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

1. Medication Management for Older Adults:Pitfalls, Perils, and Proper Practices RaChelle Eid Zylstra Northwest Regional Council Bellingham, Washington Zylstra@dshs.wa.gov

2. Overview • Extent of the Problem • Why Older Adults? • Medication Non-compliance • Have a Beer. It’s on the House! • Suggested Next Steps

3. The future looks “Grayer”

4. Annual Cost of Diseases Affecting Americans Age 65+ Rx

5. 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.

6. 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.

7. 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.

8. 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)

9. 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.

10. Who’s At Risk • 85+ • > 6 Chronic conditions • kidney function • Cancer/Depression • 6-9 medications • > 12 doses/day • Prior ADR • Recent hospital discharge 

11. 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

12. 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.

13. 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

14. 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 • Don’t refill when out

15. 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.

16. 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

17. 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

18. Healthcare Changes Contribute to Non-compliance • The prescription triad—patient/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

19. 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”

20. 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.

21. Prescriptive Behavior:Elders at Risk • Very few Geriatricians • Fewer still geriatric pharmacists • “Prescription Cascade” • Often a side effect is treated with another drug…and so on…

22. Prescriptive Cascade

23. Beer’s 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%--3+Rx. • 41% of these had nervous system effects--FALLS!

24. 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. Why Beers?

25. 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

26. 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 don’t keep anything secret.

27. 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.