Rx Compliance in the Elderly
Note to Readers:
This article supplements our March CE course on Rx Compliance in the general population. Because of the length of that course, we decided to publish this additional material for all registered web site members to see.
Why is this subject so important?
Because of the heavy use of pharmaceuticals at ages 65 and over, a phenomenon sometimes described as “polypharmacy.”
Do older-aged persons use more Rx?
“Although only about 13% of the US population is over age 65, this segment uses more than 30% of prescription and 35% of OTC [over-the-counter] drugs.”
Mark H. Beers
American Journal of Managed Care
Do the words “compliance,” “adherence” and “persistence” all mean essentially the same thing in an Rx context?
Yes – although in some studies they are used to make distinctions that have little or no relevance to us in underwriting.
Does patient age affect Rx compliance?
In one large study, compliance was best at ages 55-64, then dropped off progressively at 65-75 and 75+, to the point where it was worse than at ages 45-54. [Chapman]
What % of older age persons are noncompliant (defined as failing to take a drug at least 80% of the time, as indicated on the pill bottle)?
Do prescription refill records overestimate compliance in older age people?
Yes – which means that if we have access to and make use of Rx refilling records, our estimate of actual noncompliance will be a conservative one. [MacLaughlin]
What % of geriatric hospitalizations for circulatory problems are thought to be due to noncompliance?
What factors have been shown to affect compliance in the elderly? [Bambauer, Col, Friedlander, Kulkarni, Ownby, Soumerai, Tsai]
- Living alone
- The presence of depression
- Relatively lower income
- Education less than high school (12 years of formal education)
- Low levels of health literacy (not understanding their ailments)
- Lack of sufficient English reading ability
- Self-rated health less than EXCELLENT or VERY GOOD
- Comorbid illnesses (having 2 or more impairments vs. just 1)
- Having 1 or more ADL impairments
- Forgetfulness/benign memory impairment
- Clinical cognitive disorder
- More complex drug-taking regimen
- Receiving prescriptions from more than one doctor
- Lack of insurance/ability to pay
How common is cost-related noncompliance?
In a study of nearly 14,000 older persons with access to Medicare benefits, noncompliance due to inability to afford prescribed drugs was 13% overall and 29% if disabled, due to inability to afford prescribed drugs. [Soumerai]
Do older age patients tend to know the drugs they take better than younger persons?
No – in a Brooklyn, NY study, at age 66 and over only 8.3% of subjects knew the names of all their drugs, as compared to 62% under age 50 and 17% at 51-65. [Makaryus] No doubt polypharmacy was a major reason for this sharp decline.
Is geriatric polypharmacy rare?
Hardly…just look at a series of MD reports on applicants with multiple impairments and you will see what we mean!
What role does polypharmacy play?
“Among the elderly, the use of multiple medications resulting in complicated drug regimens is an important barrier to medication adherence.”
Jeannie L. Lee, PharmD et al.
Walter Reed Hospital
Journal of the American Medical Association
What level of polypharmacy is strongly associated with a high degree of noncompliance?
In a Canadian study, taking 11 or more drugs within a period of one year. [Grant]
Do all studies support a significant degree of noncompliance in polypharmacy over age 65?
No, in the above-mentioned Canadian study, compliance actually improved between 1 drug and 7 drugs being taken and only became adverse at higher levels.[Grant]
What works synergistically with the number of drugs being taken to cause noncompliance to increase?
The complexity of the drug regimen, as in:
- How many pills needed
- How many times taken each day
- Use of a non-pill delivery system such as a patch or by self-injection
What is the association between geriatric polypharmacy and the risk of a serious adverse drug reaction (requiring hospitalization and/or potentially life-threatening)?
It doubles when utilization increases from 1 to 4 drugs and then is 14-fold greater at a level of 7 drugs being taken at the same time. [Beers]
Is there excess mortality in geriatric polypharmacy?
In one study among older community-dwelling subjects, patients taking 5 or more medications had twice the mortality as those taking less, independent of the risks associated with the reasons for which they were taken. [Mazzaglia]
Is the risk of being hospitalized also greater in polypharmacy?
Yes – in the same study, patients taking 5 or more drugs were 2.2 times more likely to require hospitalization; again, independent of the reasons for which the drugs were taken.
Did this study show anything else of underwriting interest?
Absolutely…the fact that subjects who had been hospitalized within the past 6 months had 2.8-fold increased mortality as compared to those who had not!
Being hospitalized within 6 months also increased the risk of future hospitalization 3.6 times expected.
These findings suggest that we must pay close attention to recent hospitalizations in elderly applicants, independent of the reason…and more carefully review their histories (including inpatient test findings!) in cases involving recent hospital discharge for any reason.
Does Rx compliance in the elderly decrease over time after discharge from inpatient care?
Yes, in a variety of drugs. [Sud]
What is 1-year Rx compliance with common cardiac drugs at older ages?
In a cohort of Canadian patients who had experienced an MI – which should motivate them to take their medications! – the following % were noncompliant after 12 months: [Simpson]
- Aspirin 25%
- Lipid drugs 16%
- Beta-blockers 26%
- ACE inhibitors 30%
How good is statin Rx compliance at older ages?
Benner et al. found that compliance by pill count was 79% after 3 months but trailed off to 56% thereafter.
Does statin compliance affect mortality in older age post-MI patients?
Significantly…mortality being 25% higher after 3 months in those with poor compliance, as compared to patients deemed “fully compliant.” [Rasmussen]
How about compliance with BP drugs?
Yet another Canadian study showed 75% compliance after 1 year, declining to only 45% after 48 months [Perreault] – and we might add that compliance is likely to be lower in the US because of greater patient out-of-pocket cost.
Is compliance better in congestive heart failure?
Brown and Shannon found that compliance was reported to be 80% overall in various studies but that when they used refill data, only 10% of digitalis users filled enough prescriptions to be able to use the drug in the manner prescribed.
Does this have implications for CHF patient outcomes?
Yes – in their study, Brown and Shannon found that a 2.6% decline in compliance resulted in a 6.1% increased incidence of hospitalization.
Have any specific factors been linked to geriatric noncompliance with heart failure Rx?
Yes – comorbid depression, which has been shown to lessen compliance in almost every Rx scenario! [Moser]
Are most geriatric T2 diabetics compliant with oral medications?
A web-based survey found that 30% miss at least one dose per week. [Hahn]
How is compliance in osteoporosis?
In a word: lousy!
Ettinger found that after 1 year of ostensible treatment only 36.9% who received daily bisphosphonates and 54.6% who received these drugs weekly remained on therapy.
What are the implications of all of the relatively high noncompliance rates cited here?
They correlate directly with excess morbidity and mortality.
Are there specific implications for underwriting?
Yes…the fact that we tend to accept what is stated on applications.
In other words, if an applicant says he/she is “taking simvastatin,” we simply assume it is true and may use this as a favorable factor in determining insurability.
This is especially true where preferred risk coverage is offered, because being hypertensive or hyperlipidemic on treatment does not automatically disqualify the individual from getting preferred (sometimes super-preferred) premium rates in the great majority of companies.
How can we improve the quality of the information we get where underwriting noncompliance is concerned?
To do so, we must accept that not inquiring specifically – as is the case with traditional applications in the absence of teleinterviews – is not going to generate much information about Rx-taking practices. This is not something applicants will volunteer unasked.
To make effective use of this aspect of insurability, we MUST do teleinterviews and include questioning about Rx compliance on all relevant drilldowns.
How can we enhance disclosure of Rx-taking practices on teleinterview drilldowns?
If we ask something straightforward (“do you take your medication as prescribed”), the odds of getting a YES – when the real answer is NO – are higher than if we ask, for example, thusly: “how many times per week do take your medication?” At least this has been our experience.
Can we rely on medical records for reliable information on Rx compliance?
You probably think the answer is yes…but it isn’t.
Where their Rx use practices are concerned, patients are simply less likely to tell their doctors the truth than they are strangers calling them to complete the insurance-buying process! They don’t want to disappoint their physician or get a lecture.
Physicians are also notorious for not recording observations related to compliance (assuming that they even ask).
Do Americans have a huge advantage where assessing Rx compliance is concerned?
They really do…because they can get Rx profile reports – based directly on pharmacy records – for 70% or more of their applicants.
We have found that the true value of Rx profiling is significantly underappreciated unless one understands the insurability implications of not refilling prescriptions (as we have tried to show here).
Are there any other major underwriting considerations associated with compliance that we need to focus on?
Yes – one – and we get into detail about it and its ramifications in our CE course on compliance.
We refer here to what is widely recognized as the “healthy adherer effect,” which is summed up by one team of physicians as follows:
“…patients who take their medication as prescribed are more likely to engage in a broad spectrum of health-promoting behaviors that lower the risk of mortality.”
M. Alan Brookhart, et al.
American Journal of Epidemiology
Do you have some examples of health-related factors associated with Rx compliance?
Yes – but research into this domain is still in its relative infancy:
- Temperate alcohol use (vs. heavy drinking or being an ex-drinker)
- Not smoking cigarettes
- Being compliant with MD advice for routine screening tests such as mammograms, fecal occult blood, etc.
- Consuming healthier diets
And the list goes on and on…all of which suggests that we should be exploring the potential for including some of these “healthy adherer” markers in how we appraise risks!
Is this article an example of how your CE courses are formatted?
Yes, in terms of basic layout but with 3 important differences:
- CE courses are provided in both PDF and WORD documents. WORD documents, of course, are easily edited, allowing users to adjust the content to fit their own underwriting practices and viewpoints on specific issues.
- CE courses include LEARNING POINTS at the end of each segment.
- CE courses contain SELF EXAMINATIONS with true/false and multiple choice questions (linked back to the text, so that participants can validate the correct answer).
Can we get a sample CE course?
Just e-mail Esther at email@example.com and ask her for a CE sample course.
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Benner. Journal of the American Medical Association. 288(2002):455
Brown and Shannon. www.AJConline.org January, 2008
Chapman. Archives of Internal Medicine. 165(2005):1147
Col. Archives of Internal Medicine. 150(1990):841
Ettinger. Arthritis & Rheumatism. 15,Supplement(2004):S513
Friedlander. Journal of the American Geriatric Society. 55, 4, Supplement(2007)S60
Grant. Archives of Internal Medicine. 164(2004):2343
Hahn. Diabetes. 55,Supplement 1(2006):A196
Kulkarni. American Heart Journal. 151(2006):185
MacLaughlin. Drugs and Aging. 22(2005):231
Makaryus. Mayo Clinic Proceedings. 80(2005):991
Mazzaglia. Journal of the American Geriatric Society. 55(2007):1955
Moser. Circulation. 114,Supplement 2(2006):II-518
Ownby. Geriatrics. 61(2006):30
Perreault. Annals of Pharmacotherapy. 39(2005):1401
Rasmussen. Journal of the American Medical Association. 297(2007):177
Sherman. Geriatrics. 62(2007):5[editorial]
Simpson. American Heart Journal. 145(2003):438
Soumerai. Archives of Internal Medicine. 166(2006):1829
Sud. Annals of Pharmacotherapy. 39(2005):1792
Tsai. Journal of Glaucoma. 12(2003):393
Insureintell.com March 2008