In the PCP’s office a nurse met with Leona to complete her medication reconciliation and discuss a plan to avoid overmedication. He provided a pill box that allows Leona to put her daily medications in each section so she could tell when the medications had been taken. He also offered alternative methods that Leona could use, including a dry-erase board showing her daily medication times, an alarm system for her phone, and an updated printout of the names of her medications and why she was taking each one.
The nurse also helped Leona order a medication-alert necklace. Leona and her husband both liked the simple pill box method. They even took a picture to show what the pill box should look like with all her colored medications as well as the pill bottles, so they would have a visual reminder of each week as they filled the boxes. They were also taught the symptoms to look for in case of any future accidental drug overdosing.
Because older adults must manage a plethora of chronic illnesses with medications, it is critical to ensure that each medication is essential and taken as prescribed. When financial resources are stretched, elders may be inclined to extend medications by creative self-administration strategies.
Elders with low income, those without adequate prescription drug coverage, and those using high-cost medications are likely to stretch out their medication supply by skipping doses or extending the intervals between doses—or cutting the pills in half. Strategies to decrease the number of tablets needed include taking a smaller dose (splitting tablets or taking one when multiple tablets are prescribed) and substituting an OTC or herbal alternative. Taking a lower-than-prescribed dose is especially prevalent in patients with multiple medical conditions using many medications, those prone to medication side effects, and people who resist prescribed treatment due to personal or cultural beliefs.
Although these activities are not in the realm of polypharmacy per se, they are related, in that appropriate prescribing ensures that older adults purchase only the medications they need. Left to decide which medication to extend, the older person may neglect taking a critical medication such as an anti-hypertensive and continue taking a noncritical medication. Hypertension is asymptomatic, so an older adult might favor taking a proton pump inhibitor (PPI) for gastric discomfort and skip doses of the antihypertensive to save money.
A wise healthcare professional may identify the PPI as an expensive medication that might be substituted for a less expensive but effective alternative (in this case, an H2-blocker might work). Identifying problems such as this in a medication regimen could potentially reduce the overall cost of medications for the patient so that both the anti-hypertensive and an effective remedy for gastric discomfort can be afforded.
Additionally, taking the time with the patient to explore nonpharmacologic treatments such as weight loss, exercise, and modifications to the diet to decrease gastric acid production should be considered. Unfortunately, often the patient and the clinician rely on pharmacologic interventions because behavior modification is more challenging and often doesn’t create results as quickly.
Recommendations designed to improve medication management in older adults include the following (Conn et al., 2009):
- Reduce inappropriate prescribing
- Decrease polypharmacy
- Avoid adverse events
- Maintain functional status
- Drug education
- Simple written instructions
- Dose modification (to reduce frequency and number of medications)
- Disease education
- Medication reconciliation and review
- Packaging (use of pill boxes, pill blisters to identify separate doses)
- Side effect management
- Tailored interventions (versus standardized dosing recommendations)
- Medication self-monitoring (medication diary and calendar as reminders to take medications)
- Written calendar
- Disease and symptom monitoring
- Integration of provider care
- Use of alternative therapies rather than relying on pharmacotherapy
- Use of one pharmacy for all medications
Reducing 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)
Prescribers should practice the following measures (Kaur et al., 2009):
- Ask the patient to bring all medications being taken, both prescribed and OTC, to the primary care provider who can evaluate all medications being taken, especially if there are multiple physicians prescribing medications
- Discontinue medications found to be in conflict with Beers or other criteria unless compelling evidence exists for continuance
- Reinforce use of a single pharmacy for all prescription medications
- 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 (Conn et al., 2009)
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 to reduce polypharmacy 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 at regular intervals; assess for known toxicities at each visit
- Screen for drug interactions (Bergman-Evans, 2004)
Avoiding Adverse Events and Reactions
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 & Staplin, 2006).
In contrast, an adverse drug reaction (ADR) is “any response to a drug which is noxious and unintended, and which occurs at doses normally used in humans for prophylaxis, diagnosis, or therapy of disease, or for the modification of physiologic function.” This definition implies that there was no error in the use of the drug. Examples of an injury include:
- A rash or diarrhea caused by an antibiotic/anti-infective agent
- Gastrointestinal tract events such as nausea, vomiting, diarrhea, constipation, and abdominal pain
- Anaphylaxis (a serious allergic reaction) to penicillin
- A major hemorrhage from a blood-thinning agent
- Kidney failure from aminoglycosides (antibiotics often administered into veins or muscle to treat serious bacterial infections) (Lococo & 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 & Staplin, 2006).
In the same study, the most common types of preventable adverse drug events were:
- Electrolyte/renal (27%)
- Gastrointestinal tract (21%)
- Hemorrhagic (16%)
- Metabolic/endocrine (14%)
- Neuropsychiatric (9%)
The most common medication categories associated with preventable ADEs were:
- 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 & Staplin, 2006)
Adverse drug events can result from errors in prescribing or administering medication or from patient noncompliance. The percentage of community-dwelling elder Americans who had at least 1 of the 33 drugs considered potentially inappropriate for older adults improved significantly from 21.3% in 1996 to 18.4% in 2002. The percentage of community-dwelling elders who had 1 of 11 drugs that should always be avoided by older adults remained at about 3% over the 6-year time period between 1996 and 2002 (AHRQ, 2015).
An analysis of ED visits between 1992 and 2000 of patients 65 and older estimated that inappropriate medications were given in 12.6% of the visits. The top six drugs involved in inappropriate administration (accounting for 70.8% of all cases) were promethazine (22.2%), meperidine (18.0%), propoxyphene (17.2%), hydroxyzine (10.3%), diphenhydramine (7.1%), and diazepam (6.0%) (Zagaria, 2006).
Propoxyphene (Darvon) has been discontinued due to cardiac events; meperidine is known to have paradoxic excitatory effects in patients, producing a range of symptoms from tremor to myoclonus and seizure. Many persons having a seizure following exposure to meperidine might then be placed long-term on an anti-convulsant medication to control a medication-related incident, thereby compounding the list of medications a patient is receiving.
The great irony in medicine is of giving a patient a medication for a disease, and then another medication for its side effects, and following it with another medication or two or more to counter those side effects—and the negative viscious cycle continues.
Often, any diagnosis indicating an appropriate use of these medications is absent, or testing confirming the ongoing need for medication is omitted. The practice then becomes one of continuation without questioning. This practice is perpetuated when the patient does not have a consistent medical provider or medical home.
In elders, lower initial doses should be used and upward titration done at a slower rate than in younger patients. Use of a single medication within a class should be optimized before a second medication from the same class is added, and the patient should always be carefully questioned to determine that the desired effect from a medication is achieved. Side effects and the desired outcome of the medication should be agreed upon with the patient rather than just a clinican-based decision.