Table 5 Barriers to Effective Prescribing in Older Adults – A Summary based on Stakeholders involved

Patient

1) Knowledge

2) Skills

3) Beliefs about Capabilities

4) Beliefs about Consequences

5) Social Influences

• Lack of knowledge about medications they are taking

• Poor healthcare literacy

• Non-adherence to medications or visits

• Patient’s own expectations and beliefs (e.g. reluctance to discontinue medications, resistance to non-pharmacological treatment)

• Social factors (e.g. socioeconomic status, access to healthcare)

Physician

1) Knowledge

2) Skills

3) Social/Professional Role and Identity

4) Beliefs about Capabilities

5) Beliefs about Consequences

6) Reinforcement

7) Intentions

8) Memory, Attention and Decision Processes

9) Environmental Context and Resources

10) Social Influences

11) Emotion

• Medical complexity (e.g. multimorbidity, polypharmacy, increased risk of ADEs)

• Lack of knowledge or awareness about PIP

• Lack of skills and confidence

• Challenges to discussion with patient s (e.g. regarding risk, prognosis and life expectancy)

• Paternalistic doctor-patient relationship

• Role dilemma (e.g. between economic responsibility for both patients vs. society)

• Concerns on inter-professional relationships

• Perceptions of pharmacists’ expertise

• Self-efficacy issues

• Discrepant beliefs and practice

• Clinical – fear of causing harm, ‘giving up on the patient’, or withdrawal effects

• Social – fear of offending other prescribers

• Legal – damage to reputation, accountability issues, medicolegal implications

• Inertia and maintaining the status quo

• Prescribing challenges (e.g. limited alternatives, managing complex drug regimes

• Time constraints

• Lack of resources (e.g. limited alternative medications)

• Challenges with applicability of evidence-based guidelines in older adults

• Health beliefs and culture (e.g. culture to prescribe more)

• Anxiety or fear (e.g. fear of the unknown, fear of medicolegal implications)

• Fear of damaging the patient-doctor relationship

Healthcare System

1) Environmental Context and Resources

• Time constraints

• Lack of resources (e.g. access to pharmacist, limited prescribing support)

• Lack of inter-professional communication and support

• Challenges with applicability of evidence-based guidelines in older adults

• Fragmentation of care (e.g. increased specialisation, multiple healthcare providers or prescribers)

• Poor coordination of care

• Information access and documentation (e.g. lack of access to electronic prescriptions)

• Policy and regulatory issues (e.g. insufficient reimbursement for medication reviews)

• Cost issues (e.g. limited options on insurance formularies)

• Influences of the pharmaceutical industry