REDUCING MEDICATION PROBLEMS 
OF THE ELD"ERLY 
MANAGEM.ENT ADVISORY REPORT 
ItlVJCE$.
lI.r 
'0 
"d3'a 
OFFICE OF INSPECTOR GENERAL 
OFFICE OF EVALUATION AND INSPECTIONS 
OCTOBER 1990  REDUCING MEDICATION PROBLEMS 
OF THE ELDERLY 
MANAGEMENT AD  SORY REPORT 
Richard P. Kusrow 
INSPECTOR GENERAL 
OEI-Q4-89.89122  OCTOBER 1990  ......... ...........
... 
TABLE OF CONTENTS

PURPOSE  II.. II. II.. 
II  II II II II II II II II II II II II. II II II II II II II II II. II II II. II II. II. II II II II II 11.

BACKGROUND. 
II II II II II II . II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II . II II II II II II .

METHODS  II II II II II II II II II. II. II. II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II 0 0

FINDINGS  II II II II II. II II II II II II II II II II II II II II II II II II II II II II II II .

RECOMMENDATIONS 
II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II e II II II It II II .

COMMENTS. II II II II II . II . II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II II . II . II II II II II II .. 5

APPENDIX A  II II II II II . II II II II II II II II II . II II II II II II II II II II II II II II II II II II II II II II II II II II II II II a II A-1
 " "
PURPOSE 
Identify actions which the Depanent of Health and Huma Services can tae to improve 
compliance among the elderly with medcation regimens. 
BACKGROUND 
Medication utilization problems afect the health and quality of life for a substatial number of 
elderly persons. These problems also result in a significant amount of unnecessar health care 
spending. Noncompliance with prescrption drgs, or 
the failur of a patient to COlTectly 
follow instrctions for medcation use, contrbutes significantly to the medcation problems of 
the elderly. Several components of the Depanent of Health and Human Services have an 
interest in medcation problems of the elderly. 
In 1989 under Medicaid, the Federal government and the States spent $3.
7 bilion for 
prescription drgs, which is more than the $3.4 bilion spent for physician servces. 
Approximately 44 percent of Medcaid expenditus for prescrption drgs was for the elderly. 
In 1989, 1.8 millon Medcare beneficiaes were enrolled in prepaid medcal plans, may of 
drg 
which provide prescrption  benefits. In both the Medcaid and Medcare progrs, an 
incalculable amount is spent for physician and other medcal services necessitate by 
medication problems.

METHODS 
In the past year the Office of Inspector General issued thee reports related to medication 
problems among the elderly. The report "Medcare Drug Utilization Review," issued in Apri 
00 
1989, found that in 1987 an estimated 200, older adults were hospitaizd due to adverse 
drg reactions or experienced an adverse drg reaction while hospitazed. In Januar 1990 
drt 
we issued two  reports on the role of the clinical phanacist in the community settng. 
The Clinical Role of the Community Pharist" descrbes new modes of phanacy servces 
furer 
and barers to their  development. A companion report "The Cliical Role of the 
Community Phanacist: Case Studies:' descrbes the reent experience of severa phancy 
drg 
practitioners who are developing advanced forms of servce including counseling and 
utilization review. 
four 
Attached to this document is .a  report, entitled  Medcation Regimens: Causes of 
Noncompliance. " Noncompliance occur when a patient fails to cOlTectly follow instrctions 
for prescription drg use. The report reviews the scientic literatur to determe the extent to 
which, and the reasons why the elderly may have diffculty complying with their medcation 
regimens. This literatue ranges from small, narwly focused studies on aspects of 
noncompliance, to book-length discussions on the elderly and medication problems, 
including noncompliance.  In connection with this study on noncompliance, the OIG has examined (with representatives
of PHS, AoA and HCFA) the CUITent programs, policies, and initiatives of those agencies, to
identify practical ways to help the elderly adhere to medication regimens.
FINDINGS
Our review of the scientific literature (see attached repon number OEI-04-89-89121) revealed 
that: 
Many elderly do not comply with their medication regimens; the consequences 
are serious.

Based on a review of many studies of elderly noncompliance, one researcher found that,
on average, 55 percent of the elderly are noncompliant with their prescrption drg
orders. Another pai of researchers suggest that one-third of the elderly always comply, 
one-third sometimes comply, and one-third never comply with their prescription 
medication regimens. 
According to a study conducted for the Oregon Deparent of Human Resources, 
twenty-thre percent of admissions to one nuring home were diectly due to patient 
inabilty to manage medications at home. 
Over a two-month period, researchers at one large teaching hospital found that hospita
admissions for 23 patients, resulting from noncompliance with medications, accounted
for 590 hospital days and $60,000 in avoidable costs.
There are many inter-related reasons 
for noncompliance.

Varables which afect why the elderly may have diffculties complying with p  scription
medications fall into four main categories. Although separated into categories, these varables
are closely inter-related and may overlap substantialy.
Loss of vision or hearng can impede an elderly person s abilty 
Physiological factors: 
to read imponant infonnation about prescrptions or to hear instrctions about a 
regimen. Mobility limits, type of disease, symptoms of ilness, memory loss, 
dneperesgsiona, atndi vcogenitlivye i mapafifeentsc arte  octheor pmhysioplogliciaal vnaracblees th.a t can
These include social isolation, social and health beliefs, and 
Behavioral/actors: 
economic condition. Many elderly people live alone. Several studies have shown that 
people who live alone more often fail to comply with medication regimens. 
For those 
elderly on fixed, minimal incomes, the abilty to purchase expensive medications may 
also be a factor affecting noncompliance.  Imponant varables are the duration and complexity of the 
Treatmentfactors: 
medication regimen. Without exception, studies have shown that compliance rates 
decrease when the tratment is long-term and when the regimen includes many different 
medications which must be taen concUIently. Many elderly people have chronic 
conditions, and/or multiple conditions. Other treatment factors include the type of 
medication prescribed, and the patient's perception of the medication. 
These include how well the 
Health Care Provider/Patient Interactionfactors: 
physician, the phanacist, and the patient communicate with each other. The qualty 
and content of a physician s instrctions, the content of a phanacist' s label, and the 
ability of a patient to ask questions can all affect compliance. 
Education is the key to improving compliance. 
A review of the literatur showed that compliance-improving programs based on 
education can have benefit/cost ratios as high as 14: 
Several researchers have found that physicians and phanacists engagig in on-going, 
compliance-improving education, based on individual patient s needs, is the single best 
intervention for noncompliant behavior. 
Other means to help improve compliance include devices known as "compliance aids 
which can range from simple chars to record medications taken to sophisticated 
electronic bottle caps with beeping alans or flashing indicators to indicate when a dose 
is due. 
RECOMMENDATIONS 
Public Health Service

The PHS has long had an interest in prescrption medcation utiiztion among al segments of 
200: 
the population, including the elderly. In its "Healthy People  National Health 
Promotion and Disease Prevention Objectives," section 12.6 proposes to: "Increase to at least 
75 percent the proporton of primar car providers who routinely review with their patients 
aged 65 and older all prescrbed and over-the-counter medcines taken by their patients each 
time a new medication is prescrbed. " In suppon of ths objective we recommend that PHS: 
Promote research on prescrption medication compliance, and examine the issue as a 
possible topic for clinical practice guidelines. 
Evaluate CUITent programs which do or can promote education and trining of health 
care practitioners on improving medication compliance among the elderly. These 
evaluations should include programs within Area Health Education Centers,  Community and Migrant Health Centers, Geriatrc Education Centers, and the Indian 
Health Service. Programs which lack education and training in medication compliance 
should be provided the resources to develop such education and training programs 
especially suited to their clients. 
Administration on Aging 
Among other activities, the AoA has addssed the issue of mismedication and noncompliance 
among the elderly by awarding grants and by disseminating information though State and 
Area Aging Agencies. AoA's " Annual Statement of Goals for 1990 and Beyond," lists several 
goal areas that relate to the elderly s medcation problems. We recommend that AoA: 
Through State and Ara Aging Agencies continue to disseminate informational 
materials and provide educational programs to help the elderly avoid medication 
problems. 
Encourage medcal schools to apply for those health promotion or training funds that 
could be used to stress the physician s responsibilty to improve medication compliance. 
Direct some discretionar  to programs aimed at addressing medication 
grt money 
compliance problems among minority elderly groups. 
Assess the potential of home car programs to provide compliance-improving servces 
(such as the distrbution of medication reminder chars,) and implement such services as 
appropriate. 
Public Health Service and Administration on Aging 
Since 1984, representatives of PHS and AoA have met quarerly in the Committee for Joint 
Health Promotion to discuss health issues related to the elderly. Mismedication in 
genera and 
noncompliance as a contrbutor to mismedication should be a priority topic at one or more of 
these meetings. 
Health Care Financing Administration

The direct and indirect costs of prescription medication misuse among the ambulatory elderly, 
includig noncompliance, are often borne by the Medicar and Medicaid progrs. With
the Office of Research and Development, HCFA has looked at utilization of prescription 
medications among nursing home residents. In addition to this work, we recommend that 
HCFA' s Offce of Research and Development: 
Initiate demonstration projects in the States which address the problems of 
elderly. These 
noncompliance with prescrption medications among the 
 ambulatory  projects should include test models which would determine which forms of physician 
pharacist, and patient education work best to improve compliance. 
COMMENTS ON THE DRAFT REPORT 
We received comments from PHS, AoA, HCFA and ASPE on the draft of this report. 
The 
comments ar included in ApP" ndix A. Responses from al four agencies were favorable. The 
PHS, AoA and HCFA generally concurd with all OIG recommendations. These agencies 
also descrbed activities which have been or wil be taen to addess OIG recommendations. 
For example, through the National Institutes of Health (Nl), PHS is funding research 
dicted toward better medication use for older persons. The PHS wil also evaluate the 
education and training services offered to health car practitioners though geriatrc education 
centers (GEC) and ara health education centers (AHC) on the topic of the elderly and 
prescription drg noncompliance. 
The AoA wil continue to provide informational materials and trning to support the efforts of
State and Area Agencies on Aging in the area of proper medication use. The AoA also 
suggested the possibilty of encourging medcal schools to. apply for health promotion or
training funds appropriate to the subject of the elderly and noncompliance. 
Both PHS and AoA have agreed to discuss the topic of the elderly and medication at a 
National Initiative on Health Promotion and the Aging meeting. 
The HCFA is cUITently funding varous projects which addrss inappropriate use of drgs by
both the general population and among 
nuring home residents. The HCFA wil consider 
including funding for demonstrtion projects which 
assess the forms of education most likely 
to improve compliance with prescription medication regiens. 
We appreciate the agencies' supportve review of the report and its recommendations.  APPENDIX A 
PHS, AoA, HCFA, and ASPE Comments  !(et 
Of 
DEPARTMENT OF HEALTH Ia HUMAN SERVICES of th 
gIng 
Adrmmsttatlon on  Wnhington. D.C. 20201

fgg
JUL I 
DATE:
TO:(cid:1) Richard P. Kusserow
Inspector General
FROM:  s. Commsioner on Agig
SUBJECT:(cid:1) Comments on OIG Draf Report; "Reducig Medication Problems of the 
Elderly," OEI-04-89-89122 
, wlrch requested comments from 
This is in response to your memorandum of June 21, 1990
the Admstration on Aging (AoA) on this report. I am pleased to have thi opportnity 
and would offer the fonowing comments: 
The report is well reasoned and contais a strong factal basis for its fidings. AoA 
recommendation that education is the key to improvig 
concurs with the overal 
repon notes, many of the AoA
compliance with proper medicatiotnr raeiggie s. As the  th 
sponsored health promotion and  actities follow  premie.
wi 
With regard to the specific recommendations addressed to AoA, AoA  continue 
to provde  and traiing to support the effort of State and 
informational material 
Area Agencies on Agg in the area of proper use of medication. It may interest you 
to know that each of the ten AoA Regional Offces wil be convenig regional health 
promotion meetings over the  month. The issue of appropriate use of 
comig  lS 
medication is among the issues which wil be addressed by these conferences. In 
we begi the process 
addition, AoA wm seriously consider your recommendations. as 
ano 
of developing the priorities for our FY 1991 discretionary  ncement. 
rediect some of the 
Your second recommendation calls for AoA to " grt money

olleges to medical schools" for project which stress the

-g ipvehn ytos pihcairamancy  
s responsibillty to nnprove p  ient compHance. - would poiiifciut that iliere 
pharacy colleges. AoA wi 
are no funds specificay earmarked to  consider the 
promotion or 
possibilty of encouraging medical schools to apply for such health 
training funds as may be appropriate for thi subject area. 
conside'.f 
In any revisions which you make to your recommendations you may wish to 
the potential role of the Geriatric Education Centers (GECs) funded by the Burcav 
Admitrtion, 
of Health Professions, Health Resources  Public Health Servce. 
Since each GEC must have a medical school component, they might be in a position
to make a contdbution in this area. compUance 
You have recommended that AoA and PHS raise the issue of medication 
Promotion and the 
on our National Intiative on Health 
in our quarterly meetings 
s offce to resume 
Aging. We have initiated discussions with the Surgeon Genera'
th 
topic be included in the discussions. 
these meetings and wil propose that 
I hope that you fid these comments helpful. 
&ce 
Tl Beny, Ph. .  ..-.
Public Health Service 
SERVICES 
ARTMENT OF HEALTH & HUMAN 
Memorandum 
AUG 2 2  190 
Assistant Secretary for Health 
Elderly, 
Keducing Medication Problems of the 
OIG Draft Report
OEI-04-B9-B9l22 
Inspector General

Attached are the PHS comments on the subject OIG craft report. 
We concur wi th the three recommendations addressed to tthheem P.ublic 
we are taking actions to implement 
Health Service and 
0' 
D., pr. 
Mason, 
Attachment  ..--..' 
COMMNTS OF THE PUBLIC HEATH SERVICE ON THE OFFICE 
DRAT REPORT 
Q! INSPECTOR GENE
REDUCING MEDICATION PROBLEMS OF THE 
" OEI-04-B9-89l22 
ELDERLY 1 
QIG Recommendation
We recommend that PHS:
Promote research on prescription medication compliance and
examne the issue as a possible topic for clinical 
practice guidelines.
PHS Cornen t 
Natio  l Institutes of Health (NIB) has iS8ued 
We concur. The  "Pha:mcology in 
(RFA) entitled 
a request for applil!c wathiiconh   range of 
solicits a comprehensi 
Geriatric Medicine 
research directed toward better medication use for older
persons. The research Includes techniques to tmprove dru
prescribing, avoiding adverse cdormuqo nr ecaacutsieosn so,f  farnad ilt mtypr oanvded 
phar.acologi  treatments for 
disability 
In that regard, research intoim tpmporrotvnitn gp art of this 
prescription medication compliance is an 
effort  ns were received by 
One hundred and sixteen applicati 
review. NIH plans to award 
NIB and are currently under 
approxim tely eight qrants totaling some $2 million in fiscal
year 
(FY) 1991. 
In addition, the Agency for Health care policy andst uRdeyse, arch 
(AHCPR) is currently funding a major feasibility' 
Related Hospitalization, . which will quantify
Geriatric Drug- admssi9 
drug-related adverse events aSBoc1ated with hospital 
of the elderly. AHCPR expects to sponsor a foellelomwunpt . study that
will include patient compliance as a central 
AHCPR is also facilitating the development of practice
areas. As it develops these
guidelines in seven clineixcaaml ne the issue of medication 
guidelines, inAH tChPeR  twhirlel e clinical. areas il whc.h JPedication 1s a 
compliance 
These areas include:
central element of the treatment.  2) urinary 
1) diagnosis and treatment of benign prmosataagteimc,e nt. 
adult, and 3) pain 
incontinence in the 
OIG Recommendation 
s which do or can promote
EValuate current proqr 
'rese 
education and training of health care practitioners on
improving medication compliparnocge raammo nwg itthhien  ealrdeear hlye.a lth 
evaluations should includei  ty 
and migrant health centers, 
educa 
tion centers,  ceters, and the Indian Health
qeriatric education  training. in 
Service.  educa1;ion  anci 
programs whi6 
compliance should be provided the resources to 
medica tion  aining program especially 
to their clients. 
develop such education and t 
sui ted 
PHS Commen 
We concur. In FY 1991 the Health Resources and Services 
Adnistra tion (HRSA) will ascertain the extent to which the 
(GEC) and area health 
current geriatric education centers 
educat  on centers (AHC) provide education and training of
provinq medication ccmp11ance 
health care practitioners on  In FY 1992, based on the resul te of the 
among the elderly. 
evaluation, HRSA will consider modifying the funding priority 
of the AHEC Program to integrat& educational offerings on the 
patient noncompliance for 
topic of pharmcogeriatrics and 
The above actions are 
practicing health professionals. 
inq of the AHC and GEC 
contingent upon the continued fun 
Programs. currently, these programs are not included in the 
1991. 
President' s Budget for FY 
es of the final 
Later this year, HRSA will distribute cop 
version of this OIG report to its community and mmi;area antll .h heaelatlhth 
centers (C/MHC  ) and strongly encourage them to 
pro  ers  aware of this problem and obtain continuinq 
needed. In addition, by the end of 
professional education as 
FY 1991, PHS will have developed a new site-visit protocol for 
ascertain, at that level, vtihsei tn eed
C/MHCs which will help to  Site 
for education and training of practitioners. 
reviewers can then make appropriate recommendations to the
C /MHCs . 
(IRS) has the largest direct health 
The Indian Health Service  numer of elderly 
care program in PHS. There is an increasing 
patients being seen in IRS hospitals and clinics, and
pha  cists are extensively involved in counseling all patient 
Py 1991 IHS will review the 
on medication compliance. DUring 
content of. its pha.rmcy, training progthrea "m se ldanedr lyin;.c-l 'uIRdeS -mwialtle,r ialaslo , 
to improve medication compli;uice- irf  supplementa teaching 
complete an instructional video with  cists and other 
materials which is designedde tteor mtnrae. p: apth  ents ' understanding of 
heal th care providers to  applicat1  n in 
their medication. This will have specifi 
elderly. The instructional video 
medication compliance in the 
se in all XHS 
1991. The 
wfilal bec aviailliab lte ifoer disstr ibution and
by the end of the first quarter of FY 
video will also be made available to all major professpihoanramlc y 
organizations in pharmacy as well as all colleges of 
in the united States.  OIG Recommendation
Since 1984, representatives of PHS and the Admnistration on

Aging (AOA) have met quarterly with the Commttee for Joint
Health Promotion to discuss health issues related to the

elderly. 
Mismedication in general and noncompliance as a

contributor to mismedication should be a priority topic at one

or more of these meetings.

PHS Cornen t
We concur. This topic will be taken up at the next meeting of

the Subcommttee.

Technical Comments

Page 3 - M which is included as a 
Economic condition, 
behavioral factor,. might be better represented if 1
were separately cateqorized as a f.actor. 
?age 4 -
 The goal to "reduce the incidence of adverse drug 
reaction among people age 65 and older to 8. S per
100, 000" was included in the public review draft of 
the Year 2000 Objectives for the Nation. However, 
it is being removed from the final draft which is to 
be published on Septembr 6, 1990. '  . .. 
.., 
Health Care -
DEPARTMENT OF ilEALm It HUMAN SERVICE  Financing Adminisration 
N1  0 I9  Memorandurn' 
Gail R." Wilensky,  Ph. D. 
Administrator . 
ect	 OIG Draft Report: "Reducing Medication Problems of the 
Elderly" -OEI-04-89-89122 
The Inspector General" 
Office of the Secretary 
We have reviewed the subj ect draft report which discusses 
the extent to which and the reasons why the elderly may have 
difficulty complying with their medication reqimens. 
The report recommends that HCFA should initiate
demonstration proj ects in the States which address the 
problems of noncompliance with prescription medication 
reqimens amonq the ambulatory elderly. These proj ects should 
include test models which would determine which forms of
physician, 
phairmaacnisct,e a nd. p atient education work best to 
improve compl 
HCFA is currently pursuing a number ot research and 
demonstration projects that are studying methods to reduce the 
inappropriate use of drugs by the elderly. Examples of these 
followinq: 
projects include the 
The University of Minnesota has developed a taxonomy of 
inappropriate use of medications as a result of a study 
f psychotropic drug use amonq Medicare beneficiaries 
residents. In 
who are nursinq home  addition, Minnesota 
identify-
is currently involved in research which will 
classify, and evaluate alternate approaches to Drug 
utilization Review in private sector hea'th insurance
plans. 
Brandeis is studying the existing Medicaid druq data in 
t s 
order to assess its usefulness for enhancing HCFA 
understanding of the quality and effectiveness of druq 
utilization among Medicaid populations.  Page 2 - The Inspector General
The Uni versi ty of Wisconsin and SysteMetrics are 
studying medication use in quality of care indicators 
. f  r nursing home patients and drug utilization and 
expenditures among ambulatory Medicaid recipients,
respectively. 
Using the Pennsylvania Pharmaceutical 
Assistance Survey data, Pennsylvania state University
is analyzinq patterns of pharmaceutical use and adverse
drug reactions. 
with the repeal of the druq benefit under Medicare, we
are reassessing our research and demonstration priorities in
the drug area. As we develop our strateqy, we will consider
OIG t S suggestion that we  include demonstration efforts to 
assess the forms of education most likely to improve 
compliance with prescribed medication regimens. 
Please advise us whether you agree with our position on
the report t s recommendation 
at your earliest convenience.  !! 
Seet 
DEPARTMENTDE  NSERJCES 
Ofce of th 
. Washington. O.C. 2020' 
\990 
AUG . 6 
MEMORAUM 
Richard P. Kusserow 
Inspeotor General 
FROM  Assistant secretary for Planninq and Evaluation 
IIReducinq Medication 
SUBJECT:  OIG Report  Problems of the 
n-ff/ 
()I-
Elderly" 
ASPE has no comments to make about the report "Reducing
II except to 
commend the OIG
Medication Problems of the Elderly  work. 

for a fine piece of