Benefits and Harms of Older Persons’ Willingness to Take Medications

Pay-for-performance and quality-assurance initiatives stress adherence to evidence-based guidelines for the prevention or management of particular diseases. Patient preferences, however, may not agree with the guidelines. At the heart of many of the established guidelines for the prevention of primary disease is the goal of reduced risk of disease-specific outcomes, including myocardial infarction (MI) or stroke; implicit in the guidelines is the judgment of the clinician that the benefits of prevention of disease-specific outcomes outweigh any potential harms associated with the intervention. There is, however, evidence to support the thesis that the judgments of the clinicians may not match the ways in which patients view benefits and harms. Qualitative studies have shown that for some patients considering prevention interventions, the act of taking medication involves risk, including the possibility of adverse medication effects, viewed by patients as unacceptable outcomes in their own right. These disagreements between how guidelines and patients view the benefits and harms of medications are especially important to older adults who have multiple risk factors for chronic disease and meet the criteria for many guideline-directed medications for primary prevention. Researchers recently conducted a study to examine how the willingness of older adults to take medication for the prevention of primary cardiovascular disease is affected by the likelihood of reduction in MI and the type and severity of adverse medication effects. The study also sought to determine how well the older adults understood the information about the probable benefits of the therapy. Study results were reported online in Archives of Internal Medicine [doi:10.1001/archinternmed.2011.32]. Participants (n=356) were recruited from 3 senior centers, 1 serving an urban, predominantly African American population and 2 serving a suburban, predominantly white population, and 1 independent/ assisted living facility providing both market-rate and subsidized apartments. Because one of the study objectives was to determine how well participants could understand numerical information about medication benefits, all volunteers were included in the study without exclusion. In-person interviews were conducted in which participants were asked about their willingness to take medication for primary prevention of MI with varying benefits in terms of absolute 5-year risk reduction and varying harms in terms of type and severity of adverse effects. The first scenario depicted a medication without adverse effects offering a 30% relative reduction in risk of MI to an older person at what was defined as an average baseline risk (absolute risk reduction of 6 fewer persons with MI); 88% of the participants said they would take that medication. Of the participants who would not take the medication, 17% changed their preference if the absolute benefit was increased to 10 fewer persons with MI. Of those who said they would take the medication, 82% remained willing if the absolute benefit was reduced to 3 fewer persons with MI. When asked about adverse medication effects, 48% to 69% were unwilling or uncertain about taking medication with average benefit that caused mild fatigue, nausea, or fuzzy thinking. Only 3% would take medication with adverse effects severe enough to affect functioning. The most common reason given by the participants who were willing to take the medication in the original scenario but not willing to take a medication associated with mild fatigue and dizziness was not wanting to experience those symptoms. Other reasons were the belief that the benefit was not worth the symptoms, the belief that symptoms would interfere with ability to function, and effects on quality of life. In summary, the researchers stated that “an older person’s willingness to take medication for primary cardiovascular disease prevention is relatively insensitive to its benefit but highly sensitive to its adverse effects. These results suggest that clinical guidelines and decisions about prescribing these medications to older persons need to place emphasis on both benefits and harms.”