication-taking adults of any age. Our study revealed that home medication management among older adults is complex and highly variable. From pill boxes to visual cues and routine-based reminders, participants use a wide range of tools to help them remember medications and these are mostly selected through trial-and-error rather than physician or pharmacist guidance. Travel or a disruption to routine, such as waking up late, can lead to medication nonadherence.
Given that medication adherence in the United States is a meager 50% and a significant contributor to preventable deaths and hospitalizations, it is imperative to understand how older adults—the population taking the most prescription medications—manage their medications.
We think one of the ways to increase adherence is through more guidance from doctors or pharmacists about how to establish a durable medication routine. The older adults we interviewed wanted such guidance, and it matched what we learned in an earlier study we did, in which 96% of middle-aged and older adult participants expressed the desire to have more time with their doctors and pharmacists to discuss medication management with the people who best know their health history. Although this isn’t a Band-Aid to the problem of medication nonadherence; it may be a way of reducing trial-and-error and easing the process of taking a first medication, as well as helping when medications are added to a regimen.
Lisa Gualtieri, PhD, is an associate professor in Public Health and Community Medicine at Tufts University School of Medicine and teaches at the Harvard T.H. Chan School of Public Health and in the Master of Science in Health System at Cedars-Sinai. As a Computer Science and Psychology undergraduate at Tufts University, Tilly Rigby worked alongside Dr. Gualtieri as a research assistant. She is completing her master’s degree in Biomedical Informatics at Harvard Medical School.
The study: Medication Management Strategies of Older Adults to Support Medication Adherence: Results from an Interview Study, was recently published in the Journal of Medical Research (JMIR).
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