“Imagine that your doctor has prescribed you these medications,” the researchers told the older adults, aged 55 to 74, who were participating in an experiment at several Chicago health centers.
“Please show me when you would take these medicines over the course of one day.” After reading the instructions on seven pill bottles, the participants were asked to distribute them in a medication box with 24 slots, one for each hour of the day.
Ideally, the seven meds could have been grouped into just four dosings per day. But only 15 percent of the 464 subjects grasped that possibility. Most commonly, they decided they needed to take pills six times a day; one-third organized the pills into seven daily doses.
Two of the drugs carried identical instructions, but a third of participants didn’t realize that they could be taken together. Almost 80 percent didn’t understand that they could take two drugs together if one label read “every 12 hours” and the other “twice daily” — even though, in this context, they meant the same thing.
“We learn over and over again how challenging it is to maintain a drug regimen,” said Michael Wolf, an epidemiologist at the Feinberg School of Medicine at Northwestern University, who led the experiment.
Medication adherence, a widespread public health concern, is a particular problem for older people. They take many more drugs than younger patients do — seven prescriptions is hardly unusual. Yet studies have repeatedly demonstrated that “the more times a day you have to take a medication, the lower your adherence,” Dr. Wolf said.
When patients can’t come up with a workable plan, or can’t stick to a plan, unhappy consequences can follow.
Drug A seems ineffective, leading a physician to add Drug B, when the real problem is that the patient simply misunderstood the dosage and wasn’t taking enough A. Or an older patient simply throws up his hands over a complex regimen and remains unmedicated or undermedicated, risking serious illness.
“I see this stuff every day in my clinical practice,” said Dr. William Hall, a geriatrician who directs the Center for Lifetime Wellness at the University of Rochester in New York. “There’s tremendous possibility for confusion.”
Let’s acknowledge that some of the reasons that older adults get their drugs wrong are tough to fix.
Cost, for instance. Despite Medicare Part D, and the Affordable Care Act’s gradual closing of the dreaded “doughnut hole,” some older people just can’t afford to take medications as frequently as they are supposed to.
Or worse: “Maybe you never fill the prescription because the pharmacist says it’s not in your Part D formulary and you’d have to pay it all yourself,” said Todd Semla, a pharmacist and past president of the American Geriatrics Society.
Cognitive impairment, unsurprisingly, has been shown to affect older patients’ ability to manage medication, too. Seniors may also deliberately discontinue drugs when they dislike their side effects.
But drug lapses and errors also occur because of problems that, in a more rational world, should be fairly simple to address. Researchers and reformers already have come up with relatively easy fixes.
■ The universal medication schedule: Instead of asking patients to decipher perplexing labels (some still use Latin abbreviations, like TID for three times a day), labels would set out four standard times — morning, noon, evening, bedtime — for taking drugs.
Nearly all drugs can be made to fit into this schedule, which could help patients group pills so they are less likely to take unnecessarily frequent doses, skip them, or just give up altogether.
At a National Institutes of Health conference last month, Dr. Wolf and his colleagues reported on a trial (not yet published) involving 845 patients in Northern Virginia. Those who received so-called patient-centered labels using the universal medication schedule — and larger type — made significantly fewer mistakes while taking their prescriptions.
The biggest improvements occurred among patients at highest risk for nonadherence: those with lower health literacy and those with more complex regimens.
California began calling for (though not requiring) the universal medication schedule — along with simpler labels in larger type — in 2011, despite drug industry resistance. But so far no other state has followed suit.
■ A consistent appearance: Older people often rely on the size, shape and color of pills and capsules to remember what to take when. But because pharmacies constantly negotiate for lower prices on generic drugs and frequently change suppliers, the appearance of pills changes quite often.
In a study of more than 11,000 people discharged from hospitals after heart attacks and prescribed cardiovascular drugs, for instance, 29 percent took pills that changed shape or color during the first year. Patients take these drugs for years, so they are likely to encounter many such alterations.
“The year after a myocardial infarction is a time in a person’s life when adherence to medication is extremely important,” said Aaron Kesselheim, an internist and health policy researcher at Brigham and Women’s Hospital in Boston and the lead author of the study.
Those cosmetic alterations led to trouble. While most patients stuck to their regimens, those whose pills changed color were 34 percent more likely to stop taking them, compared with a control group. When the pills changed shape, patients were 66 percent more likely to discontinue using them.
Dr. Kesselheim and his team suggested that the Food and Drug Administration require manufacturers to produce generic drugs that mimic the colors and shapes of the patented brand-name drugs they replace. In June, the F.D.A. issued “guidance,” nonbinding recommendations, pointing out that changes in size (it didn’t mention color) could affect compliance.
“We think it wasn’t broad enough,” said Dr. Kesselheim, whose team is developing another study that might move the F.D.A. to further action. “Things move slowly.”
While awaiting improvements that would help older people cope with their drug routines, some could take advantage of a free program available through Medicare Part D.
Medication Therapy Management, offered by private insurers that cover drugs, will review prescriptions, doses, costs and other questions for older people who have several chronic conditions and take multiple medications. It could help them stay on track.
Still, it should already be easier to do that. “The wonder,” Dr. Hall said, “is that anybody gets it right.”