Strategies for coping in a complex world: adherence behavior among older adults with chronic illness.

Abstract

BACKGROUND: Increasing numbers of medicines increase nonadherence. Little is known about how older adults manage multiple medicines for multiple illnesses. OBJECTIVES: To explore how older adults with multiple illnesses make choices about medicines. DESIGN: Semistructured interviews with older adults taking several medications. Accounts of respondents' medicine-taking behavior were collected. PARTICIPANTS: Twenty community-dwelling seniors with health insurance, in Eastern Massachusetts, aged 67-90, (4-12 medicines, 3-9 comorbidities). APPROACH: Qualitative analysis using constant comparison to explain real choices made about medicines in the past ("historical") and hypothetical ("future") choices. RESULTS: Respondents reported both past ("historical") choices and hypothetical ("future") choices between medicines. Although people discussed effectiveness and future risk of the disease when prompted to prioritize their medicines (future choices), key factors leading to nonadherence (historical choices) were costs and side effects. Specific choices were generally dominated by 1 factor, and respondents rarely reported making explicit trade-offs between different factors. Factors affecting 1 choice were not necessarily the same as those affecting another choice in the same person. There was no evidence of "adherent" personalities. CONCLUSION: Prescribing a new medicine, a change in provider or copayment can provoke new choices about both new and existing medications in older adults with multiple morbidities.