Abstract
To address the risks associated with polypharmacy, health care providers are investigating the feasibility of deprescribing programs as part of routine medical care to reduce medication burden to older adults. As older adults are enrolled in these programs, they are confronted with two dominant and legitimate accounts of medications, labeled the medication paradox: medications keep you healthy but they might be making you sick. We investigated how the medication paradox operates in the lives of older adults. In-depth qualitative interviews were conducted and analyzed with older adults aged 70+ to identify the various paradoxes that seniors live through regarding their medications and the narratives that they engage to negotiate these contradictions. Older adults were found to have established interpretative repertoires to make sense of the incongruent narratives of the medication paradox. In this article, we demonstrate older adults’ efforts to carve out their unique place in the dichotomized institution of medicine.
Keywords
We need the pharmaceuticals . . . but we don’t need all the pharmaceuticals.
Introduction
Considerable qualitative research has examined the complicated work of medication management (Hawkins, Nickman, & Morse, 2017; Malvini, Redden, Tracy, & Shafer, 2013; Minet, Lønvig, Henriksen, & Wagner, 2011; Nickman, 2017; Salt & Peden, 2011). Few studies, however, have centralized the voices and perspectives of older adults in their efforts to manage their medications given the many paradoxes that they encounter. This work is necessitated by the problematizing of polypharmacy and the promises of deprescribing in the biomedical literature (Barnett, Oboh, & Smith, 2016; Canadian Deprescribing Network, 2017; Garfinkel, Ilhan, & Bahat, 2015; Reeve, Shakib, Hendrix, Roberts, & Wiese, 2014; Scott, Anderson, Freeman, & Stowasser, 2014). This literature has identified that overprescribing older adults is as an issue, and consequently recommends a shift toward deprescribing. This article therefore presents older adults’ experiences and identifies contradictions emerging at this unique moment in history when medications are paradoxically conceived as being both a prerequisite and detriment to good health.
The important work of Cohen, McCubbin, Collin, and Pérodeau (2001) marks a shift in how scholars think about medications. This shift is notable because it demonstrates the ways in which medications are socially entrenched actors. Cohen et al. (2001) call for systemic thinking regarding medications and note the challenging task of drawing connections between society’s consumption/evaluation of medications and the motives of the numerous actors involved. Engagement in this systemic thought allows for us to “reach more profound understandings by situating [our] results within the broader social, cultural, economic, and technological transformations and contradictions at work” (Cohen et al., 2001, p. 459). The present study answers this call by situating older adults’ management of polypharmacy and deprescribing in the context of the concurrent and paradoxical narratives of diverse social actors.
We are at a point in history in which we, as consumers of health care, must confront the paradoxical nature of medications themselves. The medication paradox can be stated simply as you need your medications to be healthy but your medications might be making you sick. Therefore, when patients make decisions around if and how to use medications, they must do so in the context of these equally dominant and legitimate accounts of medications.
Older adults are particularly vulnerable to the complexities of this paradox given the likelihood of increasing engagement with the health care system as we age. In 2016, the Canadian Institute for Health Information (CIHI; 2018) found that 1.6-million Canadian seniors, which translates to 1 in 4 Canadians above age 65, have prescriptions for medications from 10 or more different drug classes. The number of prescriptions was also found to increase with age (CIHI, 2018). Statistics Canada (2015) similarly found that use of medications among Canadian seniors is very common. In fact, a nation-wide population-based study found that all seniors living in long-term care facilities (LTCF) and over 75% of seniors living at home had used a medication in the preceding 2 days (Statistics Canada, 2015). This same study also found that 53% of seniors in LTCF and 13% of seniors in the community (which translates to over half a million Canadian seniors) reported the simultaneous use of 5+ medications (Statistics Canada, 2015). Given this overwhelming presence of medications in the lives of older adults, Canadian seniors are regularly confronted with the challenges of the medication paradox. This article investigates how the medication paradox operates in the lives of older adults in Canada. In-depth qualitative interviews were conducted and analyzed with older adults aged 70+ to identify the various paradoxes that seniors live through regarding their medications and the narratives that they engage to negotiate these contradictions.
Polypharmacy and Deprescribing
This work holds great contemporary significance in light of the problematizing of polypharmacy and the promises of deprescribing. Polypharmacy has been defined in numerous ways. Although this is not an exhaustive list, some of these definitions include the following: the use/administration of more medications than are clinically indicated (Hajjar, Cafiero, & Hanlon, 2007), the use of five or more medications (Hanlon et al., 1996; Reason, Terner, McKeag, Tipper, & Webster, 2012), using multiple drugs or more drugs than are considered medically necessary (Maher, Hanlon, & Hajjar, 2014), and using several different medications simultaneously (Alpert & Gatlin, 2015). Perhaps the most wide-ranging definition comes from Maggiore, Gross, and Hurria (2010), who define polypharmacy as “the use of a large number of medications, the use of potentially inappropriate medications, which can increase the risk for adverse drug events; medication underuse despite instructions to the contrary; and medication duplication” (p. 507). These definitions of polypharmacy all seem to converge on the point that polypharmacy is characterized by the concurrent use of multiple medications.
The risks of polypharmacy have been well-documented in the biomedical literature. These risks are diverse and include, but are not limited to, adverse drug events (Barnett et al., 2016; Reason et al., 2012), escalating health care costs (Barnett et al., 2016), declines in physical functioning (Scott et al., 2014), and increased rates of hospitalization (Barnett et al., 2016; Garfinkel et al., 2015). To mitigate these many documented risks, health care providers are testing the feasibility of deprescribing programs. Deprescribing has gained increasingly popularity as the solution to polypharmacy, even leading to the establishment of the Canadian Deprescribing Network (CaDeN). CaDeN (2017) defines deprescribing as a process of decreasing or discontinuing medications that are either ineffective or harmful. CaDeN has further documented the importance of deprescribing for seniors experiencing polypharmacy given the bodily changes that accompany the aging process. These age-related changes to the body include the following: muscle and fat loss causing the medications to stay in the body longer, increasing sensitivity of the brain to medications, decreasing efficiency of the liver and kidneys, and water loss in the body leading to increased concentrations of the medications (CaDeN, 2017). Other benefits to deprescribing include resolving adverse drug interactions, improved patient outcomes, improved adherence to necessary medications, and reduced financial costs (Reeve et al., 2014).
McMaster TAPER Project
As health care providers produce, consume, replicate, and disseminate this research regarding polypharmacy and deprescribing, they are reasonably encouraged to incorporate deprescribing programs into their clinical practice. It is this incorporation of deprescribing programs that sets the stage for the present study. The Department of Family Medicine at McMaster University has developed and implemented the “TAPER” Project (“Team Approach to Polypharmacy Evaluation and Reduction”). The vision of TAPER is to design a systematic pathway for reducing the burden of polypharmacy that is part of routine primary care prevention for older adults. To do so, TAPER is tasked with identifying both gaps in knowledge and barriers to design.
Arguably, one of the most important gaps in knowledge is the patients’ perspectives on their relationships with medications and their perceptions of deprescribing. Informed by in-depth qualitative interviews with patients of McMaster Family Practice, this article seeks to fill that gap. The design and analysis of these interviews were conducted with specific interest in the participants’ perceptions of the various paradoxes that they are forced to negotiate when a medication is prescribed or deprescribed. Despite their differences, each of these health-related paradoxes are similar in that they offer conflicting yet seemingly true propositions—“my medications are good for me . . . my medications are bad for me,” “my health care provider is trustworthy . . . I cannot trust my health care provider,” “adhering to my medications makes me a good patient . . . needing medications make me a bad patient,” “using multiple medications is normal at my age . . . using multiple medications is dangerous at my age,” “my medications prevent me from getting sick . . . my medications help me because I am sick.” The operation of these paradoxes in both public and private spaces requires older adults to resolve the various paradoxes and justify defense of these resolutions. The specific aim of this article is therefore to identify these paradoxes and describe the work that older adults do to bring them to resolution.
To proceed, this article will define and provide an overview of interpretative repertoires which older adults engage to negotiate the many medication paradoxes that they encounter. Having established the conceptual orientation for this project, I will then shift attention to the methods used for data collection. Drawing on medication paradoxes, analysis will investigate how older adults navigate a complex and often contradictory medical landscape. This article will conclude with a discussion of the need for health care providers to be attuned to these types of challenges faced by older adults as they are presented with simultaneously legitimate and contradictory narratives regarding their medication practice. It is in these conditions that older adults experience polypharmacy and deprescribing. Therefore, an understanding of these conditions is a prerequisite to health care providers’ and patients’ collaborative efforts to reduce the burden of polypharmacy.
Interpretative Repertoires
Interpretative repertoires are “culturally variable ways of discussing and evaluating certain actions or events that constitute a cultural commonplace” (Charlebois, 2015, p. 1). Seymour-Smith (2017) explains interpretative repertoires as familiar routines of argument and description found in the ways we communicate. As an analytic concept, they are valuable in that they provide insight into the construction of our various versions of the world (Seymour-Smith, 2017). In the context of conversational interaction, interpretative repertoires can be adopted to persuade someone of your perspective regarding a particular cultural event. Lumme-Sandt, Hervonen, and Jylhä (2000) use interpretative repertoires to refer to a “relatively coherent system of meanings” (p. 1845) and note that they enable people to validate their specific versions of events thus justifying their behavior in the face of criticism (Burr, 1995; Lumme-Sandt et al., 2000). Therefore, in the lives of older adults, interpretative repertoires are used to speak to medications in a way that upholds their chosen side of the medication paradox. For example, “I believe medications are good for me because . . .” or “I believe medications are bad for me because . . .”
We are at a unique moment in history in which two dominant and competing narratives around the use of prescription medications are deemed legitimate. The first account of prescription medications continues to assert their benefit. This extends further to the belief that it is necessary for older adults to be on (often multiple) prescription medications. This account is present in social intuitions and is consequently reflected in the lives of older adults. The other story of prescription medications promotes an opposing message: the population is overprescribed and medications are largely damaging. This emerging yet increasingly legitimized understanding of medications is similarly reflected in both social institutions and the lives of older adults. These stories are used as guides to help older adults make decisions for how to best manage their health.
It is these binary narratives that seek to classify a polypharmaceuticalized person into one of two opposing categories: healthy–sick, moral–immoral, and healing–deteriorating. In alignment with Bowker and Star’s (2000) position, bodies and diseases change over time and thus these contradictory classification systems lead to the experience of torque in which the individual lives through categories of meaning that are incongruent. Older adults are left to manage their health within this paradoxical context.
Data collection and analysis was conducted from this orientation. The research design and thematic analysis used in this study investigates the interpretative repertoires that older adults engage with as a means of normalizing their relationship with medications in the context of numerous paradoxes. It is only through this type of reasoning that older adults can make decisions about how to use their medications specifically and how to manage their health and well-being more generally. These paradoxes are the result of the institutional systems of classifications that categorize polypharmaceuticalized bodies into incongruent categories. As health care providers aim to reduce the burden of polypharmacy on these bodies, they should be mindful of these conditions that older adults encounter when advised to deprescribe.
Method
The present study is one component of a larger interdisciplinary mixed-methods research project with the overall goal of reducing the burden of polypharmacy as part of routine medical care for older adults. To do so, qualitative methods were necessary to provide insight into patients’ perspectives on polypharmacy and deprescribing. The present study is the qualitative element of the larger study.
It is important to begin this explanation of the methods used by first providing an overview of the larger interdisciplinary study, as it is this larger project that sets the stage for this qualitative study. This larger study was a randomized controlled trial (RCT) for deprescribing (blinding participants was neither feasible nor necessary). Participants were recruited from McMaster Family Practice—a routine primary care setting—and provided written consent. All participants had to be aged 70+ and experiencing polypharmacy (defined as using 5+ medications concurrently). Participants were excluded for language and cognitive challenges, and/or if mortality was anticipated within 6 months.
Baseline data were collected, including demographic information, illness assessment, functional goals, symptom goals, treatment preferences, and perceived medical problems. At this time, all participants were asked if they may be contacted for an interview to discuss their perspectives on medication use and/or deprescribing. Next, the pharmacist performed a medication reconciliation. A medication reconciliation involves the creation and maintenance of an accurate medication list, including information related to medication name, dose, frequency, and route of administration (Al-Hashar, Al-Zakwani, Eriksson, & Al Za’abi, 2017). The list produced was then used to inform consultation between the participant and family physician. Participants in the intervention group were invited to deprescibe if medications were identified as appropriate and feasible for deprescription. In total, 40 participants were enrolled in the study. Both the control and treatment groups consisted of 20 participants.
Following the establishment of these plans for deprescribing, qualitative methods began. Participants who had consented to being contacted for an interview (regardless of group assignment) were called. When called for an interview, participants were asked where they would like the interview to take place. All participants wished to be interviewed in their homes. In total, 16 participants agreed to participate in the interview; eight participants from the deprescribing group and eight participants from the control group. In-depth qualitative interviews were completed with these 16 adults ranging in age from 73 to 90 years. The mean age was 81 years. All participants were patients of McMaster Family Practice; 11 identified as female and five identified as male. Data were collected from December 2016 to October 2017. Interviews ranged in length from 30 to 82 minutes.
The interviews were in-depth and semistructured. The interview guide included five sections. Section 1 involved clarifying any questions that the participants had about the study and asking about their history of medication use. Section 2 facilitated a discussion around the approaches that participants use in managing their polypharmacy and potential deprescribing. Through story-telling, Section 3 involved identifying specific experiences that participants had involving their polypharmacy and potential deprescribing. Section 4 aimed to elicit participants’ values and beliefs about their medications. Finally, Section 5 provided space for participants to add any information that they felt was relevant and to ask any questions about the study. This interview structure was consistently used across all interviews to ensure trustworthiness and credibility of the data. All interviews were audio recorded and transcribed verbatim. Thematic analysis involved the use of inductive measures to identify emerging theoretical insights from the data. Facilitated by Dedoose software, thematic analysis was conducted on interview transcripts by two coders. Materials were coded in three stages. First, coding involved a line-by-line analysis of the transcripts to identify and label phenomenon. Relationships were then drawn between these identified phenomena. The final stage of analysis involved the identification of central phenomena to which all other coded categories were related. Fundamentally, the focus of this analysis was to identify incongruent systems of classifications that torque the biographies of older adults, and to highlight the various ways in which older adults employ interpretative repertoires to resolve the many resulting medication paradoxes. This research was approved by the Hamilton Integrated Research Ethics Board (HiREB; Project #665).
Results
Data analysis revealed that older adults are confronted with numerous emerging contradictory narratives (paradoxes) that must be negotiated for health-related decisions to be made. Before presenting in-depth analysis of this finding, it is important first to acknowledge my position as researcher and the paradoxes that are inherent to the research process. Social science research itself is a paradoxical endeavor as it is a social process with the clear objective of deepening our understanding of social processes. In conducting each interview, it was necessary for me, as the interviewer, to be aware of the social nature of the qualitative interview itself. These interviews were social engagements about the complexities of participants’ social engagements with the health care system. In fact, many participants initially believed that I was a health care provider visiting their home to help them with their medications. For example, I was frequently asked if I was a medical student, pharmacist, or nurse. As a result, the interviews often began with an explanation of my role as a social science student and qualitative researcher interested in how they perceive their medications, rather than a health care provider seeking to influence their perceptions of their medications. As such, each interview began with a collaborative process between myself and the participant to negotiate the first identified paradox: “I work with members of your health care team who advise you to use your medication in a certain way, but I am not here to promote that advice.” This collaborative negotiation typically occurred before audio recording began, as it was important to establish this level of trust and understanding before seeking informed consent to record the interviews.
Having established the irony of the paradoxical social endeavor of uncovering social paradoxes, analysis will now shift to the medication paradoxes confronted by older adults experiencing polypharmacy uncovered in these interviews and their efforts to bring them to resolution. Doing so addresses the specific aims of this research. Regardless of the nature of the identified paradox, older adults were found to have established interpretative repertoires to make sense of these incongruent narratives. Analysis will continue by presenting each interpretative repertoire that participants employed to resolve the medication paradoxes.
Interpretative Repertoire 1: A Personalized Medication Routine Is Needed to Promote Well-Being in Later Life
The older adults interviewed in this study reported that they receive competing narratives regarding how medications affect their bodies, health, quality of life, and longevity. One of the stories that is often told is that “medications keep you healthy.” This story suggests that it is through medications that aging is optimized. In framing medications this way, they are seen as a possible means of mitigating the common fears associated with aging, including a lack of independence, immobility, and deterioration in cognitive function.
In some cases, respondents explained that their medications—or perhaps one or two of their medications in particular—are serving a very important and identifiable function. This specified functioning proved important in older adults’ understandings of how medications act on their bodies and the resulting implications for overall quality of life. For example, one respondent explained that by taking Prolia, a drug to treat osteoporosis, she may be preventing a future fracture: Taking [Prolia], I’m hopeful my bones will stay as strong as they can for quality of life. If I fall, break my hip, well that’s how the ball bounces. But I try very hard and hope that won’t happen and maybe having taken Prolia, which improves bone growth, you know, will make the fracture not as bad.
This respondent has identified a specific body system (the skeletal system) that a specific medication (Prolia) is improving. She has further identified the manner by which this specified targeting might lead to positive outcomes in her overall quality of life. In striking a balance between being optimistic and realistic, this person acknowledges that even if the medication cannot be guaranteed to prevent a future fracture, at the very least it may make the inevitable fracture less severe.
This type of explanation was very common from participants, many even noting the immediate positive effects of medications on their bodies. In describing his medication for hypertension, one participant reported that “if I don’t take it, my blood pressure goes up.” It is this identification of the immediate positive effects of taking a medication (my blood pressure stabilizes) or the immediate negative effects of not taking a medication (my blood pressure goes up) contributes to the construction of the interpretative repertoire regarding the benefits of medications for older adults.
Beyond noting the influence of medications on specific body systems, many respondents spoke to the more general ways in which medications improve their lives, often asserting their lifesaving benefits. In one participant’s words, “God help if I was in the States. I would be dead because I couldn’t afford them at all.” In this example, access to medications is of such importance because it is the medications that are keeping her alive. This participant explained further that it is not simply enough to stay alive, but that her life must not be burdensome to others: “If I were to stop all [the medications], I’d be a vegetable or dead. I don’t want to be a burden to my family, I want to live as long as I have quality of life.” This sentiment was expressed by almost all participants, emphasizing the positive roles that medications play in their lives, not only in promoting life but also in promoting a life deemed worth living.
For others, the role of medications was not so gravely related to life and death, but the smaller benefits still warranted their use. For example, one respondent explained her realistic expectations regarding her medications, laughing as she noted that “I know you’re not going to get the fountain of youth, just less aches and pains.” In this way, medications are not deemed powerful enough to reverse aging, but were justifiable if they alleviate the physical discomforts characteristic of the aging body.
Health care providers were found to be the key actors in the construction of this narrative of the benefits of medications for seniors’ health. For example, one participant stated as follows: “I asked [my doctor] why don’t you take me off my cholesterol pill and they tell me your cholesterol is good because you’re taking it.” In such cases, the person questioned the benefit of their medication, and the benefit was reinforced by the physician and consequently internalized by the patient. For other participants, it is not necessary to question the health care provider, because the prescription itself represents reason enough to believe in the beneficial power of medications: “I just take them because they were prescribed, I want to stay well, and I just do it. I don’t even question it.” This demonstrates the power of physician as prescriber in the construction of interpretative repertoires.
Opposing this narrative promoting the benefits of medications is an equally dominant yet contradictory story of medications as destructive. In this story, respondents express concerns that medications (or perhaps, too many medications) might be harming the body and mind, and ultimately impacting quality of life and longevity. When framed this way, medications arguably are associated with more risks than benefits. Participants consistently reported that these medication-related harms are of particular concern for older adults given the likelihood that they are on multiple medications. For example, in most interviews, participants described their medications as beneficial to their lives on a personal level, but would frequently point to the overmedication of older adults more generally and the negative consequences of this overmedication: You read and hear things and so on, and we have a pharmacist friend who, you know, often told us about all these old people in hospital that are overmedicated and they’re sick and so on. And then once they get them off some of those meds, they go home and they’re a lot better.
In this quotation, the participant suggested that overmedication can be harmful and deprescribing is a means of mitigating these harms. Accounts such as these demonstrate that respondents are aware of the risks of polypharmacy in a general sense, but these stories were consistently told secondhand and were rarely the direct personal experiences of the interviewees themselves. These secondhand stories were a common theme that was thread throughout the interviews and were sometimes informed by the participants’ own sense of the available research. For example, I keep hearing about seniors and I know of a lot of seniors who take so many drugs and that they’re finding in studies, some of them are on drugs they shouldn’t be on anymore or drugs are counteracting other drugs.
Here, the participant indicated an awareness of the opposing narrative, but this awareness was not personalized. Rather, the risks of overmedication were positioned as the experience of other seniors who are inappropriately medicated. None of the interviewees reported that they believed they were currently exposed to the risks of overmedication. Rather, they recognized the risks of overmedication, but their personal use of medications was classified as appropriate.
In many cases, it was found that participants became aware of the risks associated with certain medications from their doctors. As one respondent recounted, One of the concerns that the medical people had was when you are on high blood pressure medication for a long time, you have to watch the kidney. So, [my doctor] was trying to get me off some of the medication. There’s something she’s watching in my kidney.
This story is representative of many other participants’ experiences. The common occurrence was that they did not mind taking their medication, but when their doctor explained any risks associated with the medication and recommended deprescribing, they were “happy to do it.”
An additional source of the “medications are destructive” narrative was found to be the older adults’ social circles. It was commonly reported that many members of their peer groups frequently discuss the risks of medications and in some cases, take pride in taking few to no medications. As one participant shared, “This one friend mentioned, he’s kind of proud that he doesn’t take any . . . it seems to him to be important. I mean, some people are like that but if something can help, why not?” This participant has touched on a theme that was found to ring true for many of the older adults interviewed for this study: “Some people say that medications are bad, but they help me, therefore in the context of my life, medications are good.”
The existence of side effects promotes this paradox, as what was meant to be helpful (medications) may result in harm (side effects). It is this iatrogenic nature of medications that frames this first paradox. Therefore, older adults were found to negotiate the medication paradox that medications promote health and cause illness by employing the following interpretative repertoire: A personalized medication routine is needed to promote well-being in later life.
Interpretative Repertoire 2: The Harms Associated With Medications Are Externalized to Other Older Adults
The cultural image of the overmedicated older adult is familiar. Underpinning this image is extensive biomedical research indicating the risks of polypharmacy to which the senior population is uniquely vulnerable (Alpert & Gatlin, 2015; Hajjar et al., 2007; Hanlon et al., 1996; Maggiore et al., 2010; Maher et al., 2014; Scott et al., 2014). In the context of this cultural commonplace emerges a medication paradox that confronts older adults with contradictory and competing accounts of polypharmacy: It is acceptable for older adults to be on many medications, but being on many medications is unacceptable because it threatens seniors’ health. When an older adult is placed on a deprescribing program, they encounter both narratives and must make sense of their incongruent elements.
Evidence of the normalizing of the “medicated older adult” emerged in many of the interviews. Much of this evidence has been presented above in accounts of participants’ general awareness of the risks of overmedication to seniors’ health (therefore it will not be repeated here). This awareness, however, was often followed up with the normalizing of the image of the medicated senior. For example, several respondents speculated about the likelihood that the other seniors in this study were also taking the same medications. In one respondent’s words, “most seniors who have any bone loss do that, it’s called Prolia. And just about every seniors takes Prolia every six months.” This statement suggests she is aware of the common age-related changes to the body (i.e., bone loss) and is further familiar with the commonly prescribed treatment regime (i.e., Prolia). Another participant shared a similar sentiment in stating, “at our age, arthritis is a part of your life,” noting the seeming inevitability of certain health conditions associated with age. Another respondent further supported this point of view in her prediction that the other participants in the study are reporting the same experiences: “You’ve probably heard from all the seniors, you’ve probably heard them all talking about Lasix.” As a result of this shared understanding of what happens at “our age,” participants were found to point to their age as the reason they take medication, rather than the action that the medication takes on their body. As such, polypharmacy was found to be widely accepted as safe by the older adults interviewed in this study, not because of the effect medications have on the body, but more specifically the effect medications have on the aging body.
This comparison to other aging bodies was also employed as a means for older adults to practice gratitude. For example, when asked why she takes her medications, this participant responded: It’s just, getting older is very challenging. You’re just going to meet it the best you can at this stage, and I feel I’m very lucky. Some people have cancer and are in terrible predicaments or other diseases, and I feel so sorry for them. And I think, you know, [I should] shut up about [my] problems, because [I’m] so much better off and I know that I am.
Here, the participant uses medications as a way of meeting the challenges of aging. As was true for many of the participants interviewed, she does not give much worry to her use of medications, sharing the sentiment that “other seniors have it worse.” By speculating that other people are worse off, older adults attempt to free themselves of concern regarding the risks of polypharmacy.
In resolving this paradox of polypharmacy as acceptable and unacceptable, older adults were found to employ the following interpretative repertoire: The harms associated with medications are externalized to other older adults. Adopting this perspective allows for older adults to acknowledge age-related decline, use medications to manage that decline, and practice gratitude for their health in comparison to others. In the words of one respondent: “I am 87 years old, so it’s only natural that certain things in my body are going to deteriorate and on the whole I’ve been enjoying good health.”
Interpretative Repertoire 3: Age-Related Illnesses Are Common and Therefore Seniors Need Medications to Promote Health and Maintain Quality of Life
A third medication paradox characterizes the ambiguous role that medications were found to play in the lives of the older adults of this study: Are medications used as preventive medicine or as a means of chronic disease management? As such, older adults may take medications to prevent disease, to slow the progression of disease, and/or to manage the symptoms of disease. In this way, medications can be both a sign of health and/or a sign of illness. In essence, older adults encounter the following conflict: I am healthy because I take medications, or I am not healthy therefore I need medications.
In support of the belief that medications promote health, this participant explained why she takes her medications: Well, simply because I want to live a good life and I feel as though they are helping. And there are days where I don’t have a lot of energy, but I know that I’d probably have less if I didn’t have the medication, the heart medication that I take.
Here, the participant has asserted the role of medications in supporting quality of life, in a similar spirit to that of another respondent: “I’m hoping that with this puffer . . . it’s a chance to get back on my feet and get down for choir after Christmas.” Representative of many other respondents, both of these accounts reveal that engaging with medications allows for fulfillment and joy, not simply the management of disease.
Others, however, noted the need for medications in controlling disease progression and symptom management. Framed in this way, an older adult has already been classified as “ill” or as having some physiological dysfunction. One participant explained that he uses medications for this reason, stating that “hopefully it will make me better, or fix the problem, or control the problem.” Here, there is no indication of the pursuit of well-being, but rather a desire to fix or control a problem.
What makes this paradoxical is that medications may be playing out both roles—health promoter and disease preventer—thus the individual might be classified by themselves or others as healthy, sick, or both. One participant summarized this embodied contradiction when he said, I don’t think medicine—I don’t think it controls my body. I think it just keeps me healthy and keeps my blood healthy I guess, by taking medicine to control my diabetes and so on. So as far as muscles and things like that, it doesn’t affect me.
For this participant, medications keep him healthy by controlling his diabetes. Such an observation reveals that we can have both health and disease concurrently. For the polypharmaceuticalized older adult, this is a key paradox—needing medications means I am “old” and “sick,” but it is medications that keep me well. As evidenced above, in negotiating this paradox, the following interpretative repertoire is adopted: Age-related illnesses are common and therefore seniors need medications to promote health and maintain quality of life.
Limitations
It is important to note that this work is limited by its cross-sectional nature. The participants of this study were interviewed at one point in time and asked to retroactively reflect on their relationship with medications. Future longitudinal approaches would add substantial insight into how older adults negotiate medication paradoxes by providing participants the space to share how their attitudes toward medications evolve or remain stable over time.
Discussion and Conclusion
Despite logical reasoning and a seemingly true premise, a paradox is self-contradicting. Carl Jung (1951) believed that it is through our paradoxical nature that we may realize the richness of life, thus making the paradox one of our top valued spiritual possessions. These paradoxes operate in all realms of human life, contributing to the fullness of each realm, and the realm of medicine is no exception. Through uncovering these medication paradoxes, this qualitative research has demonstrated the problematic presence of dichotomies in medicine. As evidenced in the findings of this study, medications themselves are inappropriately dichotomized as causing health/illness, as being acceptable/unacceptable, or as symbols of health/illness. Structuring health and health care into opposing categories of this nature leads to the torqued biographies of older adults in which they bend their experiences to fit into standard systems of classification. As an analytic concept, interpretative repertoires have offered valuable insight into how diverse accounts of medications (as social actors and cultural symbols) have been produced. Accordingly, the interpretative repertoires found to be used by the older adults of this study allow for more complete understandings of how older adults negotiate the inadequate dichotomies of medicine. These three interpretative repertoires are summarized as follows:
A personalized medication routine is needed to promote well-being in later life;
The harms associated with medications are externalized to other older adults;
Age-related illnesses are common and therefore seniors need medications to promote health and maintain quality of life.
Each of these statements demonstrates the work done by older adults to carve out their unique place in the dichotomized institution of medicine.
Greene (2006) offers significant insight into this classification system in medicine and the resulting implications on the lives of consumers of health care. He notes that medical categories and definitions of disease are not stable and objective, but are more accurately the result of a complex interplay of clinical trials, marketing strategies, epidemiology, bureaucracy, and technology. Greene (2006) provides three case studies—hypertension, diabetes, and high cholesterol—as evidence for the malleability of disease categories in the interest of pharmaceutical intervention. Notably, a threshold for diagnosis can be adjusted to justify prescription, thus risk factors for disease become reframed as diseases of their own right.
Simply, the pharmaceutical market expanded its reach to incorporate subjectively healthy people. The development of a new drug indicates the development of a new disease category; what was once a pre-pathological state becomes the pathological state (e.g., the “pre-diabetic”).
Bowker and Star (2000) also cite incentives for assigning bodies to categories, including the need for health care providers to ascribe illness labels that will be deemed appropriate by insurance companies and the subsequent self-identification with this label by patients. Despite such pragmatic motivators, the ongoing flux of the human body and human history makes these efforts futile. Assigning bodies to categories is ineffective, as neither bodies nor disease categories are fixed. It is in this ever-changing landscape that older adults construct and inevitably re-construct images of themselves as healthy, unhealthy, or in some other uniquely ambiguous space in between.
This qualitative work was particularly important in labeling these dichotomies and identifying how older adults operate outside of categories in a highly categorized system. Britten (1995) notes that clinical interviews seek to mold patient perspectives into diagnosable medical categories. Despite the value in being able to define and subsequently respond to a patient’s health concern, the respondent’s narrative is dismantled and restructured to fit into a narrow category so that appropriate treatment measures can be pursued accordingly. Therefore, qualitative research methods, such as those used in this research, are fundamental in providing a means for ascertaining the patient’s “framework of meaning” (Britten, 1995, p. 252).
A promising conclusion of this research is the alignment between the participants’ frameworks of meaning and the concept of medication optimization promoted by polypharmacy and deprescribing researchers. In reference to the National Institute for Health and Care Excellence’s definition, the King’s Fund defines medication optimization as a person-centered and individualized approach to using medications that necessitates patient engagement, evidence-informed decision making, professional collaboration, and effective patient engagement (Duerden, Avery, & Payne, 2013). This conceptualization offers an opportunity to optimize the influence of medications for the individual user, rather than categorizing polypharmacy as inherently good/bad, helpful/harmful. By reframing polypharmacy in this way, health care providers and policy makers can more effectively advocate for the well-being of older adults in Canada. Accordingly, emerging policies that govern the lives of Canadian seniors should support optimal health care utilization, which may include appropriate and optimal use of five or more medications concurrently.
Important qualitative work has examined how people undertake the complex work of medication management (Hawkins et al., 2017; Malvini Redden et al., 2013; Minet et al., 2011; Nickman, 2017; Salt & Peden, 2011). It is now important to examine and amplify the voices and perspectives of older adults as they try to manage polypharmacy and deprescribing. This article offers important contributions to this growing body of qualitative work as it specifically investigates the paradoxes that must be managed throughout the polypharmacy and deprescribing experiences. This work suggests that the institution of medicine is arguably a few steps behind its patients in recent shifts toward medication optimization: The interpretative repertoires identified in this research demonstrate that patients have long been doing the work of optimizing medications in their own lives. The institution is just starting to follow suit.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Labarge Optimal Aging Initiative (Project ID 2016-04).
