Special Article
Medication Adherence Behavior and Priorities Among Older Adults With CKD: A Semistructured Interview Study

https://doi.org/10.1053/j.ajkd.2010.04.021Get rights and content

Background

Older adults with chronic kidney disease (CKD) typically use more than 5 medications and have multiple prescribing physicians. However, little is known about how they prioritize their medical conditions or decide which medications to take.

Methods

Semistructured interviews (average length, 40 minutes) with 20 community-dwelling adults with CKD stages 3-5D receiving nephrology care at a tertiary referral center. Respondents were asked about medications, prescribing physicians, and medication-taking behaviors. We performed thematic analysis to explain patients' decisions regarding medication prioritization, understanding, and adherence decisions.

Results

Participants (age range, 55-84 years; mean, 72 years) used 5-14 prescribed medications, had 2-9 physicians, and had 5-11 comorbid conditions. All had assigned implicit priorities to their medications. Although most expressed the intention to be adherent, many regularly skipped medications they considered less important. Most identified the prescribing physician and indication for each medication, but there often was substantial discordance between beliefs about medications and conventional medical opinion. Respondents prioritized medications based on the salience of the particular condition, perceived effects of the treatment, and barriers (physical, logistic, or financial) to using the prescribed drug. Side effects of medications were common and anxiety provoking, but discussions with the prescribing physician often were delayed or unfulfilling for the patient.

Conclusions

Polypharmacy in patients with CKD leads to complex medication choices and adherence behaviors in this population. Most patients we interviewed had beliefs or priorities that were nonconcordant with conventional medical opinion; however, patients rarely discussed these beliefs and priorities or the resultant poor medication adherence with their physicians. Further study is needed to provide quantitative data about the magnitude of adherence barriers. It is likely that more effective communication about medication use could improve patients' health outcomes and reduce potential adverse drug events.

Section snippets

Participants

This study recruited patients with CKD stages 3-5D from 2 ongoing observational cohort studies at an academic medical center. Patients had to be English speaking, be in control of organizing their own medications, and, to facilitate participation, have an upcoming scheduled visit to the medical center. We included patients 55 years and older. In our final sample, all except 1 participant was older than 60 years. We excluded patients currently using transplant-related immunosuppressive therapy

Participants

We interviewed 12 men and 8 women (Table 1). Eight of the interviewees were dialysis dependent; 12 had CKD stages 3-5. As expected, these individuals had many comorbid conditions and complex medication regimens, typical of older patients with CKD.19 Although most participants indicated a general intention to be adherent, all participants could identify barriers to consistent medication use. Some participants viewed these barriers as relatively minor, but for many, the barriers had led them to

Discussion

In this study, patients with CKD stages 3-5 and complicated medication regimens had complex methods for judging the importance of medication use. They weighed possible side effects and risks of polypharmacy against the information they received about potential benefit of medications. Only a few individuals reported discussion of these decisions with their physicians despite significant concerns, a finding consistent with prior studies of older adults.21

Even participants who self-identified as

Acknowledgements

Support: This study was supported in part by grant K24DK078204 to Dr Sarnak from the National Institute of Diabetes and Digestive and Kidney Diseases/National Institutes of Health.

Financial Disclosure: None.

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    Originally published online as doi:10.1053/j.ajkd.2010.04.021 on July 31, 2010.

    Because an author of this manuscript is an editor for AJKD, the peer-review and decision-making processes were handled entirely by an Associate Editor (Dr Kevan Polkinghorne, MBChB, MClinEpi, FRACP, PhD, Monash Medical Centre) who served as Acting Editor-in-Chief. Details of the journal's procedures for potential editor conflicts are given in the Editorial Policies section of the AJKD website.

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