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 

which provide prescrption drg 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 

1989, found that in 1987 an estimated 200,00 older adults were hospitaizd due to adverse 

drg reactions or experienced an adverse drg reaction while hospitazed. In Januar 1990 

we issued two drt 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 

and barers to their furer development. A companion report "The Cliical Role of the 

Community Phanacist: Case Studies:' descrbes the reent experience of severa phancy 

practitioners who are developing advanced forms of servce including counseling and drg 

utilization review. 

Attached to this document is .a four 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.€

Physiological factors: Loss of vision or hearng can impede an elderly person s abilty 

to read imponant infonnation about prescrptions or to hear instrctions about a 

regimen. Mobility limits, type of disease, symptoms of ilness, memory loss, 

depression, and cognitive impaients are other physiological varables that can€ negatively affect compliance. 

Behavioral/actors: These include social isolation, social and health beliefs, and 

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. 
Treatmentfactors: Imponant varables are the duration and complexity of the 

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. 

Health Care Provider/Patient Interactionfactors: These include how well the 

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 

the population, including the elderly. In its "Healthy People 200: 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 grt money to programs aimed at addressing medication 

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 

noncompliance with prescrption medications among the 
 ambulatory elderly. These 
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 
DEPARTMENT OF HEALTH Ia HUMAN SERVICES€ Of of th !(et 

Adrmmsttatlon on gIng Wnhington. D.C. 20201


JUL I fgg€

DATE:€

TO: Richard P. Kusserow€

Inspector General€

FROM: s. Commsioner on Agig€

SUBJECT: Comments on OIG Draf Report; "Reducig Medication Problems of the 

Elderly," OEI-04-89-89122 

This is in response to your memorandum of June 21, 1990, wlrch requested comments from 

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 

concurs with the overal recommendation that education is the key to improvig 

compliance with proper medication regies. As the repon notes, many of the AoA€

sponsored health promotion and traig actities follow th premie.€

With regard to the specific recommendations addressed to AoA, AoA wi continue 

to provde informational material and traiing to support the effort of State and 

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 comig lS month. The issue of appropriate use of 

medication is among the issues which wil be addressed by these conferences. In 

addition, AoA wm seriously consider your recommendations. as we begi the process 

of developing the priorities for our FY 1991 discretionary ano ncement. 

Your second recommendation calls for AoA to "rediect some of the grt money


olleges to medical schools" for project which stress the
 given to pharmacy 


- physician s responsibillty to nnprove p ient compHance. - would poiiifciut that iliere 

are no funds specificay earmarked to pharacy colleges. AoA wi consider the 

possibilty of encouraging medical schools to apply for such health promotion or 

training funds as may be appropriate for thi subject area. 

In any revisions which you make to your recommendations you may wish to conside'.f 

the potential role of the Geriatric Education Centers (GECs) funded by the Burcav 

of Health Professions, Health Resources Admitrtion, 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.€
You have recommended that AoA and PHS raise the issue of medication compUance 

in our quarterly meetings on our National Intiative on Health Promotion and the 

Aging. We have initiated discussions with the Surgeon Genera's offce to resume 

these meetings and wil propose that th topic be included in the discussions. 

I hope that you fid these comments helpful. 

&ce Tl Beny, Ph. . 
..

.

Public Health Service 

ARTMENT OF HEALTH & HUMAN SERVICES 

Memorandum 

AUG 2 2 190 

Assistant Secretary for Health 

Keducing Medication Problems of the Elderly, 

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 the Public them.

Health Service and we are taking actions to implement 

0' 

Mason, D., pr. 

Attachment 
..

..

COMMNTS OF THE PUBLIC HEATH SERVICE ON THE OFFICE 

DRAT REPORT 

Q! INSPECTOR GENE REDUCING MEDICATION PROBLEMS OF THE 

ELDERLY 1 " OEI-04-B9-89l22 

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 

We concur. The Natio l Institutes of Health (NIB) has iS8ued 

a request for application (RFA) entitled "Pha:mcology in 

Geriatric Medicine l! which solicits a comprehensi range of 

research directed toward better medication use for older€

persons. The research Includes techniques to tmprove dru€

prescribing, avoiding adverse druq reactions, and tmproved

phar.acologi treatments for comon causes of frail ty and 

disability In that regard, research into tmproving 

prescription medication compliance is an importnt part of this 

effort One hundred and sixteen applicati ns were received by 

NIB and are currently under review. NIH plans to award 

approxim tely eight qrants totaling some $2 million in fiscal

year (FY) 1991. 

In addition, the Agency for Health care policy and Research 

(AHCPR) is currently funding a major feasibility' study, 

Geriatric Drug-Related Hospitalization, . which will quantify admssi9 

drug-related adverse events aSBoc1ated with hospital €

of the elderly. AHCPR expects to sponsor a followup study that€ elemnt. will include patient compliance as a central €

AHCPR is also facilitating the development of practice areas. As it develops these

guidelines in seven clinical 

guidelines, AHCPR will examne the issue of medication 

compliance in the three clinical. areas il whc.h JPedication 1s a 

central element of the treatment. These areas include:€

1) diagnosis and treatment of benign prostatic, 2) urinary 

incontinence in the adult, and 3) pain maagement. 

OIG Recommendation 

EValuate current proqr s which do or can promote€

education and training of health care practitioners on€ 'rese 

improving medication compliance among the elderly. 

evaluations should include program within area health 

educa tion centers, i ty and migrant health centers, 

qeriatric education ceters, and the Indian Health€
Service. programs whi6 educa1;ion anci training. in 

medica tion compliance should be provided the resources to 

develop such education and t aining program especially 

sui ted to their clients. 

PHS Commen 

We concur. In FY 1991 the Health Resources and Services 

Adnistra tion (HRSA) will ascertain the extent to which the 

current geriatric education centers (GEC) and area health 

educat on centers (AHC) provide education and training of

provinq medication ccmp11ance health care practitioners on 

among the elderly. In FY 1992, based on the resul te of the 

evaluation, HRSA will consider modifying the funding priority 

of the AHEC Program to integrat& educational offerings on the 

topic of pharmcogeriatrics and patient noncompliance for 

practicing health professionals. The above actions are 

contingent upon the continued fun inq of the AHC and GEC 

Programs. currently, these programs are not included in the 

President' s Budget for FY 1991. 

es of the final 

Later this year, HRSA will distribute cop 

version of this OIG report to its community and mi;rant health

centers (C/MHC ) and strongly encourage them to mae all. health 

pro ers aware of this problem and obtain continuinq 

professional education as needed. In addition, by the end of 

FY 1991, PHS will have developed a new site-visit protocol for 

C/MHCs which will help to ascertain, at that level, the need Site visit 

for education and training of practitioners. €

reviewers can then make appropriate recommendations to the€

C /MHCs . 

The Indian Health Service (IRS) has the largest direct health 

care program in PHS. There is an increasing numer of elderly 

patients being seen in IRS hospitals and clinics, and

pha cists are extensively involved in counseling all patient 

on medication compliance. DUring Py 1991 IHS will review the 

content of. its pha.rmcy, training programs and include material 

to improve medication compli;uice- irf the " elderly;.- 'IRS- will, also, 

complete an instructional video with supplementa teaching 

cists and other 

materials which is designed to tra.: ph 

heal th care providers to determne pat ents ' understanding of 

their medication. This will have specifi applicat1 n in 

instructional video 

medication compliance in the elderly. These in all XHS will be available for distribution and facili ties by the end of the first quarter of FY 1991. The 

video will also be made available to all major professional 

organizations in pharmacy as well as all colleges of pharmcy 

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 -€

?age 4 -


Economic condition, M which is included as a 

behavioral factor,. might be better represented if 1 were separately cateqorized as a f.actor. 

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, pharmacist, and patient education work best to 

improve compl iance . 

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 

projects include the followinq: 

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 

who are nursinq home residents. In addition, Minnesota 

is currently involved in research which will identifyclassify, and evaluate alternate approaches to Drug 

utilization Review in private sector hea'th insurance

plans. 

Brandeis is studying the existing Medicaid druq data in 

order to assess its usefulness for enhancing HCFA t s 

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. 
!! 

DEPARTMENTDE NSERJCES Ofce of th Seet 

. Washington. O.C. 2020' 

AUG . 6 \990 

MEMORAUM 

Richard P. Kusserow 

Inspeotor General 

FROM Assistant secretary for Planninq and Evaluation 

SUBJECT: OIG Report IIReducinq Medication Problems of the 

Elderly" ()I-n-ff/ 

ASPE has no comments to make about the report "Reducing€

Medication Problems of the Elderly II except to commend the OIG€

for a fine piece of work.