ATrain Education

 

Continuing Education for Health Professionals

Elders and Their Care

Module 4

Medication Use and Misuse in Older Adults

Medication management is a challenge when caring for older adults. More than 90% of those 65 or older use at least one medication per week, 40% take five or more, and 12% use ten or more (Gurwitz, 2004). Medication-related problems are expensiveand deadly. In the United States, nearly 30% of all hospital admissions are older adults who have taken their medications improperly. Each year in the United States, medication-related problems account for 200,000 deaths and cost about $200 billion (Zagaria, 2006).

Older adults are at especially high risk for experiencing medication-related problems because of their high rate of medication use, age-related changes in physiology, sensitivity to medications, and polypharmacy.

Proper use of medications is critical to cost-effective disease management. As the number of older adults increases, healthcare professionals must spend more time evaluating medication regimens.

The decline of cognitive healthfrom mild cognitive decline to dementiacan have profound implications for an individual’s health and well-being. Limitations with the ability to manage medications and existing medical conditions effectively are particular concerns when an individual is experiencing cognitive decline or dementia.

Polypharmacy

Polypharmacy describes the use of multiple medications at one time, including over-the-counter (OTC) medications, dietary supplements, and herbal remedies. Polypharmacy includes prescribing more medications than are clinically indicated, using inappropriate medications, and using the correct medication for an inappropriate length of time (Lococo and Staplin, 2006; Pugh et al., 2005).

Polypharmacy significantly increases medication non-adherence, medication errors, adverse drug reactions, and drug-drug, drug-food, and drug-disease interactions. Cognitively impaired older adults, those who live alone, and those seeing multiple prescribers are especially at risk. Many of the drugs classified as potentially inappropriate for older adults offer little or no advantage over other, safer drugs, and some have a long half-life in older patients (Lococo and Staplin, 2006).

Drug metabolism is often impaired in older adults due to decrease in glomerular filtration rate and reduced hepatic clearance. Changes in body compositiona decrease in total body water and an increase in body fatmeans water-soluble drugs become more concentrated and fat-soluble drugs have longer half-lives (CMDT, 2011).

Older adults currently make up about 13% of the American population but receive 34% of all prescriptions and consume 40% of all nonprescription medications (U.S. Census Bureau, 2010). The average person over the age of 65 takes twice as many medications as a younger person and this age group is the largest consumer of prescription and nonprescription medications in the United States. The use of prescription and nonprescription medications among this group has more than doubled since 1990 (Bushardt, 2008).

The classes of drugs most commonly associated with adverse drug reactions in older adults include diuretics, warfarin, nonsteroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), beta blockers, and angiotensin-converting enzyme inhibitors (ACEI).

Improving Medication Management

Because older adults often manage a number of chronic illnesses with medications, it is critical that medications be essential and taken as prescribed. Healthcare providers should determine if their patients are able to manage their medication regiment successfully once they leave the hospital or clinic.

In the home, medication management systems range from the methodical to the inventive. Some who have difficulty opening medication bottles utilize the “candy dish” methoddumping multiple medications into a bowl and fishing out the appropriate medication at the scheduled time. Some store medications in shopping bags or shoeboxes while others carefully fill medi-sets weeks in advance.

When financial resources are stretched, one common strategy is to extend medications by creative self-administration strategies. People with low income, inadequate prescription drug coverage, and high-cost medications are likely to stretch out their medication supply by skipping doses or extending the interval between doses.

Others may take a smaller dose (split tablets or take one when multiple tablets are prescribed) or substitute an OTC or herbal alternative. Taking a lower-than-prescribed dose is especially prevalent in patients with multiple medical conditions who are using many medications, those prone to medication side effects, and people who resist prescribed treatment due to personal or cultural beliefs. Adverse drug events can result from errors in prescribing or administering medication or patient noncompliance. In older adults, lower initial doses should be used and upward titration done at a slower rate than in younger patients. If there is renal failure, dosages for drugs that are renally excreted needs to be adjusted (Bergman-Evans, 2004).

The following recommendations are made to improve medication management in older adults.

1. Reduce Inappropriate Prescribing

A number of studies have looked at methods to reduce inappropriate prescribing for older adults. Evidence supports the following practice guidelines:

  • Incorporate pharmacist recommendations.
  • Use computerized alerts.
  • Review patient’s medication list regularly.
  • Utilize patient education. (Garcia, 2006)

Recommended for prescribers:

  • Discontinue medications found to be in conflict with Beers criteria unless compelling evidence exists for continuance.
  • Follow treatment guidelines for chronic and acute disorders that affect older adults.
  • Identify methods for payment other than giving drug samples.
  • Provide Medicare prescription information.
  • Consider generic drugs.
  • Use pre-filled drug boxes and regular reminders to improve adherence.
  • Work with your patient to design a system for remembering the medication regimen. (Bergman-Evans, 2004)

2. Decrease Polypharmacy

Inappropriate prescribing and polypharmacy are closely linked. Evidence suggests that both can be reduced by up to 25% by utilizing a pharmacist to review the patient’s chart and medication list (Garcia, 2006).

Other recommendations include:

  • Use combination drugs or tablets and alternative routes.
  • Use one-a-day dosing when possible.
  • Avoid prescribing medications to counteract the effects of other medications.
  • Monitor lab results more frequently.
  • Screen for drug interactions. (Bergman-Evans, 2004)

3. Avoid Adverse Events

An adverse drug event (ADE) is defined as “an injury resulting from the use of a drug.” Adverse drug events include “expected adverse drug reactions (or side effects) as well as events due to errors.” Adverse drug events due to errors are, by definition, preventable (Lococo and Staplin, 2006).

Adverse events can be categorized as fatal, life-threatening, serious, or significant. Events resulting in permanent disability included stroke, intracranial bleeding events, hemorrhagic injury to the eye, and drug-induced pulmonary injury. Deaths in one study were related to fatal bleeding, peptic ulcers, neutropenia/infection, hypoglycemia, drug toxicity related to lithium or digoxin, anaphylaxis, and complications of antibiotic-associated diarrhea (Lococo and Staplin, 2006).

Adverse drug events can result from errors in prescribing, administration, or patient noncompliance. In older adults, lower initial doses should be used and upward titration done at a slower rate than in younger patients. If there is renal failure, dosages for drugs that are renally excreted should be adjusted (Bergman-Evans, 2004).

The most common types of preventable adverse drug events include:

  • Electrolyte/renal (27%)
  • Gastrointestinal tract (21%)
  • Hemorrhagic (16%)
  • Metabolic/endocrine (14%)
  • Neuropsychiatric (9%)

The most common medication categories associated with preventable adverse drug events include:

  • Cardiovascular medications (24.5% of the ADEs)
  • Diuretics (22.1% of the ADEs)
  • Nonopioid analgesics (15.4% of the ADEs)
  • Hypoglycemics (10.9% of the ADEs)
  • Anticoagulants (10.2% of the ADEs) (Lococo and Staplin, 2006)

4. Maintain Functional Status

Older adults have good functional status when they are able to successfully and safely perform all the activities needed for daily living. A decline in functional status is a good indicator of a person’s overall health.

Functional decline can occur gradually or abruptly following an illness, injury, or personal loss. Determining the functional status includes a thorough assessment of an individual’s ability to perform basic activities such as dressing, bathing, grooming, and transferring and instrumental activities such as cooking, shopping, medication management, and other high-level cognitive tasks. Balance, postural control, and mobility are also essential components of a functional assessment.

Functional decline can be managed and even slowed by encouraging a range of activities:

  • Encourage socialization
  • Minimize bed rest
  • Maintain a daily routine
  • Encourage independence
  • Assess and treat medical problems
  • Assess and treat pain
  • Avoid use of restraints
  • Encourage daily exercise
  • Provide assistive devices as needed

5. Follow Beers Criteria

In 1991 thirteen nationally recognized geriatrics experts developed what is known as the Beers criteria, named after their colleague, Mark Beers. The researchers developed a list of medications that can lead to adverse drug events or are inappropriate for use in older adults, particularly in nursing home patients. The Beers criteria are commonly used to identify “potentially inappropriate medications” for older adults, meaning the risk may outweigh the benefit.

Zhan and colleagues (2001) refined the Beers list of medications by identifying drugs that should (1) always be avoided (have serious potential effects and alternative medications are available, (2) are rarely appropriate and (3) have indications for use in older patients but are frequently misused. Zhan’s research showed that 21.3% of older Americans received at least one potentially inappropriate drug and 2.6% received an “always avoid” drug.

A number of other studies have identified common medications that are associated with adverse drug events, including diphenhydramine, amitriptyline, and propoxyphene. Pugh and colleagues (2005) implicated pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents as the cause of 61% of the incidents of inappropriate prescribing.

Fick and colleagues (2003) identified two classes of medications considered problematic when used with older adults:

  • Medications or medication classes that should generally be avoided in people 65 years or older because they are either ineffective or they pose unnecessarily high risk for older people and a safer alternative is available
  • Medications that should not be used in older people known to have specific medical conditions (Fick et al., 2003)

Of particular note are 66 drugs considered to have the potential for severe adverse outcomes when used in older adults (see list that follows).

Medications Potentially Inappropriate for Older Adults

A
alprazolam (Xanax)
amiodarone (Cordarone)
amitriptyline (Elavil)
amphetamines
anorexic agents
B
barbiturates
belladonna alkaloids (Donnatal)
bisacodyl (Dulcolax)
C
carisoprodol (Soma)
cascara sagrada
chlordiazepoxide (Librium, Mitran)
chlordiazepoxide-amitriptyline (Limbitrol)
chlorpheniramine (Chlor-Trimeton)
chlorpropamide (Diabinese)
chlorzoxazone (Paraflex)
cimetidine (Tagamet)
clidinium-chlordiazepoxide (Librax)
clonidine (Catapres)
clorazepate (Tranxene)
cyclandelate (Cyclospasmol)
cyclobenzaprine (Flexeril)
cyproheptadine (Periactin)
D
desiccated thyroid
dexchlorpheniramine (Polaramine)
diazepam (Valium)
dicyclomine (Bentyl)
digoxin (Lanoxin)
diphenhydramine (Benadryl)
dipyridamole (Persantine)
disopyramide (Norpace, Norpace CR)
doxazosin (Cardura)
doxepin (Sinequan)
E
ergot mesyloids (Hydergine)
estrogens
ethacrynic acid (Edecrin)
F
ferrous sulfate (iron)
fluoxetine (Prozac)
flurazepam (Dalmane)
G
guanadrel (Hylorel)
guanethidine (Ismelin)

H
halazepam (Paxipam)
hydroxyzine (Vistaril, Atarax)
hyoscyamine (Levsin, Levsinex)
I
indomethacin (Indocin, Indocin SR)
isoxsuprine (Vasodilan)
K
ketorolac (Toradol)
L
lorazepam (Ativan)
M
meperidine (Demerol)
meprobamate (Miltown, Equanil)
mesoridazine (Serentil)
metaxalone (Skelaxin)
methocarbamol (Robaxin)
methyldopa (Aldomet)
methyldopa-hydrochlorothiazide (Aldoril)
methyltestosterone (Android, Virilon, Testred)
mineral oil
N
naproxen (Naprosyn, Anaprox, Aleve)
Neoloid
nifedipine (Procardia, Adalat)
nitrofurantoin (Macrodantin)
O
orphenadrine (Norflex)
oxaprozin (Daypro)
oxazepam (Serax)
oxybutynin (Ditropan)
P
pentazocine (Talwin)
perphenazine-amitriptyline (Triavil)
piroxicam (Feldene)
promethazine (Phenergan)
propantheline (Pro-Banthine)
propoxyphene (Darvon) and combination products
Q
quazepam (Doral)
R
reserpine (Serpalan, Serpasil)
T
temazepam (Restoril)
thioridazine (Mellaril)
ticlopidine (Ticlid)
triazolam (Halcion)
trimethobenzamide (Tigan)
tripelennamine

Source: Adapted from Fick et al., 2003.

There are many medications on the questionable list, and research constantly identifies other problematic medications. Deciding when a medication is inappropriate because of medical condition, genetic predisposition, or age is a complex task. Understanding the scope of the problem highlights the importance of being alert to polypharmacy when caring for older adults.

Other Factors (ADME)

The absorption, distribution, metabolism, and excretion (known commonly as ADME) are important features of any medication and the importance of ADME is heightened in elders.

Absorption

Medications are absorbed differently in older adults than in younger individuals. Age-related changes can impede absorption due to decreased blood flow to the tissues and the GI tract and changes in gastric pH (Banning, 2007). The use of certain medications can enhance this effect and alter absorption significantly. For example, proton-pump inhibitors (PPIs) such as omeprazole lower gastric pH and may inhibit Vitamin B12 absorption (Dharmarahan et al., 2008). Elders should take PPIs for the least time necessary to ameliorate the condition they are meant to treat. An older adult taking a PPI for a prolonged period of time should have periodic monitoring of vitamin B12 or take supplements.

Chronic illness and age-related variations in plasma proteins may also cause significant problems with medications that are highly protein bound, such as phenytoin and levodopa/carbidopa. Blood levels can vary, especially if food intake and dosing are not consistent. For example, if phenytoin is taken with a high-protein meal, less medication is absorbed because phenytoin binds with the protein in the stomach.

Decreased cardiac output in older adults and those with chronic conditions may reduce subcutaneous and intramuscular drug absorption, thus affecting the pharmacokinetics of injectable medications. Transdermal medications are absorbed through subcutaneous fat, which is reduced with aging (Banning, 2007).

Distribution

Once a medication is absorbed into the bloodstream, it is distributed throughout the body and exerts both desired and undesired effects. Distribution dynamics can be affected by body weight and body composition, which changes with age. Distribution of a medication is also affected by impaired absorption, which influences its onset, strength, and duration.

In general as we age, total body water and muscle mass decrease while percentage of body fat increases. These changes can lead to drugs having a longer duration of action and increased effect.

Protein binding refers to the amount of medication bound to albumin in the blood. Serum albumin is decreased in older adults, creating unique issues with medications that are highly protein-bound, such as levodopa, warfarin, and phenytoin. Serum albumin is decreased 15% to 20% compared to the levels in healthy younger adults and is perhaps even lower during times of illness (Banning, 2007). If an older adult has low albumin, there is more drug free and active. This is one reason older adults need a lower dose of medication, especially if the drug is highly protein bound.

Metabolism

Following absorption across the gut wall, drug metabolism occurs almost entirely in the liver. With age and chronic illness, liver size and hepatic blood flow are decreased; therefore, dosing of medications that are significantly metabolized by the liver should be adjusted.

Excretion

Age-related changes in renal function are an important factor in the clearance of drugs from the body. About two-thirds of the population experiences a decline in creatinine clearance with aging. This can lead to a prolonged half-life for many drugs and cause the build-up of toxic levels if the dose and frequency are not adjusted (Katzung, 2007). Renal impairment requires dosage adjustment of medications that are metabolized and excreted by the kidneys. There are two laboratory values commonly used to estimate renal function: creatinine clearance and glomerular filtration rate.

Cognitive Impairment

Impairment of cognitive functions presents significant problems for medication management. It is important to prescribe as few medicines as possible and to tailor doses to the person’s personal habits. It is also important to observe the person’s ability to use medication organizers if they are utilized.

Automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. Assistance with medication management should be implemented when safety becomes an issue (PubMed.gov, 2008).

Alcohol Abuse

According to a 2008 National Survey on Drug Use and Health, about 40% of adults age 65 and older drink alcohol, although most do not have a drinking problem. More men than women tend to abuse alcohol (NIH, 2010).

As people age, they can become more sensitive to alcohol’s effects. Older people metabolize alcohol more slowly than younger people so alcohol stays in the body longer. The amount of water in the body decreases with age and, as a result, older adults have a higher percentage of alcohol in their blood than younger people after drinking the same amount (NIH, 2010).

Heavy drinking over time can damage the liver, the heart, and the brain. It can increase the risk of developing certain cancers, damage muscles, and cause immune system disorders. It can also increase the risk of developing osteoporosis.

Alcohol abuse can worsen pre-existing conditions such as diabetes, high blood pressure, congestive heart failure, liver problems, and memory problems. Mood disorders such as depression and anxiety can also be worsened by alcohol abuse. Adults with major depression are more likely than adults without major depression to have alcohol problems (NIH, 2010).

Mixing alcohol with prescription (and some over-the-counter) medications can cause unintended side-effects such as sleepiness, confusion, dizziness, nausea, vomiting, headaches, and other health problems. Medications that can interact adversely with alcohol include:

  • Aspirin and arthritis medications
  • Large doses of acetaminophen
  • Cold and allergy medicines that contain antihistamines
  • Medicines that aid sleep, reduce pain, or relieve anxiety or depression
  • Medications for high blood pressure, diabetes, ulcers, gout, and heart failure (NIH, 2010)

Drug Abuse

Illicit drug use generally declines as individuals move through young adulthood into middle adulthood and maturity, but research has shown that the baby boom generation (people born between 1946 and 1964) has relatively higher drug use rates than previous generations. Higher rates of drug use and abuse may require the doubling of substance abuse treatment services needed for this population by 2020. Substance abuse at any age is associated with numerous health and social problems, but age-related physiologic and social changes make older adults more vulnerable to the harmful effects of illicit drug use (SAMHSA, 2010).

Illicit Drugs Used by Older Adults

According to a Substance Abuse and Mental Health Services (SAMHSA) report, an estimated 4.3 million adults aged 50 or older (4.7%) used an illicit drug in the past year. In fact, 8.5% of men aged 50 to 54 had used marijuana in the past year (as opposed to 3.9% of women in this age group). The SAMHSA report also shows that marijuana use was more common than nonmedical use of prescription drugs among males 50 and older, (4.2% vs. 2.3%), and among females the rates of marijuana use and nonmedical use of prescription drugs were similar (1.7% and 1.9%) (SAMHSA, 2010).

Although use of illicit drugs is problematic for individuals of all ages, it may be of particular concern for older adults because they experience physiologic, psychological, and social changes that place them at greater risk of harm from illicit drug use. The increasing prevalence and effects of illicit drug use among older adults suggest the need both to better understand illicit drug use among this population and to plan for and develop age-appropriate prevention and treatment services (SAMHSA, 2011).

Marijuana use was more common than nonmedical use of prescription drugs for adults age 50 to 59, but among those aged 65 and older nonmedical use of prescription drugs was more common than marijuana (SAMHSA, 2011).

An estimated 4.8 million adults aged 50 or older, or 5.2%, had used an illicit drug in the past year. The most common illicit drug among older adults was marijuana (3.2%, or 3 million users), followed by nonmedical use of prescription-type drugs (2.3%, or 2.1 million users) (SAMHSA, 2011).

Screening and Intervention

As with younger age groups, effective treatment for older adults begins with accurate screening, assessment, and diagnosis. However, addressing the needs of older adults presents different challenges and requires different strategies. For example, screening and assessment tools designed for younger adults may use criteria not relevant to older adults (eg, the negative impact of substance use on work or school), which calls for the development and use of age-specific tools to properly recognize and diagnose substance abuse problems among older adults (SAMHSA, 2011).

Importantly, age-appropriate screening can help clinicians intervene early and may improve medical care because many health conditions are associated with illicit drug use. In addition, while conducting screenings, clinicians should ask older adults about the specific types of drugs used and the duration of use because these factors tend to affect decisions about appropriate treatment. For example, use of marijuana may be a decades-long experience for some older adults, indicating a different intervention than one that is appropriate for those with an abuse history of a few years (SAMHSA, 2011).

Finally, treatment of older adults must be adjusted to account for the life stage of the individual and the aging process, and should be expanded to settings that are convenient and comfortable, such as retirement communities and senior centers. Also, treatment planning and approaches that include adult children and friends of substance-abusing older adults may be critical to treatment initiation, engagement, and recovery (SAMHSA, 2011).

Health Literacy

The U.S. Department of Health and Human Services report, Healthy People 2010, identified health literacy as an important component of health communication, medical product safety, and oral health. In this report, health literacy was defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Nearly 90 million people in the United States have difficulty understanding and using health information. Poor health literacy is a stronger predictor of a person’s health than age, income, employment status, education level, and race (National Network of Libraries of Medicine, 2011).

Health literacy is not simply the ability to read. It requires reading, listening, analytical, and decision-making skills, and the ability to apply these skills to health situations. It includes the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, and doctor’s directions and consent forms, and to negotiate complex healthcare systems.

Older adults have documented health literacy problems. In 2003 the first ever national assessment of health literacy was completed as part of a national assessment of adult literacy. The survey found that adults age 65 and older have lower health literacy scores than all other age groups surveyed. Only 3% of the older adults who were surveyed were measured as proficient (DHHS, ND).

Good health literacy includes the ability to:

  • Evaluate information for credibility and quality
  • Analyze relative risks and benefits
  • Calculate dosages
  • Interpret test results
  • Locate health information

In order to accomplish these tasks, individuals must be:

  • Visually literateable to understand graphs or other visual information
  • Computer literateable to operate a computer
  • Information literateable to obtain and apply relevant information
  • Numerically or computationally literateable to calculate or reason numerically

Oral language skills are important as wellpatients must be able to articulate their health concerns and describe their symptoms accurately. They need to ask pertinent questions and be able to understand spoken medical advice and treatment directions. In an age of shared responsibility between healthcare provider and patient, patients need strong decision-making skills. Increasingly, health literacy also includes the ability to search the Internet and evaluate healthcare websites.

Anyone can have low health literacy, including people with good literacy skills. Even those who have a medical background can have trouble understanding healthcare information at some point in their lives.

Cost of Medications

Medicines are an important part of treating an illness because they often allow people to remain active and independent. However, medicine can be expensive. Some ideas from the Food and Drug Administration (FDA) to help lower costs include:

  • Tell your doctor if you are worried about the cost of your medicine. The physician may know about other less expensive alternatives.
  • Ask for a senior citizen’s discount.
  • Shop aroundlook at prices at different stores or pharmacies. Consider whether other services are needed, such as home delivery, patient medicine profiles, or pharmacist consultation, or if a senior citizen discount is not available.
  • Ask your doctor for medicine samples.
  • Buy in bulk.
  • Use mail order pharmacies, which can often provide medications at lower prices.
  • Buy over-the-counter medicines when they are on sale. Check the expiration dates and use them before they expire. (FDA, 2012)

Mixing Alcohol with Medications

Because of age-related physiologic changes, declining health and functional status, and medication use, older adults can incur problems at low levels of alcohol consumption. Estimates of alcohol dependence in the population over the age of 65 range from 1% to 5%, while the prevalence of problem drinking in older adults varies from 10% to 15%. Within the high percentage of adults 65 and older who are admitted to a hospital at least once a year (20% of the population of this age), 20% to 50% who entered the hospital for non-alcohol or other drug-related problems were identified as having such problems (Lococo and Staplin, 2006).

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