>G~MENsz 
- 
CAUSES  OF  NONCOM~L~ANCE 
OFFICE OF INSPECTOR GENERAL 
OFFICE OF EVALUATION AND IJ5iSPECTIONS 
I 
JUNE  1990  OFFICE OF INSPECTOR GENERAL 
The mission of the Ofice of Inspector General (OIG) is to promote the efficiency, 
effectiveness, and integrity of programs in the United States Department of Health and Human 
Services (HHS).  It does this by developing methods to detect and prevent fraud, waste, and 
abuse.  Created by statute in 1976, the Office of Inspector General keeps both the Secretary 
and the Congress fully and currently informed about programs or management problems and 
recommends corrective action. The OIG perfoms its mission by conducting audits, 
investigations, and inspections with approximately 1,400 staff strategically located around the 
country. 
OFFICE OF EVALUATION AND INSPECTIONS 
This report is produced by the Office of Evaluation and Inspections (OEI), one of the three 
major offices within the OIG.  The other two are the Office of Audit Services and the Office of 
Investigations. Inspections are conducted in accordance with professional standards 
developed by OEI. These inspections are typically short-term studies designed to determine 
program effectiveness, efficiency, and vulnerabilities to fraud or abuse. 
, , 
Entitled "Medication Regimens: Causes of Noncompliancey't his report identifies why elderly 
people have  following instructions for prescription medication use. 
The study was carried out under the direction of Linda Herzog, Regional Inspector General, 
Office of Evaluation and Inspections, Atlanta Region. Participating in the project were the 
following people: 
ATLANTA  HEADQUARTERS 
Jean Dufresne  =cki  Greene  MEDICATION  REGIMENS; 
CAUSES  OF  NONCOMPL~ANCE 
Richard P. Kusserow 
INSPECTOR GENERAL 
- 
OEl-04-89-8912 1  JUNE  1990  - 
I 
EXECUTIVE SUMMARY 
PURPOSE 
The purpose of this inspection is to determine why elderly people fail to follow prescription 
medication regimens. 
BACKGROUND 
Failure to adhere to medication instructions, either willful or inadvertent, has been termed 
noncompliance with medication regimens.  Instances of noncompliance can include failing to 
initially fill a prescription, taking either more or fewer doses than instructed, and taking 
medications that have been prescribed for someone else. 
Writ research indicates that 55 percent of the elderly do not follow the medication 
regimens prescribed by their physicians. 
METHODS 
This inspection examines and summarizes extensive prior research in the area of 
noncompliance with medication regimensJt also draws on congressional testimony, reports 
issued by consumer groups involved with medication issues, and reports of government 
agencies concerned about the elderly, medications, and medical compliance. 
FIND1N  GS 
The consequences of noncompliance are serious and costly. 
Noncompliance with medication regimens can result in the increased use of medical resources 
such as nursing homes, hospitals, physician visits, and unnecessary treatment. Noncompliance 
with medication regimens may also result in therapeutic failure. For example, missed doses of 
cardiac anti-arrhythmics can lead to arrhythmia and cardiac arrest. 
There are many inter-related reasons for noncompliance. 
Reasons why elderly people fail to comply with medication ~gimenfsa ll into four main 
categories: 
Physiological factors: Loss of vision or heaxing can impede an elderly person's ability to 
read important information about his prescription or to hear instructions about his regimen. 
Mobility limits, type of disease, the presence of symptoms, memory loss, depression, and 
cognitive impairment are other physiological variables that can negatively affect compliance.  Behavioral factors:  These include social isolation, social and health beliefs, and economic 
condition. Many elderly people live alone.  Studies have shown that people who live alone 
more often fail to comply with medication regimens.  For those elderly on fixed, minimal 
incomes, the ability to purchase expensive medications may also be a factor in noncompliance. 
Treatment factors: These include the duration and complexity of the medication ~gimen. 
Compliance rates decrease when the treatment is long-term and when the regimen includes 
many different medications that must be taken concurrently. Other treatment factors include 
the type of medication prescribed, and the patient's perception of the medication. 
Health Care Providerkatient Interaction factors: These include how well the physician, 
the pharmacist, and the patient communicate with each other.  The quality and content of a 
physician's instructions, the content of a pharmacist's label, and the ability of a patient to ask 
questions can all affect compliance. 
Education is the key to improving compliance. 
Strategies to improve compliance include physicians and pharmacists better educating patients 
about their medication regimens. Effective counseling by the physician and pharmacist may 
be the single best intervention for patients with compliance problems.  Public education 
groups are also currently involved in informing and educating elderly citizens about 
medication issues.  Compliance aids such as medication reminder charts may be useful tools 
for patients with memory impairments, or patients on complex medication regimens. 
Attempts to improve compliance through educational and other behavioral strategies do work, 
as long as they are matched to the individual patient's needs.  There is evidence to suggest that 
kith the proper education and support the elderly can overcome compliance difficulties.  TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
.................................................. 
INTRODUCTION  1 
....................................................... 
FINDINGS  3 
MANYE LDERLYD O NOT COMPLYW .IT.H. .M.E.D.I.C.A.T.IO.N. .R.E.G.I.M.E.N.S.;. ............. 
THECONSEQUENCESARESERIOUS  3 
.................................... 
Extent of Medication Use  3 
................................ 
Frequency of Noncompliance  4 
............................ 
Consequences of Noncompliance  5 
THEREA RE MANY IN.T.E.R..-R.E.L.A.T.E..D.R .E.A.S.O..N.SF. O..R. ......................... 
NONCOMPLIANCE  6 
........................................ 
Physioiogical Factors  ..  6 
......................................... 
Behavioral Factors  9 
...................... 
Health Care Provider~Patienltn temction  12 
.................. 
EDUCATIOINS  THE BEST WAYT  O IMPROVE COMPLIANCE  15 
................. 
Educating Patients and Health Care Providers  15 
.................................... 
Using Compliance Aids  16 
............................... 
Compliance Can Be Improved  17 
APPENDIX  A 
.................... 
. 
Other 010 Studies of Elderly Medication Issues  .A  1 
APPENDIX B 
..................................................... 
Endnotes  8.1 
APPENDIX C 
.......................................... 
. 
Selected Bibliography  C  1  INTRODUCTION 
PURPOSE 
Research has shown that a significant proportion of elderly people do not correctly follow 
their physicians' instructions for taking prescribed medications.  The purpose of this study is 
to determine why elderly people may fail to follow prescription medication regimens: 
BACKGROUND 
In April 1989, the Office of Inspector General issued a report entitled "Medicare Drug 
Utilization Review" (ON-01-88-00980).  The report describes patterns of mismedication 
among elderly adults, identifies components of the drug delivery system that contribute to the 
problem, and describes drug utilization review (Dmin)te rventions that appear most 
promising to Medicare. 
This inspection is related to that April report. Its focus is noncompliance among the elderly 
with medication regimens. Willful and inadvertent noncompliance contribute significantly to 
the problem of mismedication. 
Appendix A lists additional studies related to medication and the elderly which have been 
completed, are underway.or are planned by the Office of Inspector General. 
DEFINITIONS 
Mismedication occurs when a patient fails to take medication as prescribed by his physician. 
This failure, either willful or inadvertent, is termed noncompliance. Noncompliance can 
include: 
failing to initially fill a prescription;  . 
failing to refill a prescription as directed; 
omitting a dose(s); 
over dosing; 
prematurely discontinuing medication; 
taking a dose at the wrong time; 
taking a medication prescribed for someone else; 
taking a dose with prohibited foods, liquids, and other medications;  taking outdated medications; 
taking damaged medications; 
storing medications improperly; and 
improperly using medication administration devices (e.g. inhalers.) 
METHODS 
This report is based on the findings of numerous researchers in the field of medical 
compliance. The number of original studies on compliance is itself extensive. The number of 
reviews of the literature now exceeds the number of original studies.'  This inspection draws 
on both the original research and the reviews for many of its findings.  The literam ranges 
from small, narrowly focused studies on aspects of noncompliance, to books which 
extensively discuss the elderly and their medication problems, including noncompliance.  In 
addition, various authors of the literature were contacted for information and clarification of 
issues. This report also draws on congressional testimony, reports issued by consumer groups 
involved with medication issues, and reports issued by government agencies which are 
concerned about the elderly, medications, and compliance. See Appendix C for a list of 
compliance-related literam reviewed for this inspection.  MANYE LDERLYD O NOT COMPLYW ITHM  EDICATION REGIMENS; 
THE CONSEQUENCEOSF  THEIRN  ONCOMPLIANCE ARE SERIOUS. 
Extent of Prescription Medication Use By fhe Elderly 
Adults aged 65 and over comprise approximately 12 percent of the United States population. 
but they consume 30 pexcent of all prescription medications dispensed By the year 2030, the 
proportion of elderly to the total population is expected to reach 23 percent.3 It is likely that 
their consumption of prescription medications will also rise, as more and more elderly come to 
rely on medications for management of chronicCdi sease. Eighty-six percent of the elderly 
have at least one chronic disease requiring medication!  The following table shows that those 
over 65 have a greater incidence of chronic disease which commonly requires medication 
therapy. 
I 
Extent of Chronic Disease 
Commonly Treated with Medication by Age Group  I 
I  I 
Under 45  45-54  65 and Over 
Arthritis  3%  27%  48% 
Hypertension  4%  25%  35% 
Heart Disease  3%  12%  30% 
Diabetes  3%  5%  10% 
Adapted from:  National Center for Health Statistics, C.A. Shoenborn and M. Marano, 1988 
"CmntE stimates from the National Health Interview Survey: United States 1987. 
Vital and Health Statistics Series 10, No. (PHS) 88-1594,P ublic Health Se~ce.W ashington: 
U. S. Government Printing Office. 
Then is heightened concern in the health care field about patients with chronic conditions. 
Their use of prescription medication shifts the mode of their treatment fiom direct medical 
care to continuous patient self-management? Ninety-five percent of the elderly live outside 
of institutions and are responsible for their own medications! 
One researcher found that 25 percent of elderly patients discharged fiom a hospital leccived 
7 
six or more prescriptions. 
A community-based sample showed that 25 percent of the elderly use four or more 
8 
prescriptions regularly.  The types of prescription medications most used by the elderly are: 
cardiovascular; 
diuretic; 
anti-infective; and 
9 
psychotropic. 
The American Association of Retired Persons (AARP) has estimated that the total amount 
spent by elderly persons for medications (including over-the-counter preparations) in a single 
year is over $9 billion. lo 
Frequency of Noncompliance Among the Elderly 
Prior research indicates that 55 percent of the elderly fail to comply in some way with their 
medication ~~imens."Po dell and Gary have suggested that one-third of the elderly always 
comply, one-third sometimes comply, and one-third never comply with their medication 
12 
regimens. 
An American Association of Retired Persons (AARP) survey of ambula&y elderly found that 
33 percent said they had prematurely discontinued a prescribed medication, and 14 percent 
fa 
failed to initially  a prescription at least once.') 
Noncompliance with medication regimens is a problem not only among the elderly. 
" 
Forty-three percent of the general population made errors in self-administration of their 
medications according to one study. However, the same study showed that 58 percent of the 
 medication^.'^ 
elderly made errors when taking their  In one of the early studies done on the 
subject of noncompliance, 26 percent of the elderly studied made errors which had potentially 
15 
serious consequences as judged by the patients' primary physicians. 
Rates of medication compliance are difficult to generalize. An individual patient's compliance 
behavior may not be consistent.  A patient may comply with one medication but not another.16 
Compliance behavior may change over time due to the patient's perceptions of efficacy of 
treatment and other factors.l7 
Methodological m~ulties  associated with conducting compliance studies may lead to an 
underestimation of the extent of the compliance problem l8 The development of electronic 
compliance monitoring &vices may help researchers, clinical trial investigators, and 
practicing physicians better track noncompliance in their patients.  Consequences of Noncompliance 
Of all age groups the elderly benefit the most from taking medications and risk the most from 
failing to take them properly.  The consequences are more serious, less easily detected, and 
19 
less easily resolved than in younger age groups. 
Noncompliance with medication orders can increase the use of medical resources. 
Across the general population it has been estimated that noncompliance with 
treatment for cardiovascular disease results in an excess of 125,000 deaths and 
several thousand hospitalizations per year.  (Six of the ten most frequently used 
drugs for patients 75 years and older are cardiova~cular.)~~ 
.  Up to 23 percent of nursing home admissions may be due to elderly patients' 
inability to self-administer medications21 
About 10 percent of ho  ital admissions may be due to poor patient compliance 
% 
with medication orders. 
Over a two-month period, researchers at a large teaching hospital found that 
drug-noncompliance-related hospital admissions for 23 patients accounted for 590 
hospital days and appmximately $60,000i n avoidable costs? 
Emergency care may be required if patients fail to take their medications properly. 
Increased physician visits may be required if, because of medication 
noncompliance, the patient's condition does not improve. If the physician is not 
aware of the noncompliance, higher doses or additional medications might be 
prescribed which are unnecessary and possibly dangerous.a 
Additional diagnostic tests may be ordered if, because of medication 
noncompliance, the patient's condition does not improve or worsens. 
Additional or unnecessary alternative treatments may be prescribed as a result of 
I 
noncompliance. 
There is documentation that medication noncompliance is directly related to therapeutic 
failure.  For instance: 
Missed doses of anti-glaucoma medications lead to optic nerve damage and 
blindness. 
Missed doses of cardiac anti-arrhythmics lead to arrhythmia and cardiac arrest, 
Missed doses of anti-hypertensives lead to rebound hypertension (sometimes worse 
than if no medication had been taken in the Errst place). 
Missed doses of antibiotics lead to recurrent infection and also to ,the emergence of 
25 
resistant micro-organisms.  The foregoing section described the adverse consequences of patients' failure to take 
medication as prescribed.  However, there is another side to the story. Noncompliance can 
reveal when a medication has been unnecessarily prescribed. The patient who has been 
prescribed an unnecessary medication may be better off if helshe does not comply, provided 
that the physician is aware of the noncom2 l iance.  Otherwise the physician may keep 
prescribing the unnecessary medication. 
THERE ARE MANY INTER-RELATEDR EASONS FOR NONCOMPLIANCE. 
One group of researchers identified over 200 variables that have been examined in relation to 
compliance with medical regimens."  This nport by the Office of Inspector General identifies 
those variables that have the most bearing on reasons why the elderly may fail to comply with 
their medication.r egimens.  These variables fall into four main categories: 
physiological factors 
behavioral factors 
treatment factors 
health care providerlpatient interaction. 
Despite the fact that the variables are discussed as separate classes, in practice they overlap 
substantially. They should not be viewed as independent. 
It is also important to keep in mind that age by itself is not a determining factor in 
noncompliance. Rather, the many factors discussed below may combine to render the elderly 
28 
less able to comply with their medication regimens. 
Finally, there is evidence to suggest that with the  roper motivation, education, and support, 
9 !
the elderly can overcome compliance 
Physiological Factors 
- 
Sensory Impairmenf: Well over a million older adults have impaired vision  a critical factor 
in compliance with prescription medication regimens.u) Loss of vision can impair reading 
and understanding of prescription labels and other printed instructions handed out by the 
physician or pharmacist. 
Fifty-four percent of partially sighted persons are estimated to be at least 65 years 
old.  (Most partially sighted persons are unable to read newspaper column type at 
normal reading distances even with the help of eyeglasses, and have 
31 
recognizing faces even when they are close.) 
Forty-six percent of the functionally blind group sre 65 years or 0lder.3~  Critical communication with the physician or pharmacist can be missed by the patient with a 
hearing defi~it.3~ 
At least 30 percent of individuals 65 and older have significant  impairment of 
34 
hearing in the frequencies associated with normal speech. 
Mobility Limits: Decreased mobility and dexterity can limit a  erson's ability to have 
35 
prescriptions filled, and to open and close childproof containers. 
Almost half of all noninstitutionalized elderly are limited in mobility because of 
36 
chronic conditions. 
Type of Disease:  Studies of patients with chronic conditions show that compliance is worse 
when: 
the medicine is taken preventively; 
the disease is without symptoms; and 
37 
there are no immediate negative consequences of noncompl.i ance. 
. 
Presence of Symptoms: An illness with easily mognized and unpleasant symptoms that are 
relieved b  the use of medication is more likely to promote compliance with medication 
regimens?  However, Haynes claims that it is the degree of disability brought about by 
symptoms that promotes good compliance. He speculates that compliance improves because 
the disability results in closer supervision of the patient?9 
Some symptoms may fail to stimulate the commitment to follow medication orders. The 
elderly in particular may adapt to a steady state of symptomatic discomfort, or resign to 
"feeling pretty good for my age.'*'  Some of these elderly may prefer to live with mi& 
symptoms than deal with the inconvenience of a medication regimen. 
Some patients use symptoms as barometers to determine when they should discontinue taking 
medication.  Such decisions to discontinue medication are based on the mistaken assumption 
that the abatement of symptoms indicates recover#'  In a study of a group of hypertensives, 
some patients reported that they only took their medication(s) when they knew their blood 
pressure was high.  Their assessments of blood pressure levels were based on symptoms such 
as headaches and stress, although research shows that hypertension is a disease without 
42 
symptoms.  Memory Loss:  Memory loss is a critical problem for many elderly trying to recall a 
physician's or pharmacist's instruction for medication use. 
Memory loss can be caused by prescribed medications. 
Memory loss may indicate senile dementia, a condition difficult to recognize in its 
earliest stages.43 The prevalence of dementia in the noninstitutionalized elderly 
44 
population is about five percent. 
Depression: Depression is one of the most important psychological disorders of late age. A 
community-based sample estimated the prevalence of depressive symptoms among the elderly 
to be approximately 15  The ol&r adult with depression can present serious 
problems to the health care provider who depends on the patient's cooperation to achieve 
compliance with a medication ~gimen.S ome depressive symptoms include: 
sadness; 
loss of gratification; 
constant fatigue; 
apathy; 
psychomotor retardation; 
diminished social interaction; and 
. 
insomnia. 46 
Cognitive Impairment: According to Lamy, approximately 15 percent of the 
noninstitutionalized elderly have significant cognitive impairments likely to affect their ability 
 instruction^?^ 
to give an accurate medical history as well as to follow physicians' 
Some older persons do not seem to process new information as thoroughly as younger persons 
and may need more time to learn new information.  Distractions and information presented at 
48 
a fast pace can seriously disrupt learning. 
Trying to learn a great deal of information in a short period of time (such as learning a 
complex medication regimen), can create a state of information overload. People deal with 
information overload by: 
- 
omission  failing to process information; 
- 
error  processing information incorrectly; 
- 
delay  processing information at a later time; 
- 
fdtering  fitting input into existing belief;  - 
approximation  processing only a part of the information; and 
-  49 
avoidance  ignoring information. 
Behavioral Factors 
Social Isolation:  People who live alone more frequently fail to comply with medication 
regimens. This suggests that for those not living alone, the spouse, companion, or associate 
assumes a role in ensuring that medications are taken as prescribed.50 
Approximately 35 percent of individuals over 65 live alone (the large majority of 
5 1 
whom are women). 
The effects of social isolation include: 
rusty social skills, including difficulty asking and answering questions; and 
 direction^?^ 
cognitive impairment, including difficulty understanding 
Even regular contact with children may not compensate for the loss of a spouse or 
a dwindling social networQ3 
Social and Health Beliefs:  Patients hold many beliefs about their health and about the 
potential efficacy of any proposed treatment action. Patients' beliefs can be based on: 
misconceptions; 
faulty information; and/or 
cultural conditioning. 
For example, some elderly people may believe: 
"You need to give your body some restfiom medicine once in awhile or else your 
body becomes dependent on it or immune to it," or 
'You only take medicine when you are ill and not when you feel better," or 
"Ifo ne dose is good, two must be better." 
These beliefs and feelings may be shared and supported by significant  others in the patient's 
life.54 
Economic Condition: Elderly people on minimal fixed incomes may be unable to afford 
necessary medications. Overall, the elderly pay 14 percent more per prescription than the 
nonelderly because of the mix of medications and the number of doses, which is often greater 
due to long-term therapy. Furthermore, the elderly pay a larger percentage of their 
55 
prescription medication costs out of pocket.  Since 1980 prescription medication prices have increased two to three times faster than all 
consumer prices, while real income has remained relatively static.56 Social Security payments  . 
have increased at about the same rate as general inflation, but medication price inflation has 
far exceeded general inflati~n.~' 
About 14 percent of the noninstitutionalized elderly live below the poverty level. An 
additional 25 percent live just above the poves ay line?  Some of these patients may need to 
make choices between medications and food.  A survey conducted for the American 
Association of Retired Persons (AARP) in 1986 found cost the second most frequently cited 
60 
reason for not getting a prescription filled. 
TreafmenfF actors 
Side Effects of Medications: Although some researchers think that side effects of 
medications contribute to noncompliance, the research evidence is inconclusive. 
Two controlled studies found no difference in the frequency of side effects 
between persons who comply with medication regimens and those who do not6' 
In thirteen studies in which patients were asked their reasons for not taking 
medication as directed, side effects were mentioned by only five to ten percen~62 
In an anti-hypertensive drug trial, seven percent of the actually treated group 
complained of symptoms that may or may not have been medicine related; the 
placebo group had the same frequency and distribution of complaints.63 
The AARP has drawn a different conclusion about the relationship between side effects and 
noncompliance.  In a survey of people 45 and older, 40 percent of the respondents stated they 
had experienced some form of side effect during medication use.  Of this 40 percent, 59 
percent responded that they stopped taking the medication as a result of the side effect. Of the 
65 and older respondents, only 47 percent informed their physicians of the disc~ntinuation.~~ 
Furthermore, the elderly may be more prone to side effects, because their metabolic response 
to doses of medications tested on younger people may be 
Finally, for diseases (such as hypertension) which have no unpleasant symptoms, a medication 
that causes unpleasant effects may well increase the likelihood of noncompliance.66 
Medication Class: There is evidence to suggest that compliance will vary with the type of 
medication.  Researchers have observed: 
an 89 percent compliance rate with cardiac medicines; 
a 78 percent compliance rate with insulin and antidiabetic medicines; 
a 72 percent compliance rate with dimtic medicines;  a 61 percent compliance rate with anti-hypertensive medicines; 
a 41 percent compliance raw with sedatives; 
Research in this area is not complete.  Researchers do not offer conclusive reasons for their 
findings6' 
Perception of Medication:  Researchers have found that the size, form, and color of 
medication affect compliance. 
Capsules are viewed as significantly stronger than pills. 
Larger preparations arc equated with greater strength. 
Capsule or pill colors can elicit expectations of medication action. Green is 
associated with tranquilizing effects, and yellow is associated with energizing 
68 
effects. 
A patient may deci& to discontinue or alter medication use because. the pill or capsule simply 
looks like it will have an effect that the patient does not want to experience. 
Some elderly patients with vision or cognitive deficits may be confused by similarly shaped 
and colored medications? 
The nature of the dosage form, such as the size of the pill or a liquid preP oa ration, can 
negatively affect compliance if it is inconvenient to take or unpalatable. 
Duration of 'lkeatment:  A consistent finding in the research on medication compliance is 
that compliance rates decrease over time.  This is significant for the elderly because of the 
higher frequency of chronic conditions which require long-term or permanent medication 
therapy?' 
Complexity of Treatment: The number of medications taken can neB La tively affect 
compliance. The mon medications taken, the worse the compliance. 
It has not conclusively been shown that the frequency of dosing (how often medications 
~IE 
taken during the day) affects compliance, but differing concurrent dosage schedules can be 
inconvenient, confusing, and easy to forgern  Furthermore, the number of medications 
prescribed can affect the fnquency of dosing?4  Health Care Pro vider/Patient Interaction 
Role of the Physician:  Although most research focuses on the issue of compliance as a 
patient problem, compliance is the physician's responsibility as well as the patient's.75 
Physicians generally unde~stimateth e levels of noncompliance among their own patients?6 
They have also been shown to be unreliable predictors of whether or not individual patients 
77 
will comply. 
Physicians' beliefs about and attitudes toward elderly patients can affect their interaction and 
communication with them. 
Studies have shown that many physicians have an overall negative attitude toward treating 
elderly patients?8 Gerontological studies suggest that while people form impressions of 
younger persons on a wide variety of characteristics (sex, occupation, ethnicity), these 
distinctive categories are ignored when forming impressions of older adults, and the 
stereotypes (mental weakness, contrariness, physical frailty) associated with age tend to 
dominad9 One study of physician attitude noted that 67 percent of physicians interviewed 
attributed noncompliance primarily to the patient's uncooperative personality80 
The physician-patient encounter is a situation in which patients must learn a very specific role 
and set of expectations about: 
the purpose of the medication; 
which medication should be taken; 
how long each medication should be taken; and 
the dosage schedule that should be followed.81 
In Svarstaad's study on physician-patient interaction it was evident that physicians frequently 
did not discuss their expectations in an explicit manner.  Of the 347 medications prescribed 
during the course of that study: 
Seventeen percent were never discussed at all. 
In only ten percent of the cases were patients told how long to take the medication. 
Dosage schedules were discussed ambiguously-'Take  two capsules every four 
hours"--without specifying how many should be taken in a twentyTfourh our period. 
Patients were not always given printed or written instructions for proper use of 
medications.  During the patient interviews of this same study, many misconceptions were discovered. 
Fifty-two percent of the patients made at least one error when describing the physician's 
expectations. For example, patients who had been prescribed anti-hypertension medication 
sometimes thought the medication was for the relief of other ailments such as low back pain 
or asthmag2 
The traditional physician-patient encounter is ill-suited for learning to take place. 
The encounter is perhaps the most anxiety-laden of all lay-expert consultations. 
Too much information is often transmitted in too short a time. 
A potentially upsetting diagnosis and advice may disrupt learning. 
Traditional learning tools, such as notetaking, are not used. 
The patient's abili  to learn can also be hampered by the physician's use of 
%3 
technical language. 
Older patients are often reticent to ask questions of their physicians perhaps because of: 
, 
respect for professional autharity; 
fear of looking unintelligent or unsophisticated; or 
anxiety about the medical condition. 
Furthermore, physicians rarely invite questions fi-om patients regarding proposed medication 
therapy.u 
A Food and Drug Administration survey of physicians discovered that 79 percent feel they 
spend the right amount of time discussing medication therapy with their patients, and 32 
percent feel their patients are very well informed about prescribed medications. An additional 
,  56 percent feel their patients are adequately informed. 
Seventy-two percent of the physicians feel that patients frequently discontinue taking 
medication. However, only seven percent of physicians surveyed who prescribe antibiotics 
tell their patients to finish the medication. 
Twenty percent of the physicians surveyed said that sharing of medications is a problem, but 
only three percent of the physicians who prescribe tranquilizers tell their patients not to share 
the medication. 
No physicians who prescribe thiazides (anti-hypertension medication) report that they tell 
85 
their patients the therapy is long-term or permanent.  The small percentage of physicians in the survey who feel that they don't spend enough time 
discussing medications with their patients cite practice demands and limited time.  Physicians 
see an average of three patients per hour.  Physicians who are high prescribers are more likely 
to use supplemental education materials such as brochures or pamphlets to explain 
rnedication~.~~ 
Role of the Pharmacist: One study discovered discrepancies between what the physician 
wanted on the label and the information the pharmacist actually printed on the label in 20 
percent of 179 prescriptions studied. Types of discrepancies most commonly found were: 
The condition or symptom(s) to be treated were either omitted or incorrect. 
The label omitted the physician's individualized instructions for frequency or 
amount of dose. 
The label did not include a language translation for foreign speaking patients.87 
' 
In regard to patient interaction, pharmacists who were surveyed indicated that: 
Seventy-nine percent would like to have more time for patient consultation. 
Limited time and practice demands are responsible for the lack of patient 
consultation. Pharmacists dispense seven to nine prescriptions per hour. 
Forty-five percent of pharmacists say patient questions interrupt their work not at 
all, and an additional 26 percent say patient questions intempt their work just a 
little.  So, while pharmacists do not often offer information voluntarily, they do not 
seem to feel that patients' questions are an imposition on their time. 
Ninety-six percent report that they provide auxili  labels on prescriptions and 69 
"$ 
percent provide pamphlets for certain medications. 
Patient Expectations and Attitude: The AARP survey of Americans over 45 years of age 
discovered that 69 percent of re  ondents go frst to their physicians when they have questions 
about prescription medications!  However, the FDA survey of physicians found that 38 
percent of physicians screen out most or all calls about medi~ations.~ 
Twenty-five percent of respondents to the AARP survey turn to their pharmacists for 
information, and a small percent use books or other reference materials to get their 
information about medications?'  Forty-nine percent of the over-65 age group report that they never ask their doctors or 
pharmacists questions about medications.  Respondents in general, and especially the over-65 
age group, report dissatisfaction about the information they receive from both their physicians 
and pharmacists about: 
the name and purpose of the medication; 
how and when to take the medication; 
whether adverse effects are a possibility; 
whether side effects are a possibility; 
what the storage requirements are; 
how many refills are required; and 
whether there are alternative therapies for the condition?' 
Finally, over 45 percent of the above-65 respondents report that their physicians and 
pharmacists do not ask them what prescription and nonprescription medications they are 
93  . 
taking before writing or filling a prescription. 
The complex nature of the medication compliance issue suggests that there are not likely to be 
any quick or simple remedies for this problem94 A number of suggestions have been offered 
by various researchers. Haynes has pointed out that any efforts to improve compliance should 
target only treatments for which there is reasonable evidence of therapeutic efficacy?5 
Educating Patients and Health Care Providers 
PhysiciadPharmacist Level: Patient education has been suggested as a primary means of 
improving patient compliance, and has been shown to be successful in many cases. However, 
as Falvo has pointed out, patient education is not simply repeating directions or handing out 
printed materials. It is a process involving skill in data gathering; individualization of 
instructions; prompting and support; and evaluation and follow-up of the patient's success in 
implementing the treatment regimeng6 Furthermore, the patient must be involved in 
designing any intervention to improve his compliance.  Only when the patient has been 
allowed to express his or her point of view can the health care provider best decide what 
strategies will be most appropriate to improve compliance. 
Meichenbaum has suggested that when health professionals view patient education as a 
process rather than a single intervention, -theym ay fear that the process will become too time 
consuming. However, the process of patient education, if incorporated into the daily 
interactions of each patient encounter, can actually save time by increasing patient  compliance.  Fewer calls or visits to the physician or pharmacist, as well as other benefits of 
compliance such as avoiding hospitalization, may result if proper educational techniques are 
employed early in the therapy?'  Studies have shown that compliance-improving programs 
98 
have cost5enefit ratios as high as 1: 14. 
Public Education Programs:  There are currently many programs for informing and 
educating elderly patients about medication issues. Some of the better known programs are: 
The Elder-Ed and Elder Health Programs conducted by the University of 
Maryland's School of Pharmacy:  In the Elder-Ed program retired pharmacists are 
teamed with pharmacy students to provide counseling to senior citizens in group 
settings. Within the Elder-Health Program, pharmacy students are required to form 
a relationship with an elderly patient.  The student visits the elderly patient 
periodically to help educate the patient about medications. In this way the student 
learns fmt-hand some of the problems elderly people face with medication 
regimens. 
The San Francisco SRx (Senior Medication Program): Sponsored in part by the 
San Francisco Department of Health, SRx involves pharmacies in community 
outreach programs to inform and educate elderly people about their medication 
regimens. 
The National Institute of Drug Abuse (NIDA): The Institute developed a film and 
a booklet about the elderly and medication issues.  These are distributed to  State 
agencies involved in prevention of medication abuse. 
The American Association of Retired Persons (AARP):  Among other activities, 
AARP developed, with the help of the FDA, patient package inserts known as 
MILS (medication information leaflets for seniors) which contain information 
about medications and their proper use.  The MILS are distributed with over 90 
percent of medications dispensed through the AARP's mail-order pharmacy 
service. 
The National Council on Patient Information and Education (NCPIE): The 
Council employs public service announcements, education campaigns, and special 
events such as the "Talk About Prescription Month" to raise public awareness 
about problems associated with prescription med@ation~?~ 
Using Compliance Aids 
It has been suggested that various electronic and mechanical devices called "compliance aids" 
might help to improve compliance.100 There are a wide range of compliance aids available, 
from simple charts to record and remind patients of medication use, to sophisticated 
micro-electronic bottle caps that have alarms and flashing indicators to alert a patient when a  dose is due.  Compliance aids can range in price from a few cents for a chart to fifteen dollars 
for a micro-electronic cap.  Such aids may be useful for patients with memory impairments or 
patients on a complex medication regimen. 
Other strategies and mechanisms proposed to improve patient compliance include: 
providing reminder cards for refills;. 
providing written or printed information that is easy to read (large type); 
keeping medication histories; 
using large type and specifying instructions on prescription labels; never writing 
"take as directed;" 
simplifying the regimen as much as possible; 
involving family members in support and/or supervisory roles; and 
demonstrating the proper technique for using a medication application apparatus. 
Compliance Can Be Improved 
Green et al. conducted a quantitative review of 10 experimental studies specifically addressing 
the elderly with education and behavioral interventions designed to improve medication 
compliance. They discovered that all methods, with the exception of written materials used 
alone, were effective in significantly and substantially improving lcnowledge of medication 
101 
use, and decreasing the incidence of error. 
However, strategies employed to improve patient compliance have been shown to be effective 
only insofar as they are matched to individual patient necds.lo2  APPENDIX A 
Office of Inspector General Studies of Elderly Medication Issues 
Studies Completed  .  Request Report Number 
Medicare Drug Utilization Review  01-88-00980 
Physician Drug Dispensing  01-88-00590 
Implications of the Medicare Prescription Drug 
Benefit's Electric Claims Processing System 
State Discipline of Pharmacists  01 -89-89020 
The Clinical Role of the Community Pharmacist  01-89-89160 
The Clinical Role of the Community Pharmacist:  Case Studies  01-89-89161 
,: 
Studies Underway 
Adverse Drug Reaction Reporting System 
Studies Planned 
Prescription Drug Advertising  APPENDIX B 
ENDNOTES 
- 
'M.  H. Becker and I. M. Rosenstock, "Compliance with Medical Advice," In A. Steptoe and 
A. Matthews, eds., Health Care and Human Behavior (New York: Academic Press, 1984). As 
cited in Meichenbaum, Facilitating Treatment Adherence. 
2 ~S.. C ongress, Office of Technology Assessment, Health Program, "Prescription Drugs and 
Elderly Americans: Ambulatory Use and Approaches to Medicare," Staff Paper, October, 1987. 
3~ureauof  the Census, Cumnt Population Reports, Series P-25, No. 1018, Projections of the 
Population of the United States, by Age, Sex, and Race: 1988-2080, by Gregory Spencer, U. 
S. Government Printing Office, Washington D. C.,  1989. 
4~ationaCl enter for Health Statistics, Health in the Later Years of Life: Datafmm the 
National Centerf or Health Statistics, (Washington D. C.: U. S. Goverhnent Printing Office, 
1971). As cited in Phyllis Amaral, "The Special Case of Compliance in the Elderly," in 
Kenneth Gerber and Alexis Nehemkis, eds., Compliance: The Dilemma of the Chronically Ill, 
(New York: Springer, 1986). 
5 ~ ~ n aMledic henbaum and Dennis C. Turk, Facilitating Treatment Adherence: A 
Practitioner's Guidebook, (New York: Plenum Press, 1987). 
V. Lundin, "Medication Taking Behavior and the Elderly: A Pilot Study," Drug 
Intelligence and Clinical Phamcy 12 (1978): 518-22. 
'c. 
R. Smith, ''Use of Drugs in the Aged," John Hopkins Medical Jourml, 145, no. 2 (1979): 
61-64. 
 rank 
Ascione, et at, "Seniors and Pharmacists: Improving the Dialogue," American 
Pharmacist 5 (May 1980): 30-32. 
'peter  P. Lamy, Drug Use in the Geriatric Population: Problems and Approaches, Draft 
Manuscript [Baltimore 19891. 
'O~mericanA  ssociation of Retired Persons, "Cuts in Social Security Cost-of-Living 
Adjustments (COLAS): Impact Analysis," Unpublished, 1985. As cited in Off~ceo f 
Technology Assessment, "Ambulatory Use and Approaches to Coverage for Medicare."  "~h~lliAsm aral, 'The Special Case of Compliance in the Elderly," In Kenneth Gerber and 
Alexis Nehemkis, eds., Compliance: The Dilemma of the Chronically Ill, (New York: 
Springer, 1986). 
12R. N. Podell and L. R. Gary, "Compliance: A Problem in Medical Management," American 
Family Physician 13 (1976): 74-80. As cited in Donald Meichenbaum and Dennis Turk, 
Facilitating Treatment Adherence. 
 sons, 
13~mericanA ssociation of Retired  Prescription Drugs: A Survey of Consumer Use, 
Attitudes and Behavior, (Washington D. C.: AARP, 1984). 
14cJ. . Latiolas and C. C. Beny, 'Uisuse of Prescription Medications by Outpatients," Drug 
Intelligence and Clinical Phamcy 3 (1969): 270-77. 
 oris is 
Schwartz, et al., "Medication Emors Made by  Elderly Chronically Ill Patients," 
American Journal of Public Health 52, no. 12 (Dee. 1962): 2018-2019. 
"~onaldM  eichenbaum and Dennis Tmk, Facilitating Treatwent Adherence. 
"R.  Brian Haynes, et al., "How to Detect and Manage Low Patient Compliance in Chronic 
Illness," Geriatrics 355 (1980): 91-97. As cited in Helene Levens Lipton, "Elderly Patients 
and Their Pills: The Role of Compliance in Safe and Effective Drug Use," Pride Institute 
Journal of Long Term Home Health Care 8, no. 1 (Winter 1989): 26-3 1. 
18~alBe.  Christensen, "Drug-taking Compliance: A Review and Synthesis," Health Services 
Research (Summer 1978). And R. Brian Haynes, D. Wayne Taylor, and David L. Sackett, 
Compliance in Health Care (Baltimore: John Hopkins UP, 1979). And Donald Meichenbaum 
and Dennis Turk, Facilitating Treatment Adherence. 
"E. Roy Hammarlund, Jana R. Osmm, and Alice J. Kethley, 'The Effects of Drug 
Counseling and Other Education Strategies on Drug Utilization of the Elderly," Medical Care 
23, no. 2 (Feb. 1985): 165-170. 
20~etePra  Lamy, "Drug Use and the Elderly: Some Observations and Recommendations," 
The Maryland Pharmacist 64, no. 3 (March 1988): 12. 
21~R..  Strandberg, "Drugs as a Reason for Nursing Home Admissions," American Health 
Care Association Journal 10. no. 4 (July 1984): 20.  As cited in Mickey Smith, "The Cost of 
Noncompliance and the Capacity of Improved Compliance to Reduce Health Care 
Expenditures,"  in National Pharmaceutical Council, "Improving Patient Compliance: 
Proceedings of a Symposium," (Reston, VA:  NPC, 1984).  *H.  Graham and B. Livesley, "Can Readmissions to a Geriatric Medical Unit Be Prevented?" 
Lancet 1 (1983): 404-406. And, P. A. Frisk, J. W. Cooper, and N. A. Campbell, 
"Community-Hospital Pharmacist Detection of Drug-related Problems upon Patient 
Admission to Small Hospitals," Am Journal of Hospital Phamcy 35 (1977): 738-742. As 
cited in Helene Levens Lipton, "Elderly Patients and Their Pills."  . 
23~J..  McKenney and W. L. Harrison, "Drug-related Hospital Admissions," American Journal 
of Hospital Pharmacy 33 no. 8 (1976): 792. 
24~onnFaa lvo, Effective Patient Education: A Guide to Increased Compliance (Rockville, 
MD: Aspen Systems Corp., 1985). 
25~ohnU rquhart, "Drug Delivery Technology and Patient Compliance for New Products," 
Paper presented at The Conference on Advanced Therapeutics: Overcoming End User 
Barriers. Co-sponsered by the National Pharmaceutical Council and Frost and Sullivan, 
Baltimore, April 17-18 ,1989. 
%ohn  Urquhart, "Noncompliance: The Ultimate Absoption BamerYwPapeprr esented at The 
Third International Conference on Drug Absorption, Edinburgh, Sept. 27-30, 1988. 
27~eichenbaumF, acilitating Treatment Adherence. 
2B~elenLee vens Lipton, "Elderly Patients and Their Pills:  The Role of Compliance in Safe 
and Effective Drug Use," Pride Institute Journal of Long Term Home Health Care 8, no. 1 
(Winter 1989): 26-3 1. 
2g~awrencGe reen*P atricia Mullen and Gene Stainbrook, "Programs to Reduce Drug Errors 
in the Elderly: Direct and Indirect Evidence from Patient Education," in National 
Pharmaceutical Council, "Improving Patient Compliance: Promdings of a Symposium," 
(Reston, VA: NPC, 1984). 
r 
30~ma.al",T he Special Case of Compliance in the Elderly," in Gerber and Nehemkis, eds., 
Compliance: The Dilemma of the Chronically Ill. 
31~M. . Genensky and S. H. Zarrit, "Comprehensive Program of Low Vision Services," In A. 
A. Rosenbloom and M. Morgan, eds., Vision and Aging: General and Clinical Perspectives 
(Chicago: The Professional Press, 1987). As cited in Amaral, "The Special Case of 
Compliance." 
33~maral",T he Special Case of Compliance."  34~ationaCl enter for Health Statistics, C. A. Shoenbom and M. Marano, 1988. "Current 
Estimates from the National Health Inte~ewSu rvey: United States 1987," Vital and Health 
Statistics Series 10, No. 166. DHHS Pub. No. (PHs) 88-1594. Public Health Service, 
Washington D. C.: Government Printing Office. 
35~elenLee vens Lipton, Statement on "Drug Misuse Among the Elderly and Its Impact on 
Community Based Care," before the U. S. House of Representatives, Subcommittee on 
Human Services, Select Committee on Aging, April 19,1989. 
37~alBe.  Christensen, "Drug-taking Compliance: A Review and Synthesis," Health Services 
Research Summer, 1978. 
38~eichenbauman d Turk, Facilitating TreamnzA  dherence. 
39~B. rian Haynes, 'The Determinants of Compliance: The Disease and the Mechanics of 
Treatment," in R Brian Haynes, D. Wayne Taylor, and David L. Sackett, Compliance In 
Health Care (Baltimore: John Hopkins UP, 1979). 
40~eichenbaumF, acilitating Treatment Adherence. 
4%3. Leventhal and D. R. Nerenz, "A Model of Stress Research with some Implications for the 
Control of Stress Disorders," In D. Meichenbaum and M. Jarenko, eds., Stress Reduction and 
Prevention (New York: Plenum Press, 1983). As cited in Meichenbaum. 
43~elenLee vens Lipton, Statement on "Drug Misuse Among the Elderly and Its Impact on 
Community Based Care," before the U. S. House of Representatives, April 19,1989. 
44Amaral, "The Special Case of Compliance." 
4 5 ~B. l azer and C. Williams, "Epidemiology of Dysphoria and Depression in an Elderly 
Population," American Journal of Psychiatry 134, no. 4  (1980): 439-444. As cited in Amaral. 
46~mat*aml, es pecial case of Com~liance.~ 
47~etePr.  Lamy, Drug Use in the Geriatric Population: Problems and Approaches. 
48~H..  Zarrit, "Affective Carelates of Self-Reports About Memory of Older People," 
International Journal of Behavioral Geriatrics 1 (1982): 25-34. As cited in Amaral.  49~eichenbaumF,a cilitating Treatment Adherence. 
50~hristensen",D  rug-Toking Compliance: A Review and Synthesis." 
51~ureauof  the Census, StatisticalA  bstract of  the United States: 1989, (109th ed.) 
Washington D. C.: Government Printing Office, 1989. 
52~maral",T he Special Case of Compliance." 
54~elenLee vens Lipton, "Elderly Patients and Their Pills: The Role of Compliance in Safe 
and Effective Drug Use," 
5S~elenLec vens Lipton, Statement before the U. S. House of Rep~sentatives,A pril 19,1989. 
58~ederaCl ouncil on Aging, U. S. Dept of Health and Human Services, The Need for 
Long-Term Care, Information and Issues, DHHS Pub. No. (OHDS) 81-20704 (Washington D. 
C.: Government Printing Office, 1981 ). As cited in Amaral. 
.59~adeleinFee inberg, "Polymedicine and the Elderly: Is it Avoidable?" Pride Institute of 
Long Tern Home Health Care 8, no. 1 (Winter 1989): 15-25. 
60~mericanA ssociation of Retired Persons, Statement on  "Drug Misuse Among the Elderly 
and Its hpact on Community Based Care." Presented by Dr. Monroe Gilrnour before the U. 
S. House of Representatives Select Committee on Aging, Subcommittee on Human Services, 
April 19,1989. 
6 1Br~ian  Haynes, "Determinants of Compliance." 
63~eteran'sA dministration Cooperative Study Group on Anti-hypertensive Agents, "Effens of 
Treatment on Morbidity in Hypertension. III) Influence of Age, Diastolic Pressure and Prior 
Cardiovascular Disease; Further Analysis of Side Effects," Circulation 45 (1972): 991-1004. 
As cited in Haynes, "Determinants of Compliance."  @AARP, Prescription Drugs: A Survey of Consumer Use, Attitudes and Behavior 
(Washington D. C.:  AARP, 1984). 
6 5 ~F.. T  empem, "Biological Variability and hug Response Variability as Factors Influencing 
Patient Compliance: Implications for Drug Testing and Evaluation," In Ivan Barofsky, ed., 
Medication Compliance: A Behavioral Management Approach omfare, N. J.: Charles B. 
Slack, Inc., 1977). 
66~etePr.  Lamy, "Non-prescription (OTQ Drugs and the Elderly," The Mayland Pharmacist 
64 (Sept. 1988): 9-14. 
67~C.l osson and C. Kukugawa, "Noncompliance Varies with Drug Class," Hospitals 49 
(1975): 89-93. As cited in Haynes, "Determinants of Compliance." 
6%.  W. Buckalew and R. E. Sallis, "Patient Compliance and Medication Perception,'' Journal 
of Clinical Psychiatry 142 (1986): 244-45. As cited in Meichenbaum, Facilitating Treatment 
Adherence. 
69~L. . Bootman, "Maximizing Compliance in the Elderly," Phamcy Proctice for the 
~eriatriPc atient, Health Sciences Consortium, Carrboro N. C., 1985. 
70~hristensen", Drug-taking Compliance: A Review and Synthesis." 
l~eichcnbaumF, acilitating Treatment Adherence. 
7 2 ~H.  ulka, J. CasseI, L. Kupper, "Communication, Compliance, and Concordence Between 
Physicians and Patients with Prescribed Medicines," American Jownol of Public Health 66 
(1976). 
73~J.e migan, "Update on Drugs in the Elderly," American Family Physician 29, no. 4 (April 
1984): 23847. 
74~anyB lackwell, "The Drug Regimen and Treatment Compliance," In Haynes, Sackett and 
Taylor, Compliance in Health Care. 
- 
7slrving Kenneth %la,  'Taking Your Medication  Problem for Doctor or Patient?" in 
Barofsky, Medication Compliance. 
7 6 ~B.  mlq and R Gillum, ''The Diagnosis and Management of Patient Compliance," 
Journal of the American Medical Association 228 (1974): 1563-67. 
77~aviLd.  Sackett and John C. Snow, 'The Magnitudt of Compliance and Noncompliance," 
In Haynes, Compliance in Health Care.  78~R..  Smith, "Use of Drugs in the Aged," John Hopkm Medical Journal 145, no. 2 (1979): 
6 1-64, 
79~N. . Basil and J. E. Red, "On the Dominance of the Old Age Stereotype," Journal of 
Gerontology 36. no. 6 (1981): 682-88. As cited in Amaral, "The Special Case of Compliance." 
8 0 ~S..  Davis, "Variatiims in Patients' Compliance with Doctors' Orders," Journal of Medical 
Education 41 (1966): 1037-1048. As cited in Zola, 'Taking Your Medication." 
81~onniSev arstaad, "Physician-Patient Communication and Patient Conformity with Medical 
Advice," In David Mechanic, ed,T he Growth of Bureaucratic Medicine: An Inquiry into the 
Dynamics of Patient Behavior and the Organization of Medical Care (New York: John Wiley 
and Sons, 1976). 
83~avidC . Jenkins, "Cultural Differences in Concepts of Disease and How These Affect 
Health Behavior," In Barofsky, Medication Compliance. 
84Helene Levens Lipton, Statement before the U. S. House of Representatives. 
"~ooda nd Drug Administration, "Patient Information and Prescription Drugs: P d e l  
Surveys of Physiciaiu and Pharmacists," Study no. 8 12020, March 1883. 
'hid. 
87~varstaad",P hysician-Patient Communication." 
88FD~",P atient Information and Prescription Drugs." 
8 9 ~Pre,scri ption Drugs: A Survey of Consumer Use, Attitudes and Behavior. 
'%A,  "Patient Information and Prescription Drugs." 
' 
'AARP, Prescription Drugs. 
92~bid. 
93~ici. 
94~eichenbaumF, acilitating Treatment Adherence.  "R.  Brian Haynes, "Strategies to Improve Compliance with Refcwls, Appointments, and 
Prescribed Medicine Regimens," In Haynes, Compliance in Health Care. 
9%v0,  Efective Patient Education. 
97~eichenbaumF, acilitating. 
98MickeyS  mith, ''The Cost of Noncompliance and the Capacity of Improved Compliance to 
Reduce Health Care Costs," in National Pharmaceutical Council, "Improving Medication 
Compliance: Pr&eedings of a Symposium," (Reston, VA: NPC, 1984): 35-44. 
"~elene Levens Lipton and Phillip R. Lee, Drugs and the Elderly: ClinicalyS ocial, and 
Policy Perspectives, (Stanford, CA: Stanford UP, 1988). 
'%amy,  "Drug Use and the Elderly: Some Observations and Recommendations," The 
Maryland Phunnacist 64, no. 3 (March 1988): 10-1 5. 
'O1&een,  Mullen and Stainbrook, "Programs to Reduce Drug Enors in the Elderly." 
'O2~rnaral," The Special Case of Compliance."  APPENDIX C 
'COMPLIANCE ISSUES 
Selected Bibliography 
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(Washington D. C.: AARP, 1987). 
-.  
Prescription Drugs: A Survey of CO~UIZUU!s~e,  Attitudes, and Behavio,: (Washington 
D. C.: AARP, 1984). 
- 
. 
Statement on "Drug Misuse Among the Elderly and Its Impact on Communtity-Based 
Care." Presented by Dr. Monroe Gilmour before the U.S. House of Representatives 
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American Pharmaceutical Association. Statement on "Medication Use and Misuse in the 
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Representatives Select Committee on Aging, Subcommittee on Human Services. April 
19, 1989. 
- 
Ascione, Frank J. and Leslie A. Shimp. "The Effectiveness of Four Education Strategies in the 
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Ascione, Frank J., M. James, S. Austin and L. Shimp. "Seniors and Pharmacists: Improving 
the Dialogue." Am P h m5  (May 1980): 30-32. 
Bachman, Robert M. "Priorities and Approaches for Improving Medication Compliance by 
Older Americans." U.S . Pharmacist, Special Supplement. Rutgers Pharmaceutical 
Conference. Patient Compliance: Better Health Care and Lower Costs. 36th Annual 
Conference. 
Barofsky, Ivan, ed Medication Compliance: A Behavioral Management Approach. 
(Thorofare, N. J.:  Charles B. Slack, Inc., 1977). 
Blackwell, Barry. "Commentary: The Drug Defaulter." Clinical Pharmacology and 
- 
Therapeutics 13, no. 6 (Nov.  Dec. 1972): 841- 48. 
Boyd, James R., Tim R. Covington, Walter F. Stanas&  and Timothy Coussons. "Drug 
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Pharmucy 3 1 (May 1974): 485-91.  Brown, Judith. "&scription  Drug Costs for Older Americans."  American Association of 
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Christensen, Dale B. "Drug-taking Compliance: A Review and Synthesis." Health Services 
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8 
Cramer, Joyce A., Joseph F. Collins, and Richard H. Mattson. "Can Categorization of Patient 
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Clinical Trials 9 (1988): 47-63. 
- 
Cramer, Joyce A. and Michael L. Russell. "Strategies to Enhance Adherence to a Medical 
Regimen." In D. Schmidt and I. E. Leppek, eds. Compliance in Epilepsy (Amsterdam: 
Elsevier, 1988). 
Deyo, Richard, Thomas S. Inui, and Barbara Sullivan. "Noncompliance with Arthritis Drugs: 
Magnitude, Comlates, and Clinical Implications." Journal ofRheumatology 8, no. 6 
(1981): 931-936. 
Epstein, Leonard H. and Bruce J. Masek. "Behavorial Control of Medicine Compliance." 
Journal of Applied Behavior Analysis 11, no. 1 (Spring 1978): 1-9. 
Eraker, Stephen A,, John P. Kirscht and Marshall H. Becker. "Understanding and Improving 
Patient Compliance." Annals of Internal Medicine 100 (19 84): 258-68. 
Falvo, Donna R. Eflective Patient Education: A Guide to Increased Compliance. (Rockville, 
MD: Aspen Systems Corp., 1985). 
Feinberg, Madeline. "Polymedicine and the Elderly: Is it Avoidable?" Pride Institute Journal 
ofLong Tern Home Health Care 8, no. 1 (Winter 1989): 15-25. 
Gerber, Kenneth E. and Alexis N. Nehemkis, eds. Compliance: The Dilemma of the 
Chronically Ill. (New York: Springer, 1986) 
German, Pearl S., Lawrence E. Klein, Stephen J. McPhee, and Craig R. Smith. "Knowledge of 
and Compliance with Drug Regimens in the Elderly." Journal of the American Geriatrics 
Society 30 (Sept. 1982): 568-71. 
Green, Lawrence W.,  Patricia D. Mullen and Gene L. Stainbrook.  "Programs to Reduce Drug 
Errors in the Elderly: Direct and Indirect Evidence fiom Patient Education." National 
Pharmaceutical Council (NPC)," Improving Medication Compliance: Proceedings of a 
Symposium." (Reston, VA: NPC, 1984). Also in Journal of Geriatric Drug Therapy 1 
(Fall, 1986): 3-18.  Greenberg, Richard N. "Overview of Patient Compliance with Medication Dosing: A 
Literature Review." Clinical Therapeutics 6 (1984): 592-99. 
Hammarlund, E. Roy, Jana R Ostrom, and Alice J. Kethley. "The Effects of Drug Counseling 
and Other Educational Strategies on Drug Utilization of the Elderly." Medical Care 23, 
no. 2 (Feb. 1985): 165-70. 
Haynes, .R. Brian, D. Wayne Taylor, and David L. Sackett. Compliance In Health Care. 
(Baltimore: John Hopkins UP, 1979). 
Haynes, R. Brian, David L. Sackett, D. Wayne Taylor, Robin S. Robins, and Arnold L. 
Johnson. "Manipulation of the Therapeutic Regimen to Improve Compliance: 
Conceptions and Misconceptions." Clinical Pharmacology and Therapeutics 22, no. 2 
(August 1977): 125- 130. 
Lamy,P eter P. Dmg Use in the Geriatric Population: Problems and Approaches. Draft 
Manuscript. Daltimore: 19891. 
. 
- "Drug Use and the Elderly: Some Observations and Recommendations." The Maryland 
Pharmacist 64, no. 3 (March 1988): 10-15. 
-.  "Non-prescription (OTC) Drugs and the Elderly." The Maryland Pharmackt 64, no. 9 
(Sept. 1988): 9-14. 
-. P rescribing for the Elderly. (Littleton, MA: PSG Publishing, 1980). 
Levy,S usan M. "Making the Most of Medications: Patient Compliance and You." Medical 
Times 114, no. 10 (Oct. 1986): 61-66. 
Lipton, Helene-Levensa nd Philip R Lee. Drugs and the Elderb:  Clinical, Social, and Policy 
I 
Perspectives. (Stanford ,CA: Stanford UP, 1988). 
Lipton, Helene Levens. "El&rIy Patients and Their Pills: The Role of Compliance in Safe and 
Effective Drug Use." Pride Institute Journal of Long Term Home Health Care 8, no. 1 
(Winter 1989): 26-31. 
. 
- Statement on "Drug Misuse Among the Elderly and Its Impact on Community Based 
Care." before the U.S. House of Representatives Select Committee on Aging, 
Subcommittee on Human Services. April 19,1989. 
Marston, Mary-'Vesta.  "Compliance with Medical Regimens: A Review of the Literature." 
Nursing Research 19, no. 4 (July-Aug. 1970): 3 12-23.  McKenney, T. J. and W.  L. Harrison. "Drug-related Hospital Admissions."  American Journal 
of Hospital Phannacy 33, no. 8 (1976). 
Mechanic, David. The Growth of Bureaucratic Medicine: An Inquiry into the Dynamics of 
Patient Behavior and the Organization of Medical Care. (New York: John Wiley and 
Sons, 1976). 
Meichenbaum, Donald and Dennis C. Turk. Facilitating Treament Adherence: A 
Practitioner's Guidebook. (New York: Plenum Press, 1987). 
Mendelson, Marilyn A. "Drug-Regimen Review and Postmarketing Surveillance: Research 
Links to Consultant Pharmacy."  The Consultant Phcumacist (July-Aug. 1988): 313-19. 
Miller, Roger W. "Doctors, Patients Don't Communicate." FDA Consumer. July/Aug. 1983. 
DHHS Pub. No. 83-1102. (Washington D. C.:  Government Printing Office, 
1983-381-173-34). 
. 
. 
Murray, Michael D., Jeffkey Darnell, Morris Weinberger, and B. L. Martz.  "Factors 
Contributing to Medication Noncompliance in Elderly Public Housing Tenants." Drug 
Intelligence and Clinical Phannacy 20 (Feb. 1986): 146-52. 
National Center for Health Statistics, C. A. Schoenborn and M. Marano. "Current Estimates 
from the National Health Interview Survey: United States, 1987" Vital and Health 
Statistics Series 10, No. 166, DHHS Pub. No. (PHs) 88-1594. (Washington D. C.: 
Government Printing Office, 1988). 
National Council on Patient Information and Education. Resources for  "TalkA  bout 
Prescriptions" Month (Washington D.C.:  NCPIE, Oct. 1988). 
-. P riorities and Approaches for Improving Prescription Medicine Use By Older 
Americans (Washington D.C.: NCPIE, Oct 1987). 
National Data Corp. Statement on "Drug Abuse Among the Elderly." Presented by Mark L. 
Braunstein, M.D. before the U.S. House of Representatives Select Committee on Aging, 
Subcommittee on Human Services. April 19,1989. 
National Pharmaceutical Council, Inc. "Misuse of Prescription Medications: Costs and 
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. 
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