Transcription:
Caregiver Involvement in Older Adult Medication Management

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and joining me today is Dr. Rachel O'Connor. She's an Assistant Professor of Medicine in General Internal Medicine and Geriatrics at Northwestern Medicine. She's here to share her research published in the Journal of the American Geriatric Society surrounding caregiver involvement in managing medications among older adults with multiple chronic conditions. Dr. O'Connor, it's a pleasure. And you and I were speaking off the air. I think this is such a really great topic. Before we get into your research, can you tell us a little bit about the challenges and trends for the geriatric population, as far as managing their medications, the pitfalls, complications that can arise? What's been the role of the caregiver in this sometimes very complex, multiple medication schedule?

Rachel O'Conor, PhD, MPH (Guest): Yeah. Thank you so much for having me. I'm really excited to be talking with you and talking with the larger audience as well. As a brief background on medication management in older adults, it is estimated that about 40% of older adults take five or more prescription medicines. And unfortunately it's also estimated that about half of all patients demonstrate sub-optimal medication adherence. And this is really linked to greater morbidity and mortality among our patients. And so because of these low rates of adherence, I think it's really important to better understand the barriers that many patients face when they're taking medications, especially complex medication regimens; in order to ensure that they do gain the benefits of these prescribed drug therapies.

And how I like to approach my work is really thinking about the many different tasks that are involved in taking medications. So taking a step back and thinking about what's involved in taking medicines. I like to think of it as first, the individual must fill their medicine. Then they need to actually understand how to take the medicine. What time of day to take it at, how many pills to take. They need to organize their medicines into an efficient schedule, and then they actually have to take the medicines at the correct times each day. This is often multiple times per day. After taking the medicines, people must monitor how they're taking them, if they're experiencing any side effects and then really need to sustain these behaviors over time.

And so I find thinking about this series of behaviors really helpful, because it really demonstrates the complexity of taking these multi-drug regimens and what really is involved. It kind of elucidates why we're observing some of these high rates of sub-optimal medication adherence. And then at the same time, what I found is that it's estimated that about 75% of older adults do broadly receive assistance from caregivers or family members in taking their medicines.

However, what I found is that no studies really have examined to what degree caregivers or family members are assisting with these many different aspects that are involved in taking medications. I view caregivers or family members really as valuable partners when seeking to try to promote medication adherence. And a lot of my work really has been around better understanding how caregivers are involved in supporting older adults in taking complex medication regimens.

Host: Well, it can be challenging for even younger individuals when it's a complex medication regimen, as you say. So expand a little bit about your researchthat was published in the Journal of American Geriatric Society. Tell us a little bit Dr. O'Connor about the parameters and setting, the participants and really what you would like other providers to know as you tell us about this research.

Dr. O'Conor: So to pursue this research I conducted semi-structured qualitative interviews among 25 caregivers. Caregivers needed to be supporting or assisting older adults who are managing three or more chronic conditions. And I asked a series of open-ended questions to really better understand how the caregivers were helping with these many different domains that are related to taking medications throughout the day.

Host: So did your research uncover themes about patient independence and caregiver management of these medications?

Dr. O'Conor: What was really interesting throughout these interviews was what we heard a lot is that many of the caregivers were assisting with many different activities, and helping the older adults stay healthy. But one aspect of that many caregivers wanted, for the older adult to remain independent in, was in managing their medications.

I was actually pretty surprised to hear this, that many people were very open to helping with different aspects, but often did really indicate that they try to let the older adult manage their medicines independently here. And even people who were actively involved in assisting with the medicines, they often would kind of reference that the individual could do these activities on their own, but they just had taken this upon themselves to help them, or that they like to let the person kind of manage their medicines on their own, but they are continuing to monitor them, from a distance. So there really was a lot of emphasis on patient autonomy in managing medicines across all of the caregivers.

Host: Did you identify some typologies of caregiver assistance with medications that emerged in your research? How is that relevant for clinicians?

Dr. O'Conor: When we were reviewing our transcripts, three different typologies, emerged in the type of role that caregivers played in assisting the older adults in managing their medicines. These three typologies included, actively involved, peripherally involved, and not involved. And I'll just kind of explain each one of those and then I can talk about how that might be relevant to clinical practice or clinicians.

So actively involved caregivers, these caregivers perceive that the older adult needed assistance and then did offer this assistance. And then a second critical component was that the older adult did accept the assistance from the caregiver and ultimately did delegate responsibility to them.

For our caregivers who we identified as being peripherally involved, these caregivers also perceived that the older adult needed assistance and then offered assistance. However, here, the older adult did reject this caregiver assistance. But they did often rely on the caregiver as a backup. And many caregivers in this role, they are often monitoring the individual was taking their medicines, but they couldn't actually, become fully involved in, supporting the older adult. Many of these caregivers who were classified as peripherally involved, they often expressed, a level of frustration because they thought they had a lot of valuable solutions to offer. But, were often kind of just brushed aside with these suggestions.

And then our third, typology or category that we identified was caregivers who are not involved. And here caregivers did not perceive a need to offer assistance to the older adult. And so then the older adults continued to manage their medicines independently.

Host: Doctor, this is so important. And if your findings suggest that caregivers value independent medication management by their care recipient up and until safety is seriously questioned, should clinicians assume caregivers are actively and consistently involved in older adults' medication management, and if not, how should they then initiate the conversation with patients and their caregivers so that they can better understand and facilitate co-management responsibilities, especially among those whose assistance is rejected by older adults. We all know that happens, to help navigate the feeling of dependence, dignity, or miscalculating cognitive deficits.

Dr. O'Conor: There really is. I think as you mentioned, it really is important for clinicians to really not assume that a caregiver is actively and consistently involved in the older patient's medication management. I think just because someone identifies that they have someone who is a caregiver or who may even attend doctor's appointments; this individual may actually not be involved in the day-to-day management of the medication. And I think especially for our caregivers who kind of fall into this peripherally involved category, I think they really would appreciate clinicians who do initiate conversations between the patient and caregiver, and they think this can be done in a way that's really respectful to both parties, but really in, just asking open-ended questions to better understand who is responsible for these different aspects of taking medicines. So who is responsible for picking up the medicines? Who is responsible for organizing? Or where the medicines are stored? Who is responsible for actually remembering to take the medicine? Or setting reminders or actually physically obtaining the pills and taking them? I think breaking it down into these different actions, it can really help elucidate who is actually involved. Because I think asking just are you involved in your medicines or just how is it going taking your medicines? I I think it's easy for people to say, oh, it's going great. It's fine. But really digging in deeper to better understand these different roles and responsibilities, I think can provide a lot of insight, as to who is helping with different aspects.

Host: Well, anyone who's ever helped care for aging relatives really could hear this podcast and would certainly appreciate if the clinicians help to navigate that and bring that cohesiveness together, so that one caregiver knows what their care recipient is doing and vice versa. So it really is that important of a topic. And how are you incorporating this research into your work at Northwestern Medicine?

Dr. O'Conor: Thank you. I, I do think it's really important and as I did preliminary research that provided pilot data for a new study that I'm now trying to better understand this process among older adults with early stage cognitive impairment, or early stage dementia and trying to better understand in talking to both the older adult and the caregiver to understand both sides, both perspectives. Because two people are involved, I think I really needed to understand both sides in order to inform approaches that are attentive to the needs of both people. And then I'm also beginning to conduct interviews with clinicians to really understand how clinicians are approaching these conversations with their patients and family members, to see how we can support clinicians in having these conversations in the future.

Host: Well, Dr. O'Connor, I do hope that you will come on and update us as this work continues because it is so important. And we're seeing so much of this around the country with difficulty managing chronic conditions and the multiple medications that go along with it. So please leave us with one parting piece of information for providers listening, about having those discussions with families and what you're doing at Northwestern Medicine.

Dr. O'Conor: Thank you. I've really enjoyed this conversation. And I think my one parting message would be, for clinicians really to consider initiating conversations with both their older patients and family members. Just to better understand who is responsible for these different aspects of medication management and see if they can, in a sense, facilitate these co-management responsibilities, between their older patients and caregivers.

Host: Thank you so much, Dr. O'Connor. So informative, really educational and eye-opening as well. And to refer your patient or for more information, please visit our website at nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians.

And for more updates like this on the latest medical advancements, breakthroughs and research, you can always follow us on your social channels. I'm Melanie Cole.