“I’m not a pill-taker”: Medication and meaning for older people

Background: The philosophy of ageing in place has seen a greater emphasis on community care for older people. In New Zealand, access to assistance at home from health services begins with a comprehensive geriatric assessment, which includes medication management. This thesis examines specifically older participants’ self-management of medications and what medication-taking means to them. Aims 1. To explore how older people make sense of their medication-taking and medication self-management. 2. To explore the value of a narrative approach/methodology in eliciting older people’s attitudes and practices in medication-taking. 3. To critically view how the meaning older people make of their medication self- management might influence policy and practice. Methodology and Methods The overarching methodological approach to this thesis is a narrative one. Twenty participants underwent two separate sets of interviews: a needs assessment interview guided by a standardised geriatric assessment tool, and a semi-structured interview about their practices and beliefs on medication-taking. In total, forty interviews with older participants who were living in their own homes in the community were analysed using narrative analysis and presenting data in the form of themes and case studies. Results Four key findings emerged from the analysis. These were the themes of: 1. Living with illness – the impact on lives and medication-taking First and foremost, participants lived and coped with illness as part of their everyday living at home. Medication-taking was one of multiple consequences of the daily reality of living with a chronic illness. Any sense that participants made of their medication was in the first instance viewed through the lens of a recent illness, hospitalization, chronic pain or uncertainty of the future trajectory of the illness. 2. Trust and the older patient-doctor relationship The majority of participants expressed a strong sense of trust in their doctor as the main prescriber of their medication. The doctor’s word and advice was law to most participants, who imbued their doctor with an authority and competence without question. Further, many also valued a ‘social’ relationship with their doctor where a personable interaction was able to exist largely due to longevity of relationship, but also a willingness to see the doctor as a person, not just a health professional in an objective transaction. 3. Everyday routines and strategies These showed resourcefulness, coping and adaptation. Participants demonstrated a variety of unique systems and strategies related to medication self-management, from sophisticated routines where medication was checked, administered and stored correctly through to haphazard and inconsistent patterns of self-administration. Strategies depended on their beliefs but also on life circumstances and the meaning and importance placed on medication. Participants coped variously with management of their medication in the same way they coped with other aspects of daily life at home such as preparing meals, showering and socialising. Managing medication was not seen by the participants in isolation from the lived daily context of everyday managing routines and strategies. Self-management of medication required the ability to navigate through layers of complex context. For some it was more important to comply with medication taking; for others it was not a priority. 4. Advice – formal and informal Participants had valued relationships with others beyond doctors in relation to medication-taking. This was primarily with other formal health professionals such as pharmacists, but also on an ‘informal’ level, with family and friends. Some advice and recommendations came from surprising sources such as a bank teller or a women’s magazine. The gathering of information which informed medication-taking showed that older people’s lived context was far wider than a doctor-patient relationship. Views and attitudes of others all contributed to the sense older participants made of their medications. Conclusion/implications for practice Health services and professionals need to respect strategies and coping methods which older people have developed to self-manage medications and other aspects of their daily living. By listening to older people’s narratives of how they manage, health professionals can work with older people on their own terms starting with the voice of the older person as expert self-manager. Health professional education is necessary to raise awareness that meaning for older people is produced through narrative and that this is a key component of assessment and service delivery