Chapter 18. Medication Management of the 

Community-Dwelling Older Adult 

Karen Dorman Marek, Lisa Antle 

Background 

For many older adults, the ability to remain independent in one’s home depends on the ability 

to manage a complicated medication regimen. Nonadherence to medication regimens is a major 

cause of nursing home placement of frail older adults.1

 In the United States, an estimated 3 

million older adults are admitted to nursing homes due to drug-related problems at an estimated 

annual cost of more than $14 billion.2

 Older adults are the largest users of prescription 

medication, yet with advancing age they are more vulnerable to adverse reactions to the 

medications they are taking. Approximately 30 percent of hospital admissions of older adults are 

drug related, with more than 11 percent attributed to medication nonadherence and 10–17 

percent related to adverse drug reactions (ADRs).3–5 Older adults discharged from the hospital on 

more than five drugs are more likely to visit the emergency department (ED) and be 

rehospitalized during the first 6 months after discharge.6 Nursing interventions that assist older 

adults in managing their medications can help prevent unnecessary, costly nursing home 

admissions, hospitalizations, and ED visits, as well as improve their quality of life. 

The purpose of this review was to identify evidence-based interventions related to medication 

management and the community-dwelling older adult. The focus of this review was interventions 

that fall within the scope of practice of the registered nurse. The guidelines do not address the 

specific intervention of medication prescribing. However, the interventions are applicable to 

professional nurse providers whether they are prescribing or not. This chapter discusses risk 

factors for problems in medication management followed by evidence-based interventions in 

areas of medication reconciliation, medication procurement, medication knowledge, physical 

ability, cognitive capacity, intentional nonadherence, and ongoing monitoring. 

Risk Factors 

There is a wide variety of factors that place the community-dwelling older adult at risk for 

problems in medication management. The young-old (ages 66–74) have been found to be more 

adherent to medication regimens than middle-aged older adults, but after age 75, older adults 

present decreased comprehension of medication instructions and adherence.7–15 Living 

arrangements influence the older person’s ability to manage medications, and older adults who 

live alone were found to be more prone to medication errors.16–21 It is postulated that this is 

related to the fact that there is no one to monitor, assist, or remind the older person about taking 

their medications. Persons with chronic disease, especially depression, have a higher incidence 

of nonadherence to their medication regimen.7, 10, 22–30 Many of the risk factors related to 

inadequate medication management are items that are more prevalent in older adults living in the 

community. Other factors that will be discussed in more detail later in the chapter are physical 

impairments such as poor vision, grip strength, and cognitive decline. 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Older adults are more prone to adverse events due to the clinical complexity of their care 

rather than age-based discrimination.31 A study of older adult outpatients who took five or more 

medications found that 35 percent experienced adverse drug events.32 In addition, individuals 

with complex regimens had difficulty naming and explaining the purposes of medications and 

appeared to be at high risk for nonadherence.33 The greater the medication complexity, the less 

likely the older adult is to adhere to the medication regimen.34 The larger the number of 

medications, the more likely the older adult will be nonadherent.3, 9, 13, 19, 28, 35–46 It is not only the 

number of medications but also the number of doses per day and actions related to taking 

medications that contribute to complexity of a medication regimen.34 In a study of medication 

compliance, the compliance rate was 87 percent for daily dosing, 81 percent for twice a day, 77 

percent for three times a day, and 39 percent for four times a day.47 In addition, a change in 

prescribed drug regimen has been found to be a predictor of medication nonadherence in older 

adults.9

 Finally, the number of prescribing providers adds to the complexity of managing one’s 

medications, and persons with more than one prescribing provider were found to be prone to 

medication errors.16, 19

Research Evidence 

Medication Reconciliation 

Medication reconciliation is the first step in assisting older adults in the medication 

management process. Multiple studies have demonstrated discrepancies from 30 percent to 66 

percent in what medications were ordered by the prescribing provider and the actual medications 

the older adult was taking.16, 48–52 Prescribing providers were often unaware of prescribed 

medications their patients were taking,16, 53–55 and the larger the number of prescribing providers, 

the greater the chance of medication discrepancies.3, 42, 56, 57 A study of elderly patients 2 days 

after hospital discharge found 64 percent were taking at least one medication that was not 

ordered, 73 percent failed to use at least one medication according to instructions, and 32 percent 

were not taking all drugs ordered at discharge.58 Another challenge in reconciliation of 

medications is determining exactly what medications older adults are taking in their home. One 

study found 49 percent of community-based older adults kept stores of old medications from the 

year before, and 6 percent admitted they self-prescribed medications on at least one occasion.59

Over the counter (OTC) medication use also needs to be assessed, because estimates of older 

adults’ use of OTC drugs range from 32 percent to 86 percent.60–62 A recent study of older adults 

with hypertension attending a blood pressure clinic found 86 percent reported two or more selfmedication practices using OTC drugs that could result in an adverse drug interaction.63

Multiple studies have demonstrated that 10–74 percent of medications prescribed for older 

adults were inappropriate.48, 57, 64–74 A study of “brown bag” medication reviews, in which 

patients bring all of their medications with them (often in a brown paper bag) to a medical or 

pharmacy consultation, revealed that 12 percent of the patients had medication problems that 

could potentially result in hospital admission.75 A review of ED visits of patients 65 years and 

older found 10.6 percent of the visits were related to an adverse drug event, and 31 percent had at 

least one potential adverse drug interaction in their medication regimen. 

Pharmacy reviews have demonstrated a reduction in polypharmacy in older adults and 

decreased adverse drug events in older patients.76–82 Beer’s set of criteria for potentially 

inappropriate medication use in older adults is one example of criteria developed for pharmacy 

2 
Medication Management 

screening.83, 84 There are a variety of drug interaction programs that quickly identify adverse drug 

interactions. 

Also, patients who were given a medication card with a list of current medications were more 

compliant with their medication regimen.85 Use of a medication list that is shared with the 

patient’s primary care physician decreased patient rehospitalizations in one study.86

Medication Procurement 

Not filling or refilling prescriptions is a common cause for medication nonadherence in older 

adults.87–91 In a study of elderly patients at 15 days posthospitalization, 27 percent had not filled 

their new prescriptions.92 Patients who participated in programs that provided pharmacy delivery 

and refill reminders had fewer adverse drug events and higher compliance than those who did 

not.78

If the cost of medication is viewed as high, older adults are more likely to not adhere to their 

medication regimen and be hospitalized.3, 11, 56 Lack of funds, especially at the end of the month, 

is one reason older adults delay filling prescriptions.93 In addition, chronically ill older adults are 

more likely to experience financial burdens associated with covering out-of-pocket costs for their 

prescription medications, cut back on medications due to cost, and use less medicines monthly.89, 

93–98 A study of use of medications after an increase in the copayment found a reduction in use of 

up to 45 percent in nonsteroidal anti-inflammatory drugs and 23 percent in antidiabetic drugs.99

Older adults who have insurance to cover medications have greater adherence.12, 14, 19, 100 In 

one study, both adherence to medications and clinical outcomes improved while the number of 

hospitalizations declined when cardiovascular drugs were provided to indigent patients who 

could not afford to buy them.101

Medication Knowledge 

Studies of older adults’ knowledge of medications have found more than 50 percent knew the 

names and purpose of their medications; however, less than 25 percent knew the consequences 

of drug omission or toxic side effects.9, 16, 54, 102 For example, one study of elderly patients with 

congestive heart failure found that 30 days after a new medication was prescribed, only 64 

percent of the patients could identify when they were supposed to take their medicine.103 Also, 

older adults were found to have insufficient knowledge of inhaler technique and understanding 

how medications can improve their asthma.104 Noncompliant patients on anticoagulant therapy 

were more likely to report they did not know why their medication was prescribed.105 In a study 

of OTC medication use, few older adults knew precautions related to the OTC drugs they were 

taking.61 One study of older adult medication knowledge found that older adults understood 

prescribed medications better than OTC drugs, especially nutritional supplements.106

Patient education is a key intervention to assist older adults with medication management. 

Patient knowledge of drugs is positively associated with adherence.16, 21, 91, 105, 107–112 However, 

older adults require specific educational methods. Learning is more effective in older adults if 

information is explicit, organized in lists, and in logical order. Instructions that are compatible 

with the older adults’ schema for taking medications are better remembered,113 and wellorganized prescription labels are more useful for older adults.114 Pictures are not helpful unless 

the picture is clearly related to the content.115–118 A combination of both oral and written formats 

was identified by older adults as most helpful.119 Medication schedules or charts in combination 

with teaching or counseling enhances patient medication adherence.85, 86, 120–124 Four weeks after 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

starting a new medication for a chronic illness, patients identified a substantial need for further 

information.125 Studies have demonstrated that patient education and counseling over several 

home visits or with followup phone calls produces increased medication adherence in 

recipients.126–141

Physical Ability 

Poor vision and low manual dexterity are associated with poor medication selfmanagement.9,21,39,142–144 The inability to read medication labels has been associated with 

nonadherence to long-term medications in the elderly.43,145 One study found 28 percent of 

community-based older adults did not keep their medication bottles properly closed so that they 

could open them, and 47 percent admitted that labels on their medications were unclear and they 

could not read them due to poor eyesight, inability to read English, or small writing on the 

label.59 Studies have demonstrated that from 31 percent to 64 percent of older adults living at 

home have difficulty opening medication containers, with childproof containers presenting the 

most difficulty.9,144,146 In studies of persons with chronic obstructive pulmonary disease (COPD), 

38 percent used their inhaled medications with poor technique,89 and poor hand strength was 

associated with nonadherence in inhaler use.147 In another study of COPD patients, more than 50 

percent had difficulties with their inhalers.112

Medication-container modification is one area of intervention for older adults who have 

difficulty opening or reading containers. Use of nonchildproof containers is one option for older 

adults. However, blister packs or other variations of unit dose packaging have resulted in 

increased compliance.148–150 In a recent study of older adults, 64 percent were unable to open 

childproof containers, and 10 percent were unable to use blister packs.9

 Also, different tablet 

formations that increase the ease of breaking tablets have been found to increase patients’ 

abilities to comply with their medication regimen.151 Finally, talking medication containers and 

large-print labels are modifications that can be useful for persons with visual impairment. 

Cognitive Capacity 

Poor cognition is associated with both over adherence and under adherence of a prescribed 

medication regimen.9,14,18,28,37,38,142–144,152–155 A study of community-dwelling women found that 

22 percent were unable to accurately perform a routine medication regimen; however, only 2 

percent self-identified that they had difficulty with their medications.156 Forgetting is a major 

reason medication doses are missed.9,78,88,89,157–162 The most prominent type of medication 

noncompliance is dose omission, but overconsumption is a common mistake, especially in 

persons on a once-daily dose schedule.163

There are a number of interventions to assist older adults with remembering to take their 

medications. One simple method is the use of memory cues that prompt patients to take their 

medications.148 Development of memory cues must be tailored to the patient’s lifestyle.90,164

Placing medication in a special place and use of a daily event such as meal time improve 

medication adherence.91,106,165,166 A study that examined the most common ways older adults 

remembered to take their medications found the following methods to be beneficial: (1) placing 

containers in a particular location, (2) taking medications in association with meals/bedtime, (3) 

using a timed pill box, (4) reminders from another person, and (5) using written directions or a 

check-off list.159

4 
Medication Management 

Compliance aids such as pill box organizers have been found to increase medication 

adherence.16,78 Medication schedules and calendars are helpful, especially in combination with 

education and use of a pill box.38,40,78,120,150,167,168 In addition, electronic monitoring that provides 

feedback to the user increases adherence.141,169–171 Older patients using a voice-remindermessage medication dispenser were significantly more compliant than those using a pill box or 

self-administering medications.172,173 Patients using topical pilocarpine were significantly more 

compliant using an electronic medication alarm device.174 Programs that use daily telephone 

reminder calls also have demonstrated increased medication compliance.155,175 Several studies 

have demonstrated that dose simplification from two times a day to one time a day produces 

higher compliance and improved patient outcomes.122,176–182

Intentional Nonadherence 

One study of chronically ill persons who were starting a new medication found that almost a 

third did not take their medication as prescribed, and half of the time it was deliberate.125 Older 

adults’ perceptions of the seriousness of their illness and vulnerability to complications were 

significantly related to medication adherence.13,46,90,91,97,166,183 In fact, low self-efficacy and 

beliefs that others are responsible for one’s health care are predictors of medication 

nonadherence.21,89,105,159,184–194

A major reason that older adults skip doses or stop taking their medications is related to 

medication side effects.9,11,16,26,38,46,89,91,93,110,125,159,161,162,191,195–198 In a comparison of compliant 

and noncompliant patients in fluvastatin treatment, the noncompliant patients were more likely to 

experience side effects of the medication.199 Six months after discharge for acute coronary 

syndrome, 8 percent of those taking aspirin,12 percent of those taking beta-blockers, 20 percent 

of those taking ACE inhibitors, and 13 percent of those taking statins had discontinued taking 

their medications.200

Use of commitment-based interventions has been found to increase self-efficacy and 

medication compliance.201 Education that addresses patient involvement with decisionmaking, 

such as focusing on appropriate versus inappropriate use of medication, can improve selfefficacy.202 Patients with depression who participated in a program to enhance self-management 

and prevent relapse had significantly greater long-term adherence to their medication regimen.203

Patients whose provider had an open, collaborative communication style also were more 

adherent to their medication regimen.204

Ongoing Monitoring 

Older adults have narrow therapeutic windows and require close monitoring, especially when 

on multiple medications.205 Ongoing monitoring of the older adult’s medication management is 

critical. A study of home care patients found 16 percent had skipped a medication in the last 24 

hours, 6 percent were taking the wrong dose, and 5 percent were experiencing adverse effects 

from their medication.87 In one study, symptomatic hypotension was identified in 13 percent of 

community-based elderly.67 In another study, older adults treated for urinary tract infections and 

sleeping disorders experienced a significantly higher risk of ADRs.206 A review of ED visits of 

patients 65 years and older found 10.6 percent of the visits were related to an adverse drug event, 

and 31 percent had at least one potential adverse drug interaction in their medication regimen.207

Pharmacist management of repeat prescriptions found 12.4 percent of patients had compliance 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

problems, side effects, ADRs, or drug interactions.208 A total of 35 percent of elderly ambulatory 

patients reported at least one adverse event within the previous year.209

Monitoring medication adherence is an ongoing process. The longer people are on a 

medication, the more likely they are to have difficulty following the medication regimen.179, 210

For example, in one study, only 31 percent of people with type 2 diabetes who were on oral 

hypoglycemics adhered to their medication regimen.211 In another study, persons on oral 

hypoglycemic medications were nonadherent an average of 64.7 days in one year.212 Since 

adherence to medication regimen for type 2 diabetes is strongly associated with metabolic 

control, interventions related to monitoring and improving adherence are critical.213

Patients taking Digoxin who are not adherent have an increased number and duration of 

hospitalizations and twice the mortality rate than those who are adherent.214 Also, in a study of 

long-term compliance of antihypertensive drugs, patients on ACE-inhibitors, beta-blockers, 

calcium channel blockers, and diuretics were more likely to be noncompliant,215 as were persons 

using bronchodilators and benzodiazepines.60

Practice-Implications: Medication Management 

Practice Guidelines 

Medication Reconciliation 

1. Review with patient all prescribed and nonprescribed medications the patient is taking. 

Include over-the-counter (OTC) medications, herbs, and vitamins.216 

2. Screen for adverse drug interactions. If adverse drug interactions are identified, report to 

the prescribing provider any medications of concern.76–82,84,216 

3. Identify the primary or secondary medical diagnosis related to each prescribed 

medication. If the medical diagnosis is unknown, request the diagnosis from the 

prescribing provider.84,216

4. For patients age 65 and older, apply Beer’s criteria for inappropriate medication for the 

elderly. If any medications appear in Beer’s criteria, report to the prescribing provider 

any medications of concern.84

5. Provide to the prescribing provider(s) a list of all medications (prescribed and OTC) the 

patient is taking and a list of corresponding medical diagnoses.216

6. Verify prescribed medications and related medical diagnoses with the prescribing 

provider(s).84

7. Provide the patient or caregiver a current list of all medications the patient is taking with 

dose and frequency; have the patient share this list with the prescribing provider or other 

health care providers as needed.85,86,216

Medication Procurement 

1. Assess the patient’s or caregiver’s ability to procure medications.87–92

a. Identify how and where the patient obtains and refills prescriptions.87–92

b. Assess how the patient pays for medications.3,11,56

c. Assess if medications doses are ever missed due to lack of funds.93

2. If the patient or caregiver has difficulty obtaining or refilling prescriptions, assist the 

patient with creating a system to procure medications via 

6 
Medication Management 

a. Pharmacy delivery.78

b. Refill reminders or automatic refill service.78

c. Scheduling family or friends to pick up medications. 

3. If funds to purchase medication are a problem,89,93–98

a. Refer the patient to a social worker to obtain Medicare Part D coverage, other 

insurance coverage, or participation in drug company programs.12,14,19,99,100

b. Consult with the pharmacist regarding use of generic drugs. 

c. Consult the prescribing physician about availability of drug samples.101

Medication Knowledge 

1. Assess the patient’s or caregiver’s knowledge of 

a. Dose and frequency of medications taken.9,16,33,54,102,103

b. Special instructions related to medications, such as “take with food.”33

i. If the patient uses an inhaler, understanding of the correct inhaler 

technique.104

c. Medication mode of action.9,16,54,102 

d. Side effects to monitor and report.9,16,54,102

2. With each change in medication regimen (including OTC drugs), review medication 

purpose, dosage, frequency, side effects to monitor and report, and other medicationspecific instructions.61

3. Interventions related to medication knowledge include16,21,91,105,107–112

a. Provide written instructions related to medications in large letters and bullet or list 

format.115–119

b. Tailor instructions to how the patient takes his or her medicine.113

c. Group information starting with generalized information, followed by how to take 

the medicine, and then the outcomes such as side effects to watch for and when to 

call the doctor.114–118

d. Use medication schedules or charts to reinforce instructions.85,86,120–124

e. If the patient did not know important medication information at a previous 

encounter, review dose, time, side effects to monitor and report, and special 

instructions at the next visit.125–141

Physical Ability 

1. Assess for decreased manual dexterity or vision impairment and its affect on the patient’s 

ability to identify the correct medication, open medication containers, and prepare 

medications (e.g., breaking tablets) for administration.9,21,39,43,142–145

a. Observe the patient opening medication containers.9,59,144,146

b. If the patient uses an inhaler, observe the use of the inhaler.89,112,147

c. If the patient is required to break tablets, assess his or her ability to do so.151

d. If the patient is unable to open or see the label and contents of each medication 

container, provide one of the following: 

i. Pill box or other easy-open container.150,172,217 If the patient is unable to 

fill the pill box, identify someone who can assist him or her. 

ii. Medication calendar with pill box.155,167,168,218

iii. Blister packs.138,149 Consult the pharmacy about the availability of the drug 

in blister packs or nonchildproof containers. 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

iv. If tablet breaking is required and the patient has difficulty doing it, consult 

with the pharmacist about tablets that are easier to break or tablets that are 

the correct dosage without requiring breaking.151

Cognitive Capacity 

1. Assess the patient’s or caregiver’s cognitive capacity to organize and remember to 

administer medication.106, 156 

a. Assess when doses are taken. 

b. Assess what cues the patient uses to remember to take medication. 

c. Assess what dose is most difficult to remember.9,78,88,89,157–162

d. Assess how often a dose is missed or an extra dose is taken.9,14,18,28,37,38,142–144,152–

155

2. Teach the patient or caregiver the use of memory cues based on one of the following 

methods:148,159

a. Clock time. Ask if the patient or caregiver is usually aware of the time of day or 

keeps track of time through a watch or clock. 

b. Meal time.90,91,106,164–166 Ask if the patient eats meals at a regular time. 

c. Daily ritual, such as using the bathroom in the morning, shaving, or hair 

combing.90,91,106,164–166

3. If the patient requires additional support, 

a. Provide memory-enhancing methods or devices such as 

i. Medication calendar or chart.38,40,78,120,150,167,168

ii. Electronic reminder or alarm.141,169–171,174

iii. Voice-message reminder.172,173

iv. Telephone reminder.155,175

v. Pill box.16,78 (If the patient is unable to fill a pill box, identify someone 

who is willing to assist him or her.158) 

vi. Electronic medication dispensing device.173

vii. Combine methods and devices when possible.38,40,78,120,150,167,168

b. Discuss dose simplification with the prescribing provider.122,176–182

Intentional Nonadherence 

1. Assess if medication doses are missed intentionally.125

a. Drugs at high risk for intentional noncompliance include the following: 

i. ACE-inhibitors200,215

ii. Beta-blockers200,215

iii. Calcium channel blockers200,215

iv. Diuretics215

v. Bronchodilators60

vi. Benzodiazepines60

b. If the patient intentionally misses doses, assess the reason(s). 

i. Belief medication is not helping.13,46,90,91,97,166,183

ii. Fear of adverse side effects.13,46,90,91,97,166,183

iii. Side effects.9,11,16,26,38,46,89,91,93,110,125,159,161,162,191,195–198

8 
Medication Management 

c. The following medications are most risky for patients to miss: 

i. Coumadin105

ii. Digoxin214

iii. Beta-blockers200

iv. Insulin 

v. Prandinm® (repaglinide) 

vi. Antibiotics 

vii. ACE-inhibitors200

2. If the patient misses medication doses for reasons related to health beliefs, 

a. Explore with the patient his or her health concerns for not taking medication.202

b. Discuss the benefits of taking medication as prescribed.202

c. Provide positive reinforcement for taking medication as prescribed.201

3. For patients on high-risk medications, reinforce the danger of missing medication 

doses.105

4. If the patient misses medication doses for reasons related to medication side effects, 

a. Explore with the patient a plan to manage the side effects.203

b. Modify the regimen to reduce the side effects. 

Ongoing Monitoring 

1. For all patients on a prescribed medication regimen, monitor the patient with each 

encounter for the following: 

a. Medication adherence 

i. Monitor both under- and overadherence.87,179 Overconsumption occurs 

frequently in a once-daily dose schedule. 

ii. For persons using inhalers, assess 

1. Inhaler emptying rate.89,104,147

2. Reported forgetfulness.104

3. Use of short-acting inhaler.89,104

b. Medication side effects67,205

i. If medication side effects present, notify the prescribing provider, as 

appropriate. 

c. Lab work, as appropriate, for prescribed medications216

i. Cockcroft-Gault Formula or other creatinine clearance measure at least 

annually. If creatinine clearance <50 ml/min, notify the prescribing 

provider. 

d. Medication effectiveness205

i. If signs and symptoms of the problem the medication is treating are 

present, notify the prescribing provider, as appropriate. 

Research Implications 

There is a large volume of research related to medication management and the elderly. 

Medication management is a complex process that must be interdisciplinary in its approach. 

Many of the evidence-based interventions discussed are not discipline specific. A team of 

providers is needed to provide safe and therapeutic medication management. 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

There is a large amount of research related to risk factors for medication nonadherence. 

However, there is less evidence related to appropriate interventions to enhance adherence and 

medication self-management. In addition, the most effective programs have multiple 

interventions, so identifying the specific evidence for each intervention component is difficult. 

For example, one study included a combination of interventions of medication review, 

modification of containers, medication education, and a drug reminder chart.138 All are important 

components of a medication program for older adults, yet it is difficult to identify the evidence 

supporting each component. What is promising is the use of technology to assist in medication 

management.173,219 This includes clinical screening software for adverse drug interaction and 

potentially inappropriate prescribed medications, electronic adherence monitoring, and electronic 

medication reminders. Much of this new technology is currently being tested. 

Conclusion 

Medication management is a complex process that consists of multiple activities. Factors 

associated with problems in the performance of these activities include living alone, impaired 

vision, impaired cognitive function, ages 75 and older, having three or more medications and/or 

scheduled doses in one day, and more than one prescribing provider. Medication reconciliation is 

a key first step in medication management. Multiple studies have demonstrated large 

discrepancies in what medications are ordered by the prescribing provider and the actual 

medications the older adult is taking. Evidence supports medication reconciliation interventions 

that include a screen for inappropriate medications and adverse drug interactions, in addition to 

verification of medications that are prescribed. Other areas of medication management include 

assessment and interventions related to medication procurement, medication knowledge, 

physical ability, cognitive capacity, and intentional nonadherence. Ongoing monitoring of these 

areas is crucial. 

Nurses play a pivotal role in the medication management process of older adults. Considering 

the expense of prescription drugs in the current health care system, a small investment in 

providing comprehensive assessment and interventions to assist older adults in accurate and safe 

management of their medications will provide cost-effective care and increase the quality of life 

of older adults struggling to manage their often-complex medication regimens. 

Search Strategy 

To conduct this review, a search was done in August 2005 of PubMed®, the Cumulative 

Index to Nursing & Allied Health Literature, Cochrane Database of Systematic Reviews, 

HealthStar, ISI Web of Science, Social Service Abstracts, Database of Abstracts of Reviews of 

Effectiveness, and Internet searches for citations occurring from January 1990 to August 2005. 

Key search terms used alone and in combination included medication adherence, compliance, 

elderly; aged; outcomes; polypharmacy; medication management; chronic illness; chronic 

disease; and individual types of chronic illnesses. All searches were limited to patients ages 65 

and older and Web sites in the English language. The ISI Web of Science was used to track 

citations to major works, and article references were reviewed for inclusion. Bibliographies of 

retrieved articles also were searched for relevant articles not identified in the reference database 

searches. 

10 
Medication Management 

11 

Author Affiliations 

Karen Dorman Marek, Ph.D., M.B.A., R.N., F.A.A.N., associate professor, University of 

Wisconsin Milwaukee College of Nursing; e-mail: Kmarek@uwm.edu. 

Lisa Antle, A.P.R.N., B.C., A.P.N.P, clinical assistant professor, University of Wisconsin 

Milwaukee College of Nursing; e-mail: llantle@uwm.edu. 

Acknowledgment 

Development of the Medication Management of Community-Based Older Adult Guidelines 

was partially funded by the Aurora-Cerner-University of Wisconsin Milwaukee (ACW) 

Knowledge-Based Nursing Initiative. The authors would like to thank Lenore R. Wilkas, M.L.S., 

for her expert assistance. 

References 

1. Lewis A. Non-compliance: a $100 billion problem. 

The Remington Report 1997;5(4):14-5. 

2. Johnson JA, Bootman JL. Drug-related morbidity and 

mortality. A cost-of-illness model. Arch Intern Med 

1995;155(18):1949-56. 

3. Col N, Fanale JE, Kronholm P. The role of 

medication noncompliance and adverse drug 

reactions in hospitalizations of the elderly. Arch 

Intern Med 1990;150:841-5. 

4. Colt HG, Shapiro AP. Drug-induced illness as a 

cause for admission to a community hospital. J Am 

Geriatr Soc 1989;37:323-6. 

5. Hallas J, Harvald B, Gram LF, et al. Drug related 

hospital admissions: the role of definitions and 

intensity of data collection, and the possibility of 

prevention. J Intern Med1990;228(2):83-90. 

6. Alarcon T, Barcena A, Gonzalez-Montalvo JI, et al. 

Factors predictive of outcome on admission to an 

acute geriatric ward. Age Ageing 1999;28:429-32. 

7. Gray SL, Sager MA, Lestico MR, et al. Depression, 

cognitive impairment, and understanding of 

medication directions in hospitalized elderly patients. 

Pharm Res 1997;14:316-9. 

8. Morrell RW, Park DC, Kidder DP, et al. Adherence 

to antihypertensive medications across the life span. 

Gerontologist 1997;37:609-19. 

9. Nikolaus T, Kruse W, Bach M, et al. Elderly patients' 

problems with medication. An in-hospital and followup study. Eur J Clin Pharmacol 1996;49(4):255-9. 

10. Spiers MV, Kutzik DM. Self-reported memory of 

medication use by the elderly. Am J Health Syst 

Pharm 1995;52:985-90. 

11. Segal E, Tamir A, Ish-Shalom S. Compliance of 

osteoporotic patients with different treatment 

regimens. Isr Med Assoc J 2003;5(12):859-62. 

12. Kuo YF, Raji MA, Markides KS, et al. Inconsistent 

use of diabetes medications, diabetes complications, 

and mortality in older Mexican Americans over a 7-

year period: data from the Hispanic established 

population for the epidemiologic study of the elderly. 

Diabetes Care 2003;26(11):3054-60. 

13. Nelson EC, Stason WB, Neutra RR, et al. Impact of 

patient perceptions on compliance with treatment for 

hypertension. Med Care 1978;16:893-906. 

14. Raji MA, Kuo YF, Salazar JA, et al. Ethnic 

differences in antihypertensive medication use in the 

elderly. Ann Pharmacother 2004;38(2):209-14. Epub 

2003 Dec 15. 

15. Weingarten MA, Cannon BS. Age as a major factor 

affecting adherence to medication for hypertension in 

a general practice population. Fam 

Pract1988;5(4):294-6. 

16. Barat I, Andreasen F, Damsgaard EM. Drug therapy 

in the elderly: what doctors believe and patients 

actually do. Br J Clin Pharmacol 2001;51(6):615-22. 

17. Fosu GB. Social support and compliance with 

hypertensive regimens among the elderly. Journal of 

Mental Health and Aging 1995;1:7-20. 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

12 

18. Salas M, In't Veld BA, van der Linden PD, et al. 

Impaired cognitive function and compliance with 

antihypertensive drugs in elderly: the Rotterdam 

Study. Clin Pharmacol Ther 2001;70(6):561-6. 

19. Dunbar-Jacob J, Bohachick P, Mortimer MK, et al. 

Medication adherence in persons with cardiovascular 

disease. J Cardiovasc Nurs 2003;18(3):209-18. 

20. DiMatteo MR. Social support and patient adherence 

to medical treatment: a meta-analysis. Health Psychol 

2004;23(2):207-18. 

21. Lorenc L, Branthwaite A. Are older adults less 

compliant with prescribed medication than younger 

adults? Br J Clin Psychol 1993;32 (Pt 4):485-92. 

22. Carney RM, Freedland KE, Eisen SA, et al. Major 

depression and medication adherence in elderly 

patients with coronary artery disease. Health 

Psychol1995;14(1):88-90. 

23. Schron EB, Brooks MM, Gorkin L, et al. Relation of 

sociodemographic, clinical, and quality-of-life 

variables to adherence in the cardiac arrhythmia 

suppression trial. Cardiovasc Nurs 1996;32(2):1-6. 

24. Wang PS, Bohn RL, Knight E, et al. Noncompliance 

with antihypertensive medications: the impact of 

depressive symptoms and psychosocial factors. J Gen 

Intern Med2002;17(7):504-11. 

25. Ciechanowski PS, Katon WJ, Russo JE. Depression 

and diabetes: impact of depressive symptoms on 

adherence, function, and costs. Arch Intern Med 

2000;160(21):3278-85. 

26. Mohr DC, Goodkin DE, Likosky W, et al. Treatment 

of depression improves adherence to interferon beta1b therapy for multiple sclerosis. Arch Neurol 

1997;54:531-3. 

27. Kilbourne AM, Reynolds CF, Good CB, et al. How 

does depression influence diabetes medication 

adherence in older patients? Am J Geriatr Psychiatry 

2005;13(3):202-10. 

28. Maddigan SL, Farris KB, Keating N, et al. Predictors 

of older adults' capacity for medication management 

in a self-medication program: a retrospective chart 

review. J Aging Health 2003;15:332-52. 

29. McKellar JD, Humphreys K, Piette JD. Depression 

increases diabetes symptoms by complicating 

patients' self-care adherence. Diabetes Educ 

2004;30:485-92. 

30. Park H, Hong Y, Lee H, et al. Individuals with type 2 

diabetes and depressive symptoms exhibited lower 

adherence with self-care. J Clin Epidemiol 

2004;57:978-84. 

31. Thomas EJ, Brennan TA. Incidence and types of 

preventable adverse events in elderly patients: 

population based review of medical records. BMJ 

2000;320(7237):741-4. 

32. Hanlon JT, Schmader KE, Koronkowski MJ, et al. 

Adverse drug events in high risk older outpatients. J 

Am Geriatr Soc 1997;45:945-8. 

33. Spiers MV, Kutzik DM, Lamar M. Variation in 

medication understanding among the elderly. Am J 

Health Syst Pharm 2004;61:373-80. 

34. Conn VS, Taylor SG, Kelley S. Medication regimen 

complexity and adherence among older adults. Image 

J Nurs Sch 1991;23(4):231-5. 

35. Venturini F, Nichol MB, Sung JC, et al. Compliance 

with sulfonylureas in a health maintenance 

organization: a pharmacy record-based study. Ann 

Pharmacother 1999;33(3):281-8. 

36. Hulka BS, Cassel JC, Kupper LL, et al. 

Communication, compliance, and concordance 

between physicians and patients with prescribed 

medications. Am J Public Health 1976;66(9):847-53. 

37. Gray SL, Mahoney JE, Blough DK. Medication 

adherence in elderly patients receiving home health 

services following hospital discharge. Ann 

Pharmacother 2001;35(5):539-45. 

38. Okuno J, Yanagi H, Tomura S. Is cognitive 

impairment a risk factor for poor compliance among 

Japanese elderly in the community? Eur J Clin 

Pharmacol 2001;57(8):589-94. 

39. Murray MD, Darnell J, Weinberger M, et al. Factors 

contributing to medication noncompliance in elderly 

public housing tenants. Drug Intell Clin Pharm 

1986;20(2):146-52. 

40. Park DC, Morrell RW, Frieske D, et al. Cognitive 

factors and the use of over-the-counter medication 

organizers by arthritis patients. Hum Factors 

1991;33(1):57-67. 

41. Monane M, Bohn RL, Gurwitz JH, et al. The effects 

of initial drug choice and comorbidity on 

antihypertensive therapy compliance: results from a 

population-based study in the elderly. Am J 

Hypertens 1997;10(7 Pt 1):697-704. 

42. Bedell SE, Jabbour S, Goldberg R, et al. 

Discrepancies in the use of medications: their extent 

and predictors in an outpatient practice. Arch Intern 

Med 2000;160(14):2129-34. 
Medication Management 

13 

43. Botelho RJ, Dudrak R. Home assessment of 

adherence to long-term medication in the elderly. J 

Fam Pract1992;35(1):61-5. 

44. Coons SJ, Sheahan SL, Martin SS, et al. Predictors of 

medication noncompliance in a sample of older 

adults. Clin Ther 1994;16(1):110-7. 

45. Graveley EA, Oseasohn CS. Multiple drug regimens: 

medication compliance among veterans 65 years and 

older. Res Nurs Health1991;14(1):51-8. 

46. Kiortsis DN, Giral P, Bruckert E, et al. Factors 

associated with low compliance with lipid-lowering 

drugs in hyperlipidemic patients. J Clin Pharm Ther 

2000;25(6):445-51. 

47. Cramer JA, Mattson RH, Prevey ML, et al. How 

often is medication taken as prescribed? A novel 

assessment technique. JAMA 1989;261:3273-7. 

48. Bloom JA, Frank JW, Shafir MS, et al. Potentially 

undesirable prescribing and drug use among the 

elderly. Measurable and remediable. Can Fam 

Physician 1993;39:2337-45. 

49. Coleman EA, Smith JD, Raha D, et al. Posthospital 

medication discrepancies: prevalence and 

contributing factors. Arch Intern Med 

2005;165(16):1842-7. 

50. Gonski PN, Stathers GM, Freiman JS, et al. A critical 

review of admission and discharge medications in an 

elderly Australian population. Drugs Aging 

1993;3:358-62. 

51. McKinley BT, Mulhall BP, Jackson JL. Perceived 

versus actual medication regimens among internal 

medicine patients. Mil Med 2004;169(6):451-4. 

52. Moore C, Wisnivesky J, Williams S, et al. Medical 

errors related to discontinuity of care from an 

inpatient to an outpatient setting. J Gen Intern Med 

2003;18(8):646-51. 

53. Bonner CJ, Carr B. Medication compliance problems 

in general practice: detection and intervention by 

pharmacists and doctors. Aust J Rural Health 

2002;10(1):33-8. 

54. Fineman B, DeFelice C. A study of medication 

compliance. Home Healthc Nurse 1992;10(5):26-9. 

55. Torrible SJ, Hogan DB. Medication use and rural 

seniors. Who really knows what they are taking? Can 

Fam Physician 1997;43:893-8. 

56. Malhotra S, Karan RS, Pandhi P, et al. Drug related 

medical emergencies in the elderly: role of adverse 

drug reactions and non-compliance. Postgrad Med J 

2001;77(913):703-7. 

57. Tamblyn RM, McLeod PJ, Abrahamowicz M, et al. 

Do too many cooks spoil the broth? Multiple 

physician involvement in medical management of 

elderly patients and potentially inappropriate drug 

combinations. CMAJ 1996;154(8):1177-84. 

58. Beers MH, Sliwkowski J, Brooks J. Compliance with 

medication orders among the elderly after hospital 

discharge. Hosp Formul 1992;27(7):720-4. 

59. Bevil CW. Medication management in an elderly, 

community-based population: a pilot project. J N Y 

State Nurses Assoc 1981;12(2):19-29. 

60. McElnay JC, McCallion CR, al-Deagi F. Selfreported medication non-compliance in the elderly. 

Eur J Clin Pharmacol 1997;53(3-4):171-8. 

61. Conn VS. Self-management of over-the-counter 

medications by older adults. Public Health Nurs 

1992;9(1):29-36. 

62. Batty GM, Oborne CA, Swift CG. The use of overthe-counter medication by elderly medical inpatients. Postgrad Med J 1997;73(865):720-2. 

63. Neafsy PJ, Shellman J. Adverse self-medication 

practices of older adults with hypertension attending 

blood pressure clinics: Adverse self-medication 

practices. Internet Journal of Advanced Nursing 

Practice 2001;5(1). 

64. Stuck AE, Beers MH, Steiner A, et al. Inappropriate 

medication use in community-residing older persons. 

Arch Intern Med 1994;154:2195-200. 

65. Flaherty JH, Perry HM, Lynchard GS. Polypharmacy 

and hospitalization among older home care patients. J 

Gerontol A Biol Sci Med Sci 2000;55:M554-9. 

66. Aparasu RR, Sitzman SJ. Inappropriate prescribing 

for elderly outpatients. Am J Health Syst Pharm 

1999;56:433-9. 

67. Cohen I, Rogers P, Burke V. Predictors of medication 

use, compliance and symptoms of hypotension in a 

community-based sample of elderly men and women. 

J Clin Pharm Ther 1998;23(6):423-32. 

68. Golden AG, Preston RA, Barnett SD, et al. 

Inappropriate medication prescribing in homebound 

older adults. J Am Geriatr Soc 1999;47:948-53. 

69. Schmader K, Hanlon JT, Weinberger M, et al. 

Appropriateness of medication prescribing in 

ambulatory elderly patients. J Am Geriatr Soc 

1994;42:1241-7. 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

14 

70. Meredith S, Feldman PH, Frey D, et al. Possible 

medication errors in home healthcare patients. J Am 

Geriatr Soc 2001;49:719-24. 

71. Straand J, Rokstad KS. Elderly patients in general 

practice: diagnoses, drugs and inappropriate 

prescriptions. A report from the More & Romsdal 

Prescription Study. Fam Pract 1999;16(4):380-8. 

72. Willcox SM, Himmelstein DU, Woolhandler S. 

Inappropriate drug prescribing for the communitydwelling elderly. JAMA 1994;272(4):292-6. 

73. Zhan C, Sangl J, Bierman AS, et al. Potentially 

inappropriate medication use in the communitydwelling elderly: findings from the 1996 Medical 

Expenditure Panel Survey. JAMA 2001;286(22): 

2823-9. 

74. Zhan C, Correa-de-Araujo R, Bierman AS, et al. 

Suboptimal prescribing in elderly outpatients: 

potentially harmful drug-drug and drug-disease 

combinations. J Am Geriatr Soc 2005;53(2):262-7. 

75. Nathan A, Goodyer L, Lovejoy A. "Brown bag" 

medication reviews as a means of optimizing patients' 

use of medication and of identifying potential clinical 

problems. Fam Pract 1999;16(3):278-82. 

76. Fillit HM, Futterman R, Orland BI, et al. 

Polypharmacy management in Medicare managed 

care: changes in prescribing by primary care 

physicians resulting from a program promoting 

medication reviews. Am J Manag Care 1999;5:587-

94. 

77. Hanlon JT, Weinberger M, Samsa GP, et al. A 

randomized, controlled trial of a clinical pharmacist 

intervention to improve inappropriate prescribing in 

elderly outpatients with polypharmacy. Am J Med 

1996;100:428-37. 

78. Naunton M, Peterson GM. Evaluation of a homebased follow-up of high risk elderly patients 

discharged from hospital. Journal of Pharmacy 

Practice and Research 2003;33(3):176-82. 

79. Meredith S, Feldman P, Frey D, et al. Improving 

medication use in newly admitted home healthcare 

patients: a randomized controlled trial. J Am Geriatr 

Soc 2002;50:1484-91. 

80. Lipton HL, Bird JA. The impact of clinical 

pharmacists' consultations on geriatric patients' 

compliance and medical care use: a randomized 

controlled trial. Gerontologist 1994;34(3):307-15. 

81. Krska J, Cromarty JA, Arris F, et al. Pharmacist-led 

medication review in patients over 65: A randomized, 

controlled trial in primary care. Age Ageing 

2001;30(3):205-11. 

82. Kimberlin CL, Berardo DH, Pendergast JF, et al. 

Effects of an education program for community 

pharmacists on detecting drug-related problems in 

elderly patients. Med Care 1993;31(5):451-68. 

83. Beers MH. Explicit criteria for determining 

potentially inappropriate medication use by the 

elderly. An update. Arch Intern Med 1997;157(14): 

1531-6. 

84. Fick DM, Cooper JW, Wade WE, et al. Updating the 

Beers criteria for potentially inappropriate medication 

use in older adults: results of a U.S. consensus panel 

of experts. Arch Intern Med 2003;163(22):2716-24. 

85. Lourens H, Woodward MC. Impact of a medication 

card on compliance in older people. Aust J Ageing 

1994;13(2):72-6. 

86. Coleman EA, Smith JD, Frank JC, et al. Preparing 

patients and caregivers to participate in care delivered 

across settings: the Care Transitions Intervention. J 

Am Geriatr Soc 2004;52:1817-25. 

87. Ellenbecker CH, Frazier SC, Verney S. Nurses' 

observations and experiences of problems and 

adverse effects of medication management in home 

care. Geriatric Nursing 2004;25(3):164-70. 

88. Hill-Briggs F, Gary TL, Bone LR, et al. Medication 

adherence and diabetes control in urban African 

Americans with type 2 diabetes. Health Psychol 

2005;24(4):349-57. 

89. Dolce JJ, Crisp C, Manzella B, et al. Medication 

adherence patterns in chronic obstructive pulmonary 

disease. Chest 1991;99(4):837-41. 

90. Johnson MJ, Williams M, Marshall ES. Adherent and 

nonadherent medication-taking in elderly 

hypertensive patients. Clin Nurs Res 1999;8:318-35. 

91. Ogedegbe G, Harrison M, Robbins L, et al. Barriers 

and facilitators of medication adherence in 

hypertensive African Americans: a qualitative study. 

Ethn Dis 2004;14(1):3-12. 

92. Burns JM, Sneddon I, Lovell M, et al. Elderly 

patients and their medication: a post-discharge 

follow-up study. Age Ageing 1992;21(3):178-81. 

93. Ferguson RP, Ziedins E, West Z, et al. Elderly drug 

choice survey. Am J Geriatr Pharmacother 

1996;11(1):61-70. 
Medication Management 

15 

94. Heisler M, Wagner TH, Piette JD. Clinician 

identification of chronically ill patients who have 

problems paying for prescription medications. Am J 

Med 2004;116:753-8. 

95. Piette JD, Heisler M, Wagner TH. Cost-related 

medication underuse among chronically ill adults: the 

treatments people forgo, how often, and who is at 

risk. Am J Public Health 2004;94:1782-7. 

96. Heisler M, Langa KM, Eby EL, et al. The health 

effects of restricting prescription medication use 

because of cost. Med Care 2004;42:626-34. 

97. Connelly CE. An empirical study of a model of selfcare in chronic illness. Clin Nurse Spec 1993;7(5): 

247-53. 

98. Mojtabai R, Olfson M. Medication costs, adherence, 

and health outcomes among Medicare beneficiaries. 

Health Aff 2003;22(4):220-9. 

99. Goldman DP, Joyce GF, Escarce JJ, et al. Pharmacy 

benefits and the use of drugs by the chronically ill. 

JAMA 2004;291:2344-50. 

100. Jackson JE, Doescher MP, Saver BG, et al. 

Prescription drug coverage, health, and medication 

acquisition among seniors with one or more chronic 

conditions. Med Care 2004;42:1056-65. 

101. Schoen MD, DiDomenico RJ, Connor SE, et al. 

Impact of the cost of prescription drugs on clinical 

outcomes in indigent patients with heart disease. 

Pharmacotherapy 2001;21:1455-63. 

102. Blenkiron P. The elderly and their medication: 

understanding and compliance in a family practice. 

Postgrad Med J 1996;72(853):671-6. 

103. Cline CM, Bjorck-Linne AK, Israelsson BY, et al. 

Non-compliance and knowledge of prescribed 

medication in elderly patients with heart failure. Eur J 

Heart Fail 1999;1(2):145-9. 

104. Pinto Pereira LM, Clement Y, Da Silva CK, et al. 

Understanding and use of inhaler medication by 

asthmatics in specialty care in Trinidad: a study 

following development of Caribbean guidelines for 

asthma management and prevention. Chest 

2002;121(6):1833-40. 

105. Arnsten JH, Gelfand JM, Singer DE. Determinants of 

compliance with anticoagulation: A case-control 

study. Am J Med1997;103(1):11-7. 

106. Wallsten SM, Sullivan RJ, Jr., Hanlon JT, et al. 

Medication taking behaviors in the high- and lowfunctioning elderly: MacArthur field studies of 

successful aging. Ann Pharmacother 1995;29(4):359-

64. 

107. Lau HS, Beuning KS, Postma-Lim E, et al. Noncompliance in elderly people: evaluation of risk 

factors by longitudinal data analysis. Pharm World 

Sci 1996;18(2):63-8. 

108. Yilmaz MB, Pinar M, Naharci I, et al. Being wellinformed about statin is associated with continuous 

adherence and reaching targets. Cardiovasc Drugs 

Ther 2005;19(6):437-40. 

109. Windsor RA, Bailey WC, Richards JM, Jr., et al. 

Evaluation of the efficacy and cost effectiveness of 

health education methods to increase medication 

adherence among adults with asthma. Am J Public 

Health1990;80(12):1519-21. 

110. Lin EH, Von Korff M, Katon W, et al. The role of the 

primary care physician in patients' adherence to 

antidepressant therapy. Med Care 1995;33(1):67-74. 

111. Parkin DM, Henney CR, Quirk J, et al. Deviation 

from prescribed drug treatment after discharge from 

hospital. Br Med J 1976;2(6037):686-8. 

112. Powell SG. Medication compliance of patients with 

COPD. Home Healthc Nurse 1994;12(3):44-50. 

113. Morrow D, Leirer V, Altieri P. Elders' schema for 

taking medication: implications for instruction 

design. J Gerontol 1991;46(6):P378-85. 

114. Morrell RW, Park DC, Poon LW. Effects of labeling 

techniques on memory and comprehension of 

prescription information in young and old adults. J 

Gerontol 1990;45(4):P166-72. 

115. Morrow D, Leirer V. List formats improve 

medication instructions for older adults. Educ 

Gerontol 1995;21(2):151-66. 

116. Morrow DG, Leirer VO, Andrassy JM, et al. The 

influence of list format and category headers on age 

differences in understanding medication instructions. 

Exp Aging Res 1998;24(3):231-56. 

117. Hayes KS. Randomized trial of geragogy-based 

medication instruction in the emergency department. 

Nurs Res 1998;47(4):211-8. 

118. Morrow D, Carver LM, Leirer VO. Medication 

schemas and memory for automated telephone 

messages. Hum Factors 2000;42(4):523-40. 

119. Martens KH. An ethnographic study of the process of 

medication discharge education (MDE). J Adv 

Nurs1998;27(2):341-8. 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

16 

120. Raynor DK, Booth TG, Blenkinsopp A. Effects of 

computer generated reminder charts on patients' 

compliance with drug regimens. BMJ 

1993;306(6886):1158-61. 

121. Hussey LC. Minimizing effects of low literacy on 

medication knowledge and compliance among the 

elderly. Clin Nurs Res 1994;3(2):132-45. 

122. Taylor AA, Shoheiber O. Adherence to 

antihypertensive therapy with fixed-dose amlodipine 

besylate/benazepril HCl versus comparable 

component-based therapy. Congest Heart Fail 

2003;9(6):324-32. 

123. Goodyer LI, Miskelly F, Milligan P. Does 

encouraging good compliance improve patients' 

clinical condition in heart failure? Br J Clin 

Pract1995;49(4):173-6. 

124. Varma S, McElnay JC, Hughes CM, et al. 

Pharmaceutical care of patients with congestive heart 

failure: interventions and outcomes. 

Pharmacotherapy 1999;19(7):860-9. 

125. Barber N, Parsons J, Clifford S, et al. Patients' 

problems with new medication for chronic 

conditions. Qual Saf Health Care 2004;13(3):172-5. 

126. Cargill JM. Medication compliance in elderly people: 

influencing variables and interventions. J Adv 

Nurs1992;17(4):422-6. 

127. Rich MW, Gray DB, Beckham V, et al. Effect of a 

multidisciplinary intervention on medication 

compliance in elderly patients with congestive heart 

failure. Am J Med1996;101(3):270-6. 

128. Patton K, Meyers J, Lewis BE. Enhancement of 

compliance among patients with hypertension. Am J 

Manag Care 1997;3(11):1693-8. 

129. Piette JD, Weinberger M, McPhee SJ, et al. Do 

automated calls with nurse follow-up improve selfcare and glycemic control among vulnerable patients 

with diabetes? Am J Med 2000;108(1):20-7. 

130. Weinberger M, Murray MD, Marrero DG, et al. 

Effectiveness of pharmacist care for patients with 

reactive airways disease: a randomized controlled 

trial. JAMA 2002;288:1594-602. 

131. Bouvy ML, Heerdink ER, Urquhart J, et al. Effect of 

a pharmacist-led intervention on diuretic compliance 

in heart failure patients: a randomized controlled 

study. J Card Fail 2003;9:404-11. 

132. Friedman RH, Kazis LE, Jette A, et al. A 

telecommunications system for monitoring and 

counseling patients with hypertension. Impact on 

medication adherence and blood pressure control. 

Am J Hypertens 1996;9(4 Pt 1):285-92. 

133. Haynes RB, McKibbon KA, Kanani R. Systematic 

review of randomised trials of interventions to assist 

patients to follow prescriptions for medications. 

Lancet 1996;348(9024):383-6. 

134. Hovell MF, Geary DC, Black DR, et al. The effects 

of lay counseling on medication adherence and blood 

pressure: adjunctive treatment for hypertension. 

Patient Educ Couns1984;6(2):91-4. 

135. Huang C, Wu S, Jeng C, et al. The efficacy of a 

home-based nursing program in diabetic control of 

elderly people with diabetes mellitus living alone. 

Public Health Nurs 2004;21(1):49-56. 

136. Smith L, McGowan L, Moss-Barclay C, et al. An 

investigation of hospital generated pharmaceutical 

care when patients are discharged home from 

hospital. Br J Clin Pharmacol 1997;44(2):163-5. 

137. Stewart AV, Eales CJ, Davis KA. Effect of a 

telephonic intervention on the adherence of patients 

with hypertension. South African Journal of 

Physiotherapy 2003;59(1):29-36. 

138. Lowe CJ, Raynor DK, Purvis J, et al. Effects of a 

medicine review and education programme for older 

people in general practice. Br J Clin Pharmacol 

2000;50(2):172-5. 

139. Saounatsou M, Patsi O, Fasoi G, et al. The influence 

of the hypertensive patient's education in compliance 

with their medication. Public Health Nurs 

2001;18(6):436-42. 

140. Rudd P, Miller NH, Kaufman J, et al. Nurse 

management for hypertension. A systems approach. 

Am J Hypertens 2004;17:921-7. 

141. Robbins B, Rausch KJ, Garcia RI. Multicultural 

medication adherence: a comparative study. J 

Gerontol Nurs 2004;30(7):25-32. 

142. Ruscin JM, Semla TP. Assessment of medication 

management skills in older outpatients. Ann 

Pharmacother 1996;30:1083-8. 

143. Isaac LM, Tamblyn RM. Compliance and cognitive 

function: A methodological approach to measuring 

unintentional errors in medication compliance in the 

elderly. McGill-Calgary Drug Research Team. 

Gerontologist 1993;33(6):772-81. 

144. Atkin PA, Finnegan TP, Ogle SJ, et al. Functional 

ability of patients to manage medication packaging: a 

survey of geriatric inpatients. Age Ageing 

1994;23(2):113-6. 
Medication Management 

17 

145. Lile JL, Hoffman R. Medication-taking by the frail 

elderly in two ethnic groups. Nurs Forum 

1991;26(4):19-24. 

146. Kendrick R, Bayne JR. Compliance with prescribed 

medication by elderly patients. CMAJ 1982;127:961-

2. 

147. Gray SL, Williams DM, Pulliam CC, et al. 

Characteristics predicting incorrect metered-dose 

inhaler technique in older subjects. Arch Intern Med 

1996;156(9):984-8. 

148. Ware GJ, Holford NH, Davison JG, et al. Unit dose 

calendar packaging and elderly patient compliance. N 

Z Med J 1991;104(924):495-7. 

149. Wong BS, Norman DC. Evaluation of a novel 

medication aid, the calendar blister-pak, and its effect 

on drug compliance in a geriatric outpatient clinic. J 

Am Geriatr Soc 1987;35(1):21-6. 

150. Murray MD, Birt JA, Manatunga AK, et al. 

Medication compliance in elderly outpatients using 

twice-daily dosing and unit-of-use packaging. Ann 

Pharmacother 1993;27(5):616-21. 

151. Wilson MG, Kaiser FE, Morley JE. Tablet-breaking 

ability of older persons with type 2 diabetes mellitus. 

Diabetes Educ 2001;27(4):530-40. 

152. Jeste SD, Patterson TL, Palmer BW, et al. Cognitive 

predictors of medication adherence among middleaged and older outpatients with schizophrenia. 

Schizophr Res 2003;63(1-2):49-58. 

153. Edelberg HK, Shallenberger E, Wei JY. Medication 

management capacity in highly functioning 

community-living older adults: detection of early 

deficits. J Am Geriatr Soc 1999;47(5):592-6. 

154. Incalzi RA, Gemma A, Marra C, et al. Verbal 

memory impairment in COPD: its mechanisms and 

clinical relevance. Chest 1997;112(6):1506-13. 

155. Leirer VO, Morrow DG, Tanke ED, et al. Elders' 

nonadherence: its assessment and medication 

reminding by voice mail. Gerontologist 1991;31:514-

20. 

156. Carlson MC, Fried LP, Xue QL, et al. Validation of 

the Hopkins Medication Schedule to identify 

difficulties in taking medications. J Gerontol A Biol 

Sci Med Sci 2005;60(2):217-23. 

157. Taylor SA, Galbraith SM, Mills RP. Causes of noncompliance with drug regimens in glaucoma patients: 

a qualitative study. J Ocul Pharmacol Ther 

2002;18:401-9. 

158. Conn V, Taylor S, Miller R. Cognitive impairment 

and medication adherence. J Gerontol Nurs 

1994;20(7):41-7. 

159. Conn V, Taylor SG, Stineman A. Medication 

management by recently hospitalized older adults. J 

Community Health Nurs 1992;9(1):1-11. 

160. Doshi JA, Zuckerman IH, Picot SJ, et al. 

Antihypertensive use and adherence and blood 

pressure stress response among black caregivers and 

non-caregivers. Appl Nurs Res 2003;16(4):266-77. 

161. Pettinger MB, Waclawiw MA, Davis KB, et al. 

Compliance to multiple interventions in a high risk 

population. Ann Epidemiol 1999;9(7):408-18. 

162. Lee P, Tan LJ. Drug compliance in outpatients with 

rheumatoid arthritis. Aust N Z J Med 1979;9(3):274-

7. 

163. Paes AH, Bakker A, Soe-Agnie CJ. Impact of dosage 

frequency on patient compliance. Diabetes Care 

1997;20:1512-7. 

164. Cramer JA. Enhancing patient compliance in the 

elderly. Role of packaging aids and monitoring. 

Drugs Aging 1998;12(1):7-15. 

165. Littenberg B, MacLean CD, Hurowitz L. The use of 

adherence aids by adults with diabetes: a crosssectional survey. BMC Fam Pract 2006;7:1. 

166. Neely E, Patrick ML. Problems of aged persons 

taking medications at home. Nurs Res 1968;17(1):52-

5. 

167. Esposito L. The effects of medication education on 

adherence to medication regimens in an elderly 

population. J Adv Nurs1995;21:935-43. 

168. Park D, Morrell RW, Frieske D, et al. Medication 

adherence behaviors in older adults: effects of 

external cognitive supports. Psychol 

Aging1992;7(2):252-6. 

169. Nides MA, Tashkin DP, Simmons MS, et al. 

Improving inhaler adherence in a clinical trial 

through the use of the nebulizer chronolog. Chest 

1993;104(2):501-7. 

170. Perri M, Martin BC, Pritchard FL. Improving 

medication compliance: a practical intervention. J 

Pharm Technol 1995;11(4):167-72. 

171. McKenney JM, Munroe WP, Wright J. Impact of an 

electronic medication compliance aid on long-term 

blood pressure control. J Clin Pharmacol 

1992;32(3):277-83. 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

18 

172. Winland-Brown JE, Valiante J. Effectiveness of 

different medication management approaches on 

elders' medication adherence. Outcomes Manag Nurs 

Pract 2000;4(4):172-6. 

173. Buckwalter KC, Wakefield BJ, Hanna B, et al. New 

technology for medication adherence: electronically 

managed medication dispensing system. J Gerontol 

Nurs 2004;30(7):5-8. 

174. Laster SF, Martin JL, Fleming JB. The effect of a 

medication alarm device on patient compliance with 

topical pilocarpine. J Am Optom Assoc 

1996;67(11):654-8. 

175. Fulmer TT, Feldman PH, Kim TS, et al. An 

intervention study to enhance medication compliance 

in community-dwelling elderly individuals. J 

Gerontol Nurs 1999;25(8):6-14. 

176. Andrejak M, Genes N, Vaur L, et al. Electronic pillboxes in the evaluation of antihypertensive treatment 

compliance: comparison of once daily versus twice 

daily regimen. Am J Hypertens 2000;13(2):184-90. 

177. Dezii CM. A retrospective study of persistence with 

single-pill combination therapy vs. concurrent twopill therapy in patients with hypertension. Manag 

Care 2001;10(2 Suppl):6-10. 

178. Pullar T, Birtwell AJ, Wiles PG, et al. Use of a 

pharmacologic indicator to compare compliance with 

tablets prescribed to be taken once, twice, or three 

times daily. Clin Pharmacol Ther 1988;44(5):540-5. 

179. Claxton AJ, Cramer J, Pierce C. A systematic review 

of the associations between dose regimens and 

medication compliance. Clinical Therapeutics 

2001;23(8):1296-310. 

180. Mounier-Vehier C, Bernaud C, Carre A, et al. 

Compliance and antihypertensive efficacy of 

amlodipine compared with nifedipine slow-release. 

Am J Hypertens 1998;11(4 Pt 1):478-86. 

181. Detry JM, Block P, De Backer G, et al. Patient 

compliance and therapeutic coverage: comparison of 

amlodipine and slow release nifedipine in the 

treatment of hypertension. The Belgian Collaborative 

Study Group. Eur J Clin Pharmacol 1995;47(6):477-

81. 

182. Eisen SA, Miller DK, Woodward RS, et al. The 

effect of prescribed daily dose frequency on patient 

medication compliance. Arch Intern Med 

1990;150(9):1881-4. 

183. McDonald-Miszczak L, Maris P, Fitzgibbon T, et al. 

A pilot study examining older adults' beliefs related 

to medication adherence: the BERMA survey. J 

Aging Health 2004;16(5):591-614. 

184. Christensen AJ, Wiebe JS, Lawton WJ. Cynical 

hostility, powerful others control expectancies, and 

patient adherence in hemodialysis. Psychosom Med 

1997;59(3):307-12. 

185. Horne R, Weinman J. Patients' beliefs about 

prescribed medicines and their role in adherence to 

treatment in chronic physical illness. J Psychosom 

Res 1999;47(6):555-67. 

186. Aljasem LI, Peyrot M, Wissow L, et al. The impact 

of barriers and self-efficacy on self-care behaviors in 

type 2 diabetes. Diabetes Educ 2001;27(3):393-404. 

187. Denhaerynck K, Abraham I, Gourley G, et al. 

Validity testing of the Long-Term Medication 

Behavior Self-Efficacy Scale. J Nurs Meas 

2003;11(3):267-82. 

188. Clark NM, Dodge JA. Exploring self-efficacy as a 

predictor of disease management. Health Educ Behav 

1999;26(1):72-89. 

189. Brus H, van de Laar M, Taal E, et al. Determinants of 

compliance with medication in patients with 

rheumatoid arthritis: the importance of self-efficacy 

expectations. Patient Educ Couns1999;36(1):57-64. 

190. McDonald-Miszczak L, Maki SA, Gould ON. Selfreported medication adherence and health status in 

late adulthood: the role of beliefs. Exp Aging Res 

2000;26(3):189-207. 

191. Grant RW, Devita NG, Singer DE, et al. 

Polypharmacy and medication adherence in patients 

with type 2 diabetes. Diabetes Care 2003;26(5):1408-

12. 

192. Jessop DC, Rutter DR, Sharma D, et al. Emotion and 

adherence to treatment in people with asthma: an 

application of the emotional stroop paradigm. Br J 

Psychol 2004;95(Pt 2):127-47. 

193. Scott J, Pope M. Nonadherence with mood 

stabilizers: prevalence and predictors. J Clin 

Psychiatry 2002;63(5):384-90. 

194. Sharkness CM, Snow DA. The patient's view of 

hypertension and compliance. Am J Prev Med 

1992;8(3):141-6. 

195. Maidment R, Livingston G, Katona C. Just keep 

taking the tablets: adherence to antidepressant 

treatment in older people in primary care. Int J 

Geriatr Psychiatry 2002;17:752-7. 
Medication Management 

19 

196. Khalil SA, Elzubier AG. Drug compliance among 

hypertensive patients in Tabuk, Saudi Arabia. J 

Hypertens 1997;15(5):561-5. 

197. Lowry KP, Dudley TK, Oddone EZ, et al. Intentional 

and unintentional nonadherence to antihypertensive 

medication. Ann Pharmacother 2005;39(7-8):1198-

203. 

198. Reddy BK, Kennedy DJ, Colyer WR, et al. 

Compliance with antihypertensive therapy after renal 

artery stenting. Biol Res Nurs 2003;5(1):37-46. 

199. Bruckert E, Simonetta C, Giral P. Compliance with 

fluvastatin treatment characterization of the 

noncompliant population within a population of 3845 

patients with hyperlipidemia. CREOLE Study Team. 

J Clin Epidemiol 1999;52(6):589-94. 

200. Eagle KA, Kline-Rogers E, Goodman SG, et al. 

Adherence to evidence-based therapies after 

discharge for acute coronary syndromes: an ongoing 

prospective, observational study. Am J 

Med2004;117(2):73-81. 

201. Putnam DE, Finney JW, Barkley PL, et al. Enhancing 

commitment improves adherence to a medical 

regimen. J Consult Clin Psychol 1994;62(1):191-4. 

202. Edworthy SM, Devins GM. Improving medication 

adherence through patient education distinguishing 

between appropriate and inappropriate utilization. 

Patient Education Study Group. J Rheumatol 

1999;26:1793-801. 

203. Lin EH, Von Korff M, Ludman EJ, et al. Enhancing 

adherence to prevent depression relapse in primary 

care. Gen Hosp Psychiatry 2003;25(5):303-10. 

204. Bultman DC, Svarstad BL. Effects of physician 

communication style on client medication beliefs and 

adherence with antidepressant treatment. Patient 

Educ Couns 2000;40(2):173-85. 

205. Beers MH, Baran RW, Frenia K. Drugs and the 

elderly, Part 1: The problems facing managed 

care.Am J Manag Care 2000;6:1313-20. 

206. Veehof LJ, Stewart RE, Meyboom-de Jong B, et al. 

Adverse drug reactions and polypharmacy in the 

elderly in general practice. Eur J Clin Pharmacol 

1999;55:533-6. 

207. Hohl CM, Dankoff J, Colacone A, et al. 

Polypharmacy, adverse drug-related events, and 

potential adverse drug interactions in elderly patients 

presenting to an emergency department. Ann Emerg 

Med 2001;38:666-71. 

208. Bond C, Matheson C, Williams S, et al. Repeat 

prescribing: a role for community pharmacists in 

controlling and monitoring repeat prescriptions. Br J 

Gen Pract 2000;50(453):271-5. 

209. Hanlon JT, Shimp LA, Semla TP. Recent advances in 

geriatrics: drug-related problems in the elderly. Ann 

Pharmacother 2000;34:360-5. 

210. Kruse W, Koch-Gwinner P, Nikolaus T, et al. 

Measurement of drug compliance by continuous 

electronic monitoring: a pilot study in elderly patients 

discharged from hospital. J Am Geriatr Soc 

1992;40(11):1151-5. 

211. Donnan PT, MacDonald TM, Morris AD. Adherence 

to prescribed oral hypoglycaemic medication in a 

population of patients with Type 2 diabetes: a 

retrospective cohort study. Diabet Med 

2002;19(4):279-84. 

212. Lin EH, Katon W, Von Korff M, et al. Relationship 

of depression and diabetes self-care, medication 

adherence, and preventive care. Diabetes Care 

2004;27:2154-60. 

213. Schectman JM, Nadkarni MM, Voss JD. The 

association between diabetes metabolic control and 

drug adherence in an indigent population. Diabetes 

Care 2002;25:1015-21. 

214. Miura T, Kojima R, Mizutani M, et al. Effect of 

digoxin noncompliance on hospitalization and 

mortality in patients with heart failure in long-term 

therapy: a prospective cohort study. Eur J Clin 

Pharmacol 2001;57(1):77-83. 

215. Degli Esposti E, Sturani A, Di Martino M, et al. 

Long-term persistence with antihypertensive drugs in 

new patients. J Hum Hypertens 2002;16(6):439-44. 

216. Bergman-Evans B. Improving medication 

management for older adult clients. Iowa City, IA: 

University of Iowa Gerontological Nursing 

Interventions Research Center;2004. 

217. Sturgess IK, McElnay JC, Hughes CM, et al. 

Community pharmacy based provision of 

pharmaceutical care to older patients. Pharm World 

Sci 2003;25(5):218-26. 

218. Park D, Morrell RW, Frieske D, et al. Cognitive 

factors and the use of over-the-counter medication 

organizers by arthritis patients. Hum Factors 

1991;33(1):57-67. 

219. Durso S. Technological advances for improving 

medication adherence in the elderly. Annals of LongTerm Care 2001;9(4):43-8. 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

220. Allard J, Hebert R, Rioux M, et al. Efficacy of a 

clinical medication review on the number of 

potentially inappropriate prescriptions prescribed for 

community-dwelling elderly people. CMAJ 2001 

May 1;164(9):1291-6. 

221. Day RA, Moore KN, Hodgins M. The effects of 

instruction and practice on medication knowledge 

and compliance. Canadian J Rehabil 1998;12:15-24. 

222. Hawe P, Higgins G. Can medication education 

improve the drug compliance of the elderly? 

Evaluation of an in hospital program. Patient Educ 

Couns 1990;16(2):151-60. 

223. Lowe CJ, Raynor DK, Courtney EA, et al. Effects of 

self medication programme on knowledge of drugs 

and compliance with treatment in elderly patients. 

BMJ 1995;310(6989): 1229-31. 

224. Malone DC, Carter BL, Billups SJ, et al. Can clinical 

pharmacists affect SF-36 scores in veterans at high 

risk for medication-related problems? Med Care 

2001;39(2):113-22. 

225. Pereles L, Romonko L, Murzyn T, et al. Evaluation of 

a self-medication program. J Am Geriatr Soc 

1996;44(2):161-5. 

226. Solomon DK, Portner TS, Bass GE, et al. Clinical and 

economic outcomes in the hypertension and COPD 

arms of a multicenter outcomes study. J Am Pharm 

Assoc (Wash), 1998;38(5);574-85. 

20 
21

Evidence Table. Medication Management of the Community-Dwelling Older Adult (Includes studies design level 4 aSource Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study Design, Study Outcome Measure(s) (level) 

Study Setting and Study Population 

Study Intervention Key 

Allard 2001220 Inappropriate 

prescribed medication 

Randomized Controlled Trial (RCT) 

1. RCT (Level 2) 2. Error over time 

(Level 2) 

1. Community-dwelling 

older adults, age > 70 years and taking > 3 drugs 

2. Treatment (n = 136) 

• Subgroup received 

case conference w/ intervention (n = 80) 

3. Control (n = 130) 

Medication review by nurse, pharmacist, and physician with monthly nurse followup. Potentially inappropriate prescriptions (PIPs) reported to prescribing physician. 

Meatreatsign

Andrejak 2000176

Medication adherence 

RCT 1. RCT (Level 2) 

2. Clinical 

outcome (Level 1) 

1. Multicenter: 6 month 

study, persons 18 and older with essential HTN (diastolic BP,95-115) 

2. Mean age 57 3. Two treatment groups: 

• Twice-daily dosing (n 

= 62) 

• Once-daily dosing (n 

= 84) 

Dose simplification: once a day, group one; twice a day, group two. 

Eviddosicomdoseon tipatie

Bond 2000208 Medication 

adherence 

RCT 1. RCT (Level 2) 

2. Adverse events 

(Level 1) 

1. Outpatient general 

medical clinics (19) 

2. Community pharmacies 

(n =62) 

3. Two groups: 

• Treatment (n = 904) • Control (n = 1,397) 

Pharmacists monitored for 

• compliance • adverse reactions • symptoms • medication problems 

The more idencontpres

resucost
22

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, Key 

Study Outcome Measure(s) (level) Study Setting and Study Population Study Intervention Bonner 200253 Medication compliance Non-compar- ative study 1. Observational study without controls (Level 5) 2. Surrogate outcome: observed errors (Level 2) 1. Rural general practice older adults (50) 2. Selection: 

• Random 

presentation at surgery 

• > 4 meds • Significant medical 

history 

1. Clinical pharmacist 

medication screening 

2. Physician verification 

and correction of errors transcribed to a portable medication summary card 

40% 8% omedchanrepothe cphysuse sumclinicphysineffadul

Bouvy 2003131 

Medication compliance 

RCT 1. RCT (Level 2) 

2. Error over time 

(Level 2) 

Heart failure patients treated with loop diuretics in an outpatient heart failure clinic or admitted to participating hospitals 

• Treatment (n = 74) • Usual Care (n = 78) 

Pharmacist led monthly medication education for 6 months 

Meddecrmiss0.33 cons(rela0.19differate, life (

Cargill 1992126

Medication compliance 

RCT 1. RCT (Level 2) 

2. Error over time 

(Level 2) 

1. Age 60and older 2. Three groups (total n = 

70) • Control • Education • Education & followup 

phone call 

1. Home visits: 

medication education, followup phone call 2 weeks s/p medication education 

2. Compliance 

measured via pill count 

FolloeduccomCompresincreComhommedsupp
23

Source Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study Design, nd Study n Key 

Study OutcomeMeasure(s) (level) 

Study Setting aPopulation 

Study Interventio

Coleman 200449

Care transition 

Prospective cohort study 

1. Non-RCT 

(Level 3) 

2. Adverse events 

(Level 1 ) 

1. Age 65 and older 

posthospitalization 

2. Two groups: 

• Treatment (n = 158) • Control (n = 1,235) 

from administrative data 

1. Medication selfmanagement 2. Patient-centered 

record 

3. Primary care and 

specialist followup 

4. Education of warning 

signs and symptoms of worsening condition. 

Oddreho(95% days0.72(95% time decr

transdecradmpatieconfman

Day 1998221 Medication 

knowledge and compliance 

RCT 1. RCT (Level 2) 

2. Pretest/posttest (Level 3) 

1. Rehabilitation Hospital patients 2. Mean age = 64.8 3. Two groups: 

• Self-administered 

medication during hospitalization (n = 24) 

• Nurse-administered 

medication (

n=15) 

1. Self-administration of 

medications while hospitalized. 

2. Education 

No sfounsam

Detry 1995181 Medication 

compliance

Non-RCT 1. Non-RCT 

(Level 2) 

2. Observed 

errors (Level 3) 

1. Persons treated with 

slow release nifedipine or amlodipine 

2. for at least 4 weeks 

prior to study inclusion. 

3. Mean age = 60 4. Two groups: 

• crossover at 6 weeks • once a day (n = 160) 

• twice daily (n = 160) 

Dose simplification: once daily amlodipine versus twice daily slow release nifedipine for 4 weeks 

Comdosidaily signiden
24

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, Study Intervention Key 

Study Outcome Measure(s) (level) Study Setting and Study Population Dezii 2001177 Dosing medication compliance Retrospective cohort study 1. Retrospective cohort comparison (Level 4) 2. Medication errors related over time (Level 2) 1. HTN patients new to therapy 2. Two groups: 

• Single pill group (n = 

969) 

• Two pill combination 

group (n = 624) 

Dose simplification Dose 

pill dsignpersthera

Eisen 1990182 Medication 

compliance 

RCT 1. RCT (Level 2) 

2. Observed 

errors over time (Level2) 

1. VA medical center 

clinic HTN patients 

2. Three groups: 

• Once-daily dose (n = 

45) 

• Twice-daily (n = 40) 

• Three times daily (n 

= 20) 

1. Dose simplification 2. Measurement by 

electronic blister pack that recorded medication removal. 

Oncrate day Comnumdecr

Esposito 1995167

Medication adherence 

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2 ) 

1. Age 65 and older at 

hospital discharge 

2. Four groups: 

• Group I – standard 

education (n = 11) 

• Group II – standard 

education and 30 minute verbal instructions (n = 8) 

• Group III – standard 

education and medication schedule (n = 10) 

• Group IV – standard 

education, medication schedule, and 30 minute verbal instructions (n = 14) 

Medication schedule with verbal reinforcement. 

Highfounmedsma
25

Source Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study Design, Key Study Outcome Measure(s) (level) 

Study Setting and StudyPopulation 

Study Intervention

Fillet 199976 Polypharmacy Noncomparative 

study 

1. Observational 

study without controls (Level 5) 

2. Measurable 

outcomes with unestablished connection to outcome (Level 3) 

1. Medicare managed 

care organization patients 65 and older on 5 or more medications, over 3 month period. 

2. 5,737 identified as high 

risk and surveyed, with 2,615 responding (response rate = 46%). 

3. 275 primary care 

physicians surveyed, with 56 (20%) responding. 

1. Identification of 

patients at risk for polypharmacy. 

2. Empowerment letters 

sent to patients with brown bag to encourage a primary care provider (PCP) appointment for medication review. 

3. All PCPs provided 

with practice guidelines regarding polypharmacy and patient-specific medication management reports. 

17% PCP or nothey resuin 51repofrequhad 45% at lechan

Friedman 1996132

Medication Adherence 

RCT 1. RCT (Level 2) 

2. Clinical 

outcome (Level 1) 

1. Persons age 60 and 

older under treatment for hypertension from community sites such as senior centers with BP>160/90 

2. Two groups: 

• Treatment (n = 133) • Control (n = 134) 

1. Automated telephone 

patient monitoring and counseling. 

2. Weekly-treatment 

subjects reported selfmeasured BP, knowledge, and adherence to medications and side effects. 

Medhighbloo0.02

Fulmer 1999175

Medication compliance 

RCT 1. RCT 

2. Observed errors 

(Level 2) 

1. Community dwelling, 

age 65 and older with diagnosis of CHF 

2. Three groups: 

• Control (n = 14) 

• Telephone (n = 13) • Videophone (n = 15) 

1. Telephone group 

received daily telephone call reminders. 

2. Videophone group 

received daily videophone call reminders. 

Contcomwho vide(P < 
26

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, nd Study Study Intervention Key 

Study Outcome Measure(s) (level) Study Setting a Population Goodyer 1995123 Medication compliance RCT 1. RCT (Level 2) 2. Errors over time (Level 2 ) 1. Outpatient clinic patients 70 years and older with chronic stable heart failure 2. Two groups: 

• Treatment (n = 50) • Control (n = 50) 

Three month pharmacistled medication counseling with three home visits 

ComknowtreatBoth breatreatfor c

signin No

Hawe & Higgins 1990222

Medication compliance 

Non-RCT 1. Nonrandomized 

control trial (Level 3) 

2. Errors over 

time (Level 2) 

1. Inpatient persons age 

55 and older 

2. Two groups assigned 

by month of admission: • Treatment (n = 149) • Control: received 

dummy intervention (n = 119) 

1. Group-based 

inpatient educational session followed by individual pharmacist predischarge instruction and individual medication record card. 

2. Measurement: 

• Compliance by 

subject report 

• Interviews 1 month 

and 3 months postdischarge 

No scomhoweffecpersdrugcomthe c

Hanlon 199677 Inappropriate medications RCT 1. RCT 2. Adverse events 

(Level 1) 

1. Patients 65 and older 

of a general medical VA clinic 

2. Two groups: 

• Treatment (n = 105) • Control (n = 103) 

1. Pharmacist met with 

patients during scheduled clinic visits evaluating drug regimens. 

2. Recommendations 

made to prescribing physician. 

Inapin tre0.00inter

Hayes 1998117

Medication knowledge 

RCT 1. RCT (Level 2) 

2. Knowledge 

post-test (Level 3) 

1. Patients discharged 

from three rural emergency departments, age 60 and older. 

2. Two groups: 

• Treatment (n = 30) • Control (n = 30) 

Geragogy-based medication instruction sheets 

Utilizmedincremed
27

Source Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study Study Setting and Study 

Population 

 Design, u Key 

Study Outcome Measure(s) (level) 

St dy Intervention 

Huang 2004135

Medication education 

Non-RCT 1. Nonrandomized 

control trial (Level 3) 

2. Clinical 

outcomes (Level 1) 

1. Patients of district 

health center, 65 and older, diagnosed with diabetes mellitus, living alone, with resting BP less than 160/100 mmHg. 

2. Matched on age, sex, 

education, and history of diabetes. 

3. Three groups: 

• Group 1 – homebased nursing (n = 

15) 

• Education program 

(n = 15) 

• Control (n = 14) 

1. Group 1 – daily nurse 

visits to supervise diet, exercise, medication, and selfmonitoring blood sugar. 

2. Group 2 – weekly 

nurse visits to supervise diet, exercise, medication, and self-monitoring blood sugar. Nursing weekly home visits vs. daily home visits. 

Both reduHGAcholSubjhad 0.05

Kimberlin 199382

Medication compliance and knowledge 

Non-RCT 1. Nonrandomized 

trial (Level 3) 

2. Adverse events 

(Level 1) 

1. Subject criteria 

• Age 60 or older • Capable of self-care • Taking four or more 

medications or medications from a list of targeted drugs with narrow therapeutic ranges or likely to cause problems in the elderly. 

2. Two subject groups: 

• Treatment (n = 410) • Control (n = 352) 

3. Pharmacist assignment 

to treatment (n = 55) or control (n = 33). 

Intervention pharmacists participated in home study and 1-day workshop on drug therapy for elderly patients. 

SubjpharrepoinforprobsubjdiffecomHowmedelevrepothera
28

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, Study Intervention Key 

Study Outcome Measure(s) (level) Study Setting and Study Population Krska 200181 Medication review RCT 1. Group RCT (Level 2) 2. Errors over time (Level 2) 1. Community-dwelling older adults 

• Age 65 or older • Four or more 

medications 

• At least two chronic 

conditions 

2. Two groups: 

• Treatment (n = 168) • Control (n = 164) 

Pharmacist medication review with pharmaceutical care plan with medication regime changes in collaboration with general practitioner. 

All sleast numfollogrouwas cost 

Leirer 1991155 Medication 

adherence 

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2) 

1. Community-dwelling 

older adult volunteers • Mean age 70.9 

2. Excluded cognitively 

impaired, depressed, debilitating conditions, or taking two or more medications. 

3. Two groups: 

• Treatment (n = 8) • Control (n = 8) 

1. Both groups given 

medication schedule and portable bar code reader to record simulated medication taking for 1 week. 

2. Treatment group 

received voice mail reminders. 

Voicenhaadhe

failumed

0.05

Lipton 199480 Medication 

compliance and resource utilization

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2) 

1. Geriatric hospitalized 

patients on three or more medications at discharge. 

2. Two groups: 

• Treatment (n = 350) • Control (n = 356) 

Pharmacist-led drug consultation service at hospital discharge, 1 week, 2–4 weeks, 2 months, and 3 months postdischarge via phone (85%) or home visit. Followup phone calls. 

Phadecrcomnum0.00dose

Medmisswere 3 mosigncare iden
29

Source Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study gn, 

e 

 Desi ention Key 

Study OutcMeasure(s) (level) 

om

Study Setting and Study Population 

Study Interv

Lourens 199485

Medication compliance 

RCT 1. RCT (2) 

2. Errors over 

time (Level 2) 

1. Outpatient clinic (mean 

age 72) 

2. Two groups: 

• Counseling only (n = 

49) 

• Counseling and 

medication card (n = 48) 

1. Pharmacist 

counseling both groups. 

2. Written medication 

card in treatment group. 

Subjmedhighcom

Lowe 1995223 Medication 

compliance 

Prospective cohort study 

1. Nonrandomized 

control trial (Level 2) 

2. Errors over 

time (Level 2) 

1. Hospitalized older 

adults (mean age 79) 

2. Two groups: 

• Treatment (n = 42) • Control (n = 37) 

1. Inpatient selfmedication 

management program 

2. Education 

Both and < 0.0self-grou

Lowe 2000138 Medication 

compliance 

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level2) 

1. Community-dwelling 

older adults, > 65, taking three or more medications 

2. Two groups: 

• Intervention (n = 73) • Control (n = 79) 

Pharmacist-led Intervention that included • Medication review 

and verification with PCP 

• Modification of 

medication containers 

• Medication education • Drug reminder chart 

Mededuccontmed0.00know
30

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, Key 

Study Outcome Measure(s) (level) Study Setting and Study Population Study Intervention Malone 2001224 Optimizing medication therapy RCT 1. RCT (Level 2) 2. Clinical outcome (Level 1) 1. Older adult ambulatory veterans (mean age = 66.8) who were high risk for drug-related problems. 2. High risk defined as having three or more of the following criteria: 

• 5 or more 

medications 

• 12 or more daily 

doses 

• 3 or more chronic 

conditions 

• 4 or more changes to 

drug regimen over past year 

• Taking less than 

80% of prescribed medications 

• On medications that 

require monitoring 

3. Two groups: 

• Treatment (n = 523) • Control (n = 531) 

1. Intervention subjects 

received a minimum of three ambulatory clinical pharmacist inperson visits or phone calls. 

2. Intervention protocol 

included • Physical 

assessment: 

• Compliance 

monitoring 

• Lab monitoring • Drug screening • Identifying 

untreated diseases 

• Referrals to primary 

care and specialist physicians 

CliniinterHRQstatutreatnot cInterrelatperc(P < heal0.00

McKenney 1992171

Medication compliance 

RCT 1. RCT (Level 2) 

2. Clinical 

outcome (Level 1) 

1. Ambulatory patients 

from retirement community or primary care center 

2. Age 50 or older 3. Treated for HTN for 12 

months 

4.Four groups 

1. Group A (n = 17): 

control 

2. Group B (n = 18): 

timepiece cap as stimulant strategy 

3. Group C (n = 18): 

timepiece cap + pocket-size BP recorder 

4. Group D (n = 17): 

timepiece cap + pocket-size BP recorder + BP cuff for self-monitoring 

Timeimprsignlowe(P < blooand moncom< 0.0
31

Source Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study Design, nd Study Study Intervention Key Study Outcome Measure(s) (level) 

Study Setting aPopulation 

Meredith 200279 Inappropriate prescribing RCT 1. RCT (Level 2) 2. Clinical 

outcomes (Level 1) 

1. Newly admitted 

Medicare home health care patients 

2. Selection criteria 

• At least 4 weeks of 

skilled service 

• At least one 

medication problem 

• Age 65 and older 

3. Two groups: 

• Treatment (n = 130) • Control (n = 129) 

Medication improvement program • Screen for 

duplication, cardiovascular issues, use of psychotropics, and NSAIDs. 

• Medication use plan 

discussed directly with prescribing physician by home care nurse. 

Intermedper 1= 0.0medpatie20–7

imprcardpatie66, P changenecognand 

Murray 1993150

Medication compliance 

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2) 

1. Persons 60 and older 

living in urban public housing for older adults on at least three medications 

2. Three groups: 

• Group 1 (n = 12): 

conventional packaging, varied dosing 

• Group 2 (n = 10): 

conventional packaging and BID dosing 

• Group 3 (n = 9): unitof-use packaging 

and BID dosing 

Unit-of-dose packaging: single cup holding all meds to be taken at dosing time and BID dosing 

Comhighand 

= 0.0
32

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, u Key 

Study Outcome Measure(s) (level) Study Setting and Study Population St dy Intervention Naunton 200378 Medication compliance RCT 1. RCT (Level 2) 2. Adverse events (Level 1) 1. Community-dwelling older adults age 60 and older on four or more medications 2. Two groups: 

• Intervention (n = 57) • Control (n = 64) 

1. Pharmacist home visit 

5 days after hospital discharge included medication review, compliance encouragement, education, intervention when appropriate, with communication to community providers. 

2. Followup at 90 days. 

Intermedprobhad 90 dprob(P < groureho< 0.0high

Park 1992168 Medication 

adherence

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2) 

1. Community-dwelling 

older adults • Taking two or more 

medications 

• Age 60 or older 

2. Four groups: 

• Control (n = 16) • Medication schedule 

chart (n = 15) 

• Medication organizer 

(n = 15) 

• Schedule and 

organizer (n = 15) 

Use of medication schedule and organizer compliance devices 

Omiloweboth orgaAdullowethan 

Patton 1997128 

Medication adherence 

Pre- and post-test 

1. Nonrandomized 

control study (Level 3) 

2. Clinical 

outcomes (Level 1) 

1. HMO clinic patients 

with SBP 145 or greater and DBP 85 or higher consistently for at least 6 months. 

2. Total subjects = 107 3. Median age 69 

1. Nurse interactive 

education with written information. 

2. Followup phone calls 

at 1, 3, 6, and 12 months after initial education. 

MedtelepSBPadulin BP (P = 

Pereles 1996225

Medication compliance and knowledge 

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2) 

1. Geriatric rehabilitation 

inpatients 

2. Two groups: 

• Treatment (n = 51) • Control (n = 56) 

Inpatient program that included three stages of increasing responsibility to independently selfmedicate. 

Treahad erroNo din kn
33

Source Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study Design, Study Intervention Key Study OutcomeMeasure(s) (level) 

Study Setting and StudyPopulation 

Perri 1995170 Medication 

compliance

Non-RCT 1. Non-RCT 

(Level 3) 

2. Errors over 

time (Level 2) 

1. Community-dwelling 

pharmacy customers taking a chronic medication with a new refill or prescription 

2. Two groups: 

• Intervention (n = 88) • Control (n = 98) 

Stimulant “counter cap” prescription vile that indicates when cap was last opened. 

Subjhad com

Piette 2000129 Medication 

adherence 

RCT 1. RCT (Level 2) 

2. Clinical 

outcomes (level 1) 

1. Adults receiving 

diabetes treatment at a county health clinic 

2. Mean age 56 3. Two groups: 

• Intervention (n = 124) • Control (n = 124) 

1. Biweekly automated 

assessment and selfcare education telephone calls 

2. Nurse educator 

followup 

Interglucfrequprobadhe

lowe= 0.0

Raynor 1993120

Medication compliance 

RCT 1. RCT 

2. Errors over 

time (level 2) 

1. Inpatient adults taking 

2–6 medications 

2. Four groups: 

• Nurse standard 

counseling 

• Nurse counseling 

and reminder chart 

• Pharmacist 

counseling 

• Pharmacist 

counseling and reminder chart 

1. Counseling 2. Reminder chart or 

medication schedule 

Groucharcomknowrece0.01

Rich 1996127 Medication 

adherence 

RCT 1. RCT 

2. Errors over 

time (level 2) 

1. CHF patients at 

hospital discharge, age 70 or older 

2. Two groups: 

• Intervention (n = 80) • Control (n = 80) 

Comprehensive patient education, dietary and social service consultations, med review, and intensive postdischarge followup. 

Interadhepostcont
34

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, Study Outcome Measure(s) (level) Study Setting and Study Population Study Intervention Key Robbins 2004141 Medication adherence Non- RCT 1. Non-RCT (Level 3) 2. Errors over time (Level 2) Females age 65 and older with osteoporosis taking low-dose estrogen (n = 109) Educational program 

• Monthly phone calls 

for 12 months. 

• Quarterly clinic visits. • Pill box for 6 months. • Minority women (n = 

44) used an electronic monitoring bottle for an additional 6 months. 

Adheelect12 mmino

Rudd 2004140 Medication 

compliance 

RCT 1. RCT (Level 2) 

2. Clinical 

outcomes (Level 1) 

1. Adults treated for 

hypertension in an outpatient clinic 

2. Mean age = 60 3. Two groups: 

• Treatment (n = 74) • Control (n = 74) 

1. Nursing case 

management with patient instruction on use of blood pressure equipment and selfmonitoring. 

2. Followup nurse calls 

at 1 week, 2 and 4 months. 

3. Hypertension 

management program with standardized algorithms to modulate drug therapy based on subject’s reported home blood pressure. 

InterBP a0.05

Smith 1997136 Medication 

compliance

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2) 

1. Adults age 65 and 

older at discharge from the hospital 

2. Two groups: 

• Treatment (

n = 28) 

• Control (n = 25) 

1. Pharmacist inpatient 

discharge education related to pharmaceutical plan of care 

2. Telephone help line 

Interhigh(P < 
35

Source Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study Design, nd Study Study Intervention Key Study Outcome Measure(s) (level) 

Study Setting aPopulation 

Solomon 1998226

Medication compliance

RCT 1. RCT (Level 2) 

2. Clinical 

outcomes (Level 1) 

1. Outpatient clinic 

patients with hypertension or COPD 

2. Mean age 66 3. Treatment HTN (n = 

63), COPD (n = 43) 

4. Control HTN (n = 70), 

COPD (n = 55) 

Standardized pharmaceutical care, including assessment and regularly scheduled therapeutic and educational interventions. 

HTN greacomhospconttreatof ot(whecont

Stewart 2003137

Medication adherence 

RCT 1. RCT (Level 2) 

2. Clinical 

outcomes (Level 1) 

1. Patients attending 

hypertension clinic, mean age = 57 

2. Two groups: 

• Treatment (

n =41) 

• Control (

n =42) 

1. Both groups 

participated in an educational program related to management of hypertension and cardiovascular risk modification. 

2. Treatment group 

received six telephone calls to patient and six to family member over 34 weeks. 

Groucalls (P = to hy

adheregim

Sturgess 2003217

Medication compliance 

Group RCT 1. Group RCT 

(Level 2) 

2. Errors over 

time (Level 2) 

1. Community-dwelling 

older adults age 65 and older taking four or more medications and were regular visitors to participating pharmacies 

2. Ten pharmacies 

randomized so that five were interventional and five were control. 

3. Total of 191 subjects 

recruited: • Intervention (

n =110) 

• Control (

n = 81) 

Intervention pharmacies received intensive training related to • Disease management 

education 

• Rationalized 

medications 

• Compliance 

strategies 

• Monitoring for 18 

months 

Com

and medintercomdiffehealand iden
36

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, nd Study ention Key 

Study Outcome Measure(s) (level) Study Setting a Population Study Interv Taylor 2003122 Medication review RCT 1. RCT (Level 2) 2. Clinical outcomes (Level 1) 1. Outpatient clinic patients with three or more of the following high-risk factors: 

• 5 or more 

medications 

• 12 or more doses per 

day 

• 4 or more medication 

changes in past year 

• 3 or more concurrent 

diseases 

• history of medication 

noncompliance 

2. Two groups: 

• Treatment (n = 33) 

• Control (n = 36) 

1. Pharmacist 

intervention that included • Medical record 

review 

• Medication history 

review 

• Pharmaceotherapeutic 

evaluation 

• Patient education • Monitoring 

2. Length of treatment 1 

year 

Ratinpresinterdecrgrougrouhighpresdecr

satis0.00hospand both the c

Varma 1999124

Medication compliance 

RCT 1. RCT (Level 2) 

2. Clinical 

outcome (Level1) 

1. Persons age 65 and 

older with CHF who were hospitalized or attended outpatient clinic 

2. Two groups: 

• Intervention (n = 42) • Control (n = 41) 

1. Pharmacist-led 

medication education 

2. Medication review 

with dose simplification 

Treaknow0.00admdiffeof lif

Ware 1991148 Medication 

compliance and medication packaging 

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2) 

1. Setting both inpatient 

at a geriatric assessment and rehabilitation unit and postdischarge 

2. Two groups: 

• Treatment (n = 4) • Control (n = 39) 

1. Webster-Pak 

medication packaging unit-dose system 

2. Hospital practice prior 

to discharge in both groups 

Comsubjpack
37

Source Safety Issue 

Related to Clinical Practice 

Design Type (level) 

Study Design, Study Intervention Key Study OutcomeMeasure(s) (level) 

Study Setting and StudyPopulation 

Weinberger 2002130

Medication Compliance 

Group RCT 1. Group RCT 

(Level 2) 

2. Clinical 

outcomes (Level 1) 

1. Pharmacy customers 

who had COPD or asthma as an active problem and received 70% or more of medications from a single drug store 

2. Three groups: 

• Intervention (n = 

447) 

• Control group with 

peak expiratory flow rates (PEFR) monitoring (n = 363) 

• Usual care control (n 

= 303) 

Tailored education by pharmacist based on patient-specific data provided to the participating pharmacists. 

TreaPEFgrousatispharmore care whegrouthe phad and usua2.16 0.00age younwho

Wilson 2001151 

Medication compliance 

RCT 1. RCT (Level 2) 

2. Indirect 

connection to outcome (Level 3) 

1. Community-dwelling 

outpatients over age 70 with type 2 diabetes 

2. Two groups of 15 each 

1. Use of Glynase 

Prestabs for easier tablet breaking. 

2. Use of push-and-snap 

method to break tablets. 

Highsuccless than 

WinlandBrown 2000172

Medication adherence 

RCT 1. RCT (Level 2) 

2. Errors over 

time (Level 2) 

1. Residents of older 

adult independent living facility, continued monitoring 

2. Three groups: 

• Pre-filled pill box (n = 

16) 

• Voice activated (n = 

24) 

• Control (n = 21) 

Medication management methods 

• Pill box • Medication dispenser 

with voice-activated reminders 

Numwere groucontprefi
38

Source Safety Issue Related to Clinical Practice Design Type (level) Study Design, Study Intervention Key 

Study Outcome Measure(s) (level) Study Setting and Study Population Wong 1987149 Medication adherence Prospective cohort study 1. Cohort study with controls (Level 4) 2. Errors over time (Level 3) 1. Geriatric outpatient setting 2. Two groups of 11 each with crossover after 3 months Blister-packed medications for 3 months and standard pill bottles for 3 months Com

subjbliste