Medication Management for Older Adults: Pitfalls, Perils, and Proper Practices

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Medication Management for Older AdultsPitfalls,
Perils, and Proper Practices

• RaChelle Eid Zylstra
• Northwest Regional Council
• Bellingham, Washington
• Zylstra_at_dshs.wa.gov

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Overview

• Extent of the Problem
• Why Older Adults?
• Medication Non-compliance
• Have a Beer. Its on the House!
• Suggested Next Steps

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The future looks Grayer
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Annual Cost of Diseases Affecting Americans Age
65
Rx
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Extent of the Problem

• 106,000 deaths in 2001 95 predictable, 80
  preventable.
• For every 1 spent on drugs, 1 spent in
  healthcare to fix Rx problems in facilities, it
  is 2.
• 80 billion/ year on drugs.
• 177 billion for adverse drug reactions (ADRs).
• 8.7 million hospital admissions.

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Extent of the Problem

• 65 are 13 of population use 36 of
  prescription drugs.
• 87 of 65 take at least one Rx and three OTC
  daily.
• 40 take dietary supplements.
• Average number of Rx increases with age, but
  overall is about 3-5.
• Institutionalized take 8 drugs.

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Extent of the Problem

• Although most of the problems are preventable
• 19 of 65 hospital admissions are due to
  medication problems.
• 19.4 of 65 injuries are due to medication
  problems.
• ADRs would be the third or fourth leading cause
  of death for older adults, if listed separately.

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QUOTABLE

• Medications are probably the single most
  important healthcare technology in preventing
  illness, disability, and death in the geriatric
  population. (Avorn, 1995)
• any symptom in an elderly patient should be
  considered a drug side effect until proved
  otherwise. (Gurwitz,et al., 1997)

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Good News?

• Predictable and preventable.
• Education programs have identified actions that
  are effective.
• Government drug programs that pay for drugs and
  drug education will be helpful for some of the
  problems.

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Whos At Risk

• 85
• gt 6 Chronic conditions
• kidney function
• Cancer/Depression
• 6-9 medications
• gt 12 doses/day
• Prior ADR
• Recent hospital discharge

?
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What is Different about Older Adults?

• Little change in absorption.
• ? H20 in tissues affects distribution and
  concentration
• 50 ? in ability of liver and kidneys to clear
  drugs
• ? sensitivity to drugs

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What is Different about Older Adults?

• In the elderly, every drug can be psychoactive.
• Side effects show up slowly.
• Reversal is very slow and may not occur for
  months or years.

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Medication Non-compliance

• 21-55 fail to receive the medication
  appropriately
• No access to Rx
• Transportation
• Resources
• Take less
• Take infrequently
• Shop the Internet
• Go to Mexico
• Try an herbal/OTC

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Medication Non-Compliance

• Poor choices
• More is better
• Try one of mine.
• Unilateral decisions
• Disorganized drugs
• Subtherapeutic dose
• Cannot afford or access drugs to take less often,
  cut in half
• Dont refill when out

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Medication Non-Compliance

• Overdoses
• Medication doses were standardized for younger
  people.
• Older adults frequently need less of certain
  medications.
• Cutting or crushing some pills causes overdoses.

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Medication Non-compliance

• Poor instructions
• Inability to read written material
• Dose schedule
• Awe factor
• Adverse side effect from an appropriate drug.
• Confusion
• Dizziness
• Sleepiness
• Changes in body functions
• Bruising

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Medication Non-Compliance

• Adverse drug reaction because of mixing drugs
• Make certain that you use one pharmacy and report
  ALL medications to your pharmacist and physician
• OTC
• Herbs
• Vitamins
• Alcohol
• Foods can even be a problem
• Read materials given to you by your pharmacist

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Healthcare Changes Contribute to Non-compliance

• The prescription triadpatient/pharmacist/MD can
  no longer be counted upon to monitor meds
• Multiple MDs/pharmacies.
• Generic substitution leads to problems with
  recognizing drugs.
• Mail order is a poor substitute but required by
  some insurance companies.
• YOU have to Monitor Your OWN

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Cures for The Problem

• Medication Access Assistance
• Elder-friendly instructions, written and
  alternate format.
• Brown Bag Forums.
• Self-advocacy Education.
• SMART cards/ Vial-of-Life
• Questions to ask your MD

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Consumer Education

• Write down questions to ask MD.
• Ask for information in a readable format.
• Take notes while you talk to your doctor or
  pharmacist.
• Organize your drugs
• Carry a list of all of your medications at all
  times.

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Prescriptive BehaviorElders at Risk

• Very few Geriatricians
• Fewer still geriatric pharmacists
• Prescription Cascade
• Often a side effect is treated with another
  drugand so on

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Prescriptive Cascade
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Beers Criteria

• 1991 (2002 update) recommends meds that should
  not be used in older adults.
• 1999 study of 765,423 older adults
• 20 filled 1 Rx with med of concern 16--2 Rx
  4--3Rx.
• 41 of these had nervous system effects--FALLS!

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Why Beers?

• Drugs on list have side effects that affect older
  adults
• Fainting
• Heart Rhythm problems
• Sleepiness
• Confusion
• Dizziness
• Loss of Appetite

• Drugs on list have dosages which are too high for
  older adults or too low to be effective.
• Drugs which are not easily cleared by older
  adults and result in overdoses.

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Review the Beers List

• Look for medications that you may take
• Talk to your pharmacist about an alternative
• Talk to your doctor about making a change

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Make it Simple

• All medicines count.
• Eye drops, inhalers, antacids, pain relievers,
  ointments and creams
• Keep a list and make certain all of your doctors
  know what you take.
• Disclose that glass of wine, the sleep aids, or
  the chewing tobacco!
• Know your medical history and dont keep anything
  secret.

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Make It Simple

• Recognize and remember to take your medicines by
  using a mediset.
• Be careful what you cut and crush.
• Put your questions (and the answers) in writing!
• Ask for labels and information in large print.
• Call your local Senior Information and Assistance
  with questions.