MEDICATION USE IN OLDER ADULTS

Prescription and over-the-counter medications and herbal preparations are widely used by older adults. Surveys show at least one prescription medication is used by 87% of older adults, five or more medications by 36%, and over-the-counter medications by 38%. A sample of Medicare patients discharged from an acute hospital to a skilled nursing facility found that patients were prescribed an average of 14 medications, including over one third with side effects that could exacerbate underlying geriatric syndromes (Rochon, 2020).

Many older adults take herbal preparations; however, they often do not inform their healthcare provider, and many clinicians do not ask. Herbal medicines may interact with prescribed medications, leading to adverse events (e.g., ginkgo biloba taken along with warfarin [Coumadin] can increase risk of bleeding; St. John’s wort taken with SSRI antidepressants can increase the risk of serotonin syndrome).

Prescribing medications for older patients is challenging for several reasons:

• Premarketing drug trials often exclude geriatric patients, and approved doses may not be appropriate for them.
• Many medications must be used with caution due to age-related changes in pharmacokinetics (absorption, distribution, metabolism, and excretion) and pharmacodynamics (physiological effects of the drug).
• Hepatic function also declines with advancing age and may account for great variability in metabolism of a drug, especially when taking multiple medications.
  (Rochon, 2020)

Polypharmacy and Medication Assessment

Polypharmacy refers to receiving five or more appropriate medications for treatment of various chronic conditions. Medication-related adverse effects associated with polypharmacy may include falls, cognitive decline, and increased healthcare utilization. Drug-associated admissions to the hospital are prevalent in older adults.

Polypharmacy increases the risk for “prescribing cascade,” which develops when an adverse drug event is misinterpreted as a new medical condition and additional drug therapy is prescribed to treat it. Use of multiple medications can also lead to problems with adherence, especially in the presence of visual or cognitive impairment.

The goal of medication assessment is to reduce inappropriate polypharmacy and create an up-to-date and accurate list of medications that can be shared from patient to provider regardless of healthcare setting. This list should include prescribed medications, OTC medications, herbal therapies, dietary supplements, directions for use, and how the patient is currently taking each of them. The most direct and simplest form of assessment is medication reconciliation, which involves comparing all medications a patient is taking to the prescription orders or a medication list maintained by the healthcare provider (Fulmer & Chernof, 2019).

Determining the appropriateness of prescribed medication is a more complex form of assessment. The American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults includes 30 individual medications or medication classes to avoid for most older people and 40 medications/medication classes to use with caution or to avoid when living with certain disease/conditions. (See “Resources” at the end of this course.)

Other available tools include:

• Screening Tool of Older People’s Prescriptions (STOPP)
• Screening Tool to Alert to Right Treatment (START)
• Medication Appropriateness Index (MAI)

Medication deprescribing (removal of inappropriate medications) is another important approach to medication management. This process includes:

• Determining which medications are being taken and how they are taken
• Considering the potential harm of each medication in order to determine priority
• Assessing whether a medication should be discontinued
• Prioritizing medications for discontinuation
• Implementing the deprescribing plan
• Monitoring the patient for adverse effects
  (Fulmer & Chernof, 2019)

Medication Adherence

Older adults may face many obstacles that make it difficult to adhere to a medication regimen. The consequences of nonadherence can be detrimental and even fatal. Thirty percent of hospital admissions and 23% of nursing home admissions have been found to be attributed to medication nonadherence.

Adherence can be compromised by many factors, including:

• Voluntarily interrupting or modifying therapy
• Mistakenly believing one is adhering properly to the regimen as laid out by the prescribing individual
• Socio-economic factors
• Perceptions and motivations
• Physical or cognitive impairments
• Complexity of the regimen
• Ability to read and understand medication instructions

Prescription labels can often be difficult to read or understand due to lack of knowledge about medical abbreviations (e.g., BID, QD, TID, QHS) and routes of administration (e.g., rectal, intramuscular, ophthalmic, oral, buccal). Prescription pamphlets often contain an overwhelming amount of information about uses, cautions, and side effects in small-to-read font sizes.

Clinicians, often occupational therapists, help patients to manage their medications appropriately. Approaches may include:

• Patient/caregiver education
• Simplifying patients’ medication therapy routines
• Using aids/assistive devices, such as weekly pill containers or a pill map visual pill planner that shows which pill and how often to place each pill into a weekly pill box
  (Fulmer & Chernof, 2019)

Electronic aids and services for self-management of medication by older adults include pill reminder applications (apps) available for use with mobile devices; however, these require that either the patient or the caregiver have a mobile device and the skills required to use it.

Sensory and motor impairments can affect an older adult’s ability to self-manage a complex drug regimen. Impaired vision increases the risk of errors in drug use or timing of administration or in noting expiration dates. Joint pain or weakness may make it difficult for patients to handle small tablets, open child-proof caps on medication containers, or administer eye drops. Large capsules or tablets can be difficult for older adults to swallow and may cause choking.

Cognitive problems such as Alzheimer’s disease, other dementias, and traumatic head injury also contribute to mismanagement of medication regimens. Responsibility for managing medications often falls to family caregivers when the patient is at home. However, if the patient goes to adult daycare, the medication list and instructions must go along. Some medications, such as anticholinergics, are contraindicated in people with cognitive deficits because they can increase confusion and make memory problems worse.

Sometimes there is a combination of physical issues that cause cognitive or mental issues. One example might be an older adult with head trauma who reveals a number of cognitive deficits (physical-to-cognitive). An older individual with personality changes caused by hypothyroidism is another example, in which a mental illness may be caused by a physical disorder (cognitive-to-physical). The complexity of these diagnoses with resulting symptoms are difficult at best for the diagnostician and those who care for the older adult (Meiner & Yeager, 2019).

Cost of Medications

The ability for older adults to self-administer their medications and whether they can afford them are also important considerations in the medication assessment process. The ability to pay for medications is directly related to medication adherence and may vary throughout the year based on Medicare Part D coverage or seasonal incomes. Medication costs may be lessened through state Medicaid programs and manufacturers’ prescription drug plans for low-income patients.

The soaring cost of medications for older patients with chronic health conditions is a major reason for nonadherence to prescription drug regimens. Even with Medicare Part D reimbursement, the high cost-sharing expense makes medications unaffordable for some individuals.

To cope with high out-of-pocket costs for drugs, many older adults use such cost-cutting measures as skipping doses, going off their medication for a time, or purchasing their medications from unreliable sources online or abroad. Others take less than the recommended dosage (e.g., cutting pills in half) to make the medications last longer (Tabloski, 2014).

Prescribing physicians must be aware of medication costs and design drug regimens that carry the lowest possible out-of-pocket costs without compromising treatment effectiveness. Social workers, nurses, and clinical pharmacists can often assist in designing these regimens to reduce the financial hardship on older adult patients who need medications.

The Centers for Medicare and Medicaid (2014) provide the following recommendations on how healthcare professionals can help older adults with limited or low income to manage the cost of drugs:

• Discuss switching to less-expensive brands or generic brands.
• Help search for a medication assistance program for the specific drug needed.
• Inquire about government programs that offer assistance with premiums and other drug costs.
• Determine whether patients qualify for extra help through Medicare and the Social Security system.
• Provide resources for national and community-based charitable programs (such as the National Patient Advocate Foundation).