2.3.1 Inclusion criteria.

1. (1). Participant (P)

Elderly patients with multiple coexisting chronic diseases

1. (2). Interest of phenomena (I)

Real-life perceptions of the Polypharmacy process in elderly patients with multiple co-morbid chronic conditions Feelings

1. (3). Context (Co)

Hospitals, community health centers and homes of elderly patients

1. (4). Study design (S)

Different types of qualitative research, including rooted theory, phenomenology, descriptive research, etc.

2.3.2 Exclusion criteria.

Duplicate publications; Incomplete information or inaccessible full-text literature; Literature not in English or Chinese; Reviews and academic papers;Literature with a C-level quality evaluation.

3.3.1 Meta-Theme 1: Difficulties and challenges in Polypharmacy.

Sub-theme 1: poor polypharmacy practices: Elderly patients with multiple chronic condition are prone to a variety of problems such as low adherence and poor medication management because of the coexistence of multiple diseases and the need for long-term treatment with multiple medications [17,23–26]. The complexity of medication types, dosing times, and frequency can affect patients’ medication management, and the more complex the patient’s medication regimen, the heavier the medication management burden. The dosage form, size, and flavor of medications are also likely to negatively impact patient medication practices. Some special medications bring a greater management burden to elderly patients in terms of preservation, for example, insulin needs to be preserved at low temperatures, which is not easy for patients to carry outside the home and can easily affect their quality of life. Some elderly patients buy large quantities of medications in one visit due to the long distance to the healthcare facility, which makes them susceptible to taking expired medications. In addition, the complexity of medication regimens to mitigate adverse drug reactions may further increases the burden of medication management experienced by elderly patients with multiple chronic conditon.

“My biggest frustration with the doctors is overdosing...Here a couple years ago I ended up in the hospital because I was getting bad dizzy spells and I couldn’t breathe and after they checked me out they found out they had overdosed me with medications—the doctor had. So they had to readjust my blood work and medications all over again.” [17]

“Every time I drink that pill, especially with a bad smell, a burp of that flavor can make me want to vomit; therefore, every time I take medicine I am afraid.” [23]

“Now I’ve got rheumatoid arthritis in the wrists and I’m on methotrexate once weekly where I take eight of them every Wednesday and to counteract those I’ve a folic acid to take once a week, every Thursday, the day after I take my methotrexate.” [24]

“Taking insulin is inconvenient compared to normal. Everywhere you go, you have to pick it up, especially in the summer it’s annoying. When the temperature is high, you have to have an ice pack, or it only stays that long. It’s a pain in the ass.” [25]

“The types of medication used are many and complex. Every day I have to deal with a bunch of medications, and I’ve made several mistakes, so I’ll have to organize and classify them when I have time.” [26]

Sub-theme 2: higher economic burden of polypharmacy: Due to the different types of diseases among elderly patients with multiple chronic disease, medication treatment programs are more complex than those for patients with a single disease, and medication costs are relatively high [17,23]. At the same time, there are differences in reimbursement rates for hospitalization for patients with different types of health insurance. For those patients who do not have health insurance, do not have medication chronic disease benefits, or do not have insurance, financial hardship is an important reason why patients have a poorer experience with multiple medications. In addition, the increased cost of medications predisposed respondents to change their treatment regimen or refuse medications altogether.

“I said my God, what do they think I’m a bank here or what! I have a lot of pills. But if they [prices] jump like that I’ll have to start cutting them in half or stop taking them. So a few of them that I haven’t been taking I don’t take them anymore. Just can’t afford it.” [17]

“Every time you take a big dose of medicine, it’s not just medicine, it’s all money, it’s all the kids’ hard-earned money (helpless, frustrated expression).” [23]

Sub-theme 3: cognitive decline in the aging body: With the increase of age, all the functions of the elderly patients are declining, and at the same time, they are troubled by many kinds of diseases. Most of the elderly patients’ physical and mental state will change [21,22,24,26]. They are not easy to accept new things, and their comprehension, attention, and memory will decline to varying degrees. Lack of self-management of drug use, patients are prone to forget to take medication, omit to take medication, miss the best time to take medication, and so on. There is often improper use of drugs, poor compliance, and other phenomena, reducing the effectiveness of drugs and increasing the incidence of adverse drug reactions.

“I was really on top of my medication and I was able to say I have this pill for this and that pill for that. But I can’t anymore.” [21]

“Because now, I’ve got all my medication out in one box, all the medication that I take. That way, there is no mixing them up with the others.” [22]

“He said to me not to take the other tablets with it at the time being. That they wouldn’t be – it wouldn’t be as effective. So I do leave them until – I take them with my lunch, you know? And when I do that I forget to take them entirely if I don’t leave them on the table in the morning. “ [24]

“Hearing is failing and reactions are slow, speak louder and more slowly a few times.” [26]

Sub-theme 4: disorders of daily living due to polypharmacy: Adverse drug reactions are prone to disrupt the daily rhythms of elderly patients with multiple chronic disease, and the disruption of these rhythms will adversely affect the physical condition of elderly patients and even aggravate the adverse reactions of their conditions [17,20,23–25]. At the same time, elderly patients with multiple medications need to carry their medications with them when they go out and take their medications at the specified time points. This not only affects the convenience of going out, but also increases the medication shame of elderly patients and reduces the quality of social activities.

“The reason I don’t like to take it [diuretic], because I have to go and urinate so many times a day, it gets so discouraging, and it gets so strong, the feeling that if I ever left the house I’d be in trouble.” [17]

“My A1C was in the normal range! So I celebrated and made a juicy cake!But I beat myself up because I went against my diet plan and it was food I couldn’t eat。” [20]

“The last time the doctor gave me that medicine prescription to take before bed, I ended up spending the night in the bathroom. Originally, I had a bit of neurasthenia, which caused me to have a sleepless night. The next day, my blood pressure was high - ugh.” [23]

“Once the old man went out to eat with me, I have diabetes and have to take insulin. Before the meal, I must take a shot. On many occasions, I feel strange and embarrassed. The old man says nothing, but I rarely go out to eat with them. That kind of feeling can be bad.” [23]

“Again, the inhalers would be the top priority on my list. If by any chance the inhaler - I usually keep it in the bedroom, both of them in my bedroom - and if I go downstairs in the morning and I don’t use the brown one, I will actually go upstairs and take it because I live in fear of running into COPD.” [24]

“Metformin is very damaging to the stomach, and when I take this medication, my stomach gets upset, rises, and I can’t eat.” [25]

Sub-theme 5: negative emotions resist medication: Due to the length of their illnesses, the strain of taking numerous drugs over time, and the significant financial load, elderly individuals with multiple chronic disease experience unpleasant feelings like anxiety, pain, fear, shame, and even social stigma [17,20,23,26].

“I’ve tried to stop taking those tablets [carbamazepine] for a while and I got a really bad pain in my face and it made me cry and I went back to my doctor and he said you’re stupid. Don’t stop taking those medicines.” [17]

“You look at all the bottles up there and you justshakeyourhead.” [20]

“In a rural family, my partner has left and my children are running a small business here. They don’t make much money, so in addition to feeding and clothing me, they have to spend money on my medication, so I feel quite sorry for them.” [23]

“When all you do is take pills all day long, aside from eating, what’s the point of living?” [26]

3.3.2 Meta-theme 2: low level of drug literacy.

Sub-theme 1:medication behavioral bias: Due to a variety of factors such as side effects of medications, cost, comfort, and patients’ subjective concept of medication, some elderly patients with multiple chronic disease may have deviations in medication behavior, such as stopping medication without authorization and arbitrarily adjusting the dosage and frequency of medication use [17,23,26].

“The reason I don’t like to take it [diuretic], because I have to go and urinate so many times a day, it gets so discouraging, and it gets so strong, the feeling that if I ever left the house I’d be in trouble.” [17]

“I often forget to take the medicine, sometimes feel no discomfort, so I do not eat. When it is difficult, I then take it quickly. After all, the medicine is three times poison.” [23]

“Take an extra tablet when you feel serious, skip it occasionally for a few days when you’re better, and take it again when you’re serious.” [26]

Sub-theme 2:limited absorption of drug information: Cognitive decline with age affects the acquisition, understanding, absorption, and application of drug information in elderly patients. Moreover, elderly patients with multiple chronic disease often need long-term treatment with multiple medications and have complex medication regimens [23,26]. Complicated medication instructions and different dosing schedules make elderly patients with multiple chronic disease unable to absorb and internalize medication information, which leads to a decrease in medication adherence.

“I’m getting old and my memory is poor. I often forget to take my medication and have to be reminded by my children before I remember.” [23]

“Remember it now and forget it in a few days.” [26]

Sub-theme 3: complexity of multi-physician management: When multiple physicians are involved in medication management, elderly patients with multiple chronic disease find it difficult to keep track of the medications they take and what they are used for, which makes them feel powerless and confused, increases their fear of medication, and even leads to a reluctance to take their medication on time or adjust the dosage on their own [18,19,21]. Particularly if the doctor fails to clearly explain the cause of the illness and the effects of the treatment, the patient may stop taking the medication because he or she believes that the medication is not important.

“I see two different doctors on a regular schedule and the only thing I really worry about is if one of them changes my medicine I want the other one to know about it because I get medicine from each of them and I don’t want to add something or take away something that is going to cause problems.” [18]

“I received a letter from my GP saying she has been in contact with the rheumatologist and cardiologist, and she cannot understand why they have taken me off Indomee.” [19]

“I think it’s a matter of prestige between the doctors. They don’t like to consult each other. The family doctor is not willing to make contact with the kid ney specialist, nor is the cardiologist, who prescribed inappropriate tablets even though I asked him to consult the kidney specialist.” [21]

3.3.3 Meta-theme 3: multi-party support facilitates polypharmacy in older patients with coexisting chronic conditions.

Sub-theme 1:self-support: Some elderly patients with multiple chronic disease demonstrate positive coping attitudes by adjusting daily routines to accommodate medication-taking schedules, or by using medication boxes to manage medications, or by shifting attention from medication-taking behaviors to more meaningful activities [17,19,20,22,26]. They look for personal success in the medication-taking process and strive to keep polypharmacy positive and active. In addition, elderly patients with multiple chronic disease try to obtain information about medication management through a variety of channels, such as medication instruction manuals, telephone counseling, or Internet searches.

“She gave me some stretching exercises that seemed to help an awful lot. I was able, finally, not to take the [celecoxib] and still get along pretty well.” [17]

“The only thing that bothers me is my eyes because I love reading. But I don’t care about anything else as long I have my books.” [19]

“have a pill box for morning, noon and evening. Every Sunday morning, I organize everything so that it is much easier to take my daily medication.” [20]

“I take my medication in the kitchen in the morning, before breakfast.” [22]

“Don’t look at our age, we also use smartphones well, small programs, and the Internet.” [26]

Sub-theme 2:family support: At present, the number of elderly patients with multiple chronic disease, a special group of patients who often face mental and psychological distress during the prolonged use of multiple medications, is increasing [22–24]. They desperately want the care, help, and companionship of their spouses and children, as family members offer significant benefits in helping patients with self-care and proper medication use. In addition, the concurrent medication-taking behavior of family members can serve as a reminder and support for each other.

“But when she takes hers, I see it, and I say “Hey! I’d better take mine.” If I take mine, she says “Oh! I’ve got to take them too.” [22]

“I live with my daughter, who is a nurse and reminds me to take my medication every day. I haven’t been sick for so many years, thanks to my daughter.” [23]

“I’ve a good wife, fair play to her. She puts the drops in me [sic] eyes and apart from that ‘tis only a matter of taking the tablets. She’ll look after me.” [24]

Sub-theme 3:medical support: Elderly patients with multiple chronic disease receive correspondingly less medical support after discharge from the hospital and move from a state of being fully cared for to a state of self-care in a short period of time; the rapid role change is prone to negatively affect their polypharmacy behaviors, and the patients expect to have channels of communication and feedback even after discharge from the hospital [19,20,23,26]. Physician assistance is closely related to the polypharmacy ability of elderly patients with multiple chronic disease. During their daily contact and communication with patients, doctors can not only provide patients with different types of health counseling, health education, and health assessment services but also teach patients disease-related knowledge and precautions for medication use, and urge them to take medication on time. Therefore, high-quality doctor-patient communication can not only promote patients’ medication adherence but also improve their polypharmacy ability.

“I’ve known the nurses for a long time and they always explain the medications for me. They take good care of me and I can always ask them if I have some questions or concerns about the medications I take.” [19]

“I feel a kinship with my physician.” [20]

“The last time I had a stomachache, my daughter gave me the Internet to find out if the side effects of these drugs, that the Internet is a mess, say what there. I do not dare to believe; I still believe that the big hospital doctor’s” [23]

“I expect that there will still be avenues for communication and ongoing follow-up on medications after discharge.” [26]

3.3.4 Meta-theme 4:positive attitude towards taking medication.

Sub-theme 1:proactive access to medication information: Some elderly patients with multiple chronic disease will take the initiative to have face-to-face consultations with the healthcare team when they are faced with doubts about medication use (e.g., precautions for medication use, how to recognize adverse reactions, how to cope with unexpected situations, etc.) [20,23,26]. As the elderly patient seeks information, takes the initiative to track his health status, and adjusts his medication strategy accordingly, his self-confidence gradually increases. He begins to face reality, providing comfort and encouragement to himself, as well as being filled with gratitude and always maintaining a positive attitude towards taking his medication on time.

“These are all very conscious daily decisions that you have to make when you take multiple medicines.... If you want to look at it, it’s a pain in the neck, but, you know, it’s keeping me going and I feel very good because of it” [20]

“My son told me that he had seen a lot of people with similar illnesses to mine who were cured, so I thought, “If others can be cured, why can’t I?” I have to stick to the medication, even for the sake of my child.” [23]

“I tell my doctor about the medications I’m not comfortable with and ask for them to be adjusted to fit my personal habits so I’m better able to stick to them.” [26]

Sub-theme 2:proactive response measures: Some older multimorbid patients demonstrate positive coping attitudes by adjusting their daily routines to accommodate the timing of their medications or using medication cartridges to manage their medications.

“I do the regimen the way I figure it will fit, trying to balance them on the 12-hour schedule.” [20]

“The weekly pillbox is always there, in the same place. Ah! That stays right there, always on my table.” [22]