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Medication Management in the Elderly
Today’s primary care providers who care for the elderly spend more time than ever trying to manage medications. This is a time-consuming, resource-intense process that requires skill, concentration, and the ability to keep a number of problems actively under consideration at any one time. Patients also bring to this equation a greater burden of disease with increasing frailty and vulnerability.1 In an Op-Ed in Caring for the Ages (January 2005) author EGT stated:
Whether in the outpatient setting, the nursing home, or the hospital, today’s physicians who care for the elderly spend more time than ever trying to manage medications and the medication list. The only drugs that really matter are those that actually go in the patient’s mouth, through their skin, or into them via another orifice. What patients tell us they take, what’s recorded on their chart that they take, the information kept at a variety of pharmacies on the medications they take, and the drugs patients bring to the office that they say they take may not be anywhere close to the reality of what they consume.
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Given the burden of illness now present in our patients, there are more opportunities for drug adverse effects, noncompliance, and significant expense. Although noncompliance affects all age groups, older adults have specific barriers against effective medication use and can be more vulnerable to the incorrect use of medication. Some age-related barriers are vision loss and cognitive impairment. In persons age 60 years or older, noncompliance with medication regimens varies from 26-59%.2 The availability of effective medications and the increasing knowledge of the importance of treating chronic disorders have led to an increased prevalence of polypharmacy.3 The available evidence suggests that polypharmacy and poor patient–healthcare provider relationships (including the use of multiple providers) may be major determinants of nonadherence among older persons, with the impact of most sociodemographic factors being negligible.4 Reasons for nonadherence include confusion over doses and schedules, forgetfulness in taking the medication, toxic interactions, and excessive financial expense leading to underuse of some drugs.5,6 We must be ever mindful of pharmaceutical misadventures, but we should not walk away from new opportunities to deliver better care. Issues of safety will dominate the medical debate for the next decade.
Overall inappropriate medication use in elderly persons is a serious problem. In 1996, 21.3% of community-dwelling elderly persons in the United States received at least 1 of 33 potentially inappropriate medications.7 Individuals with poor health and more prescriptions had a significantly higher risk of inappropriate medication use. One study by Lazarou et al8 revealed that adverse drug events in older persons led to hospitalizations in 25% of those age 80 years and older. Drug dosage recommendations may have to be modified based on estimates of lean body mass. Pharmacokinetic changes with age principally affect absorption, metabolism, distribution, excretion, and to a lesser extent, absorption. Distribution of most medications is related to body weight and composition changes that occur with aging, including decreased lean muscle mass, increased fat mass, and decreased total body water. Fat-soluble drugs may have to be administered in lower dosages because of the potential for accumulation in fatty tissues and a longer duration of action.9
A variety of agents exist with improvements in side-effect profile and reduced adverse events to effectively manage hypertension, diabetes, lipids, respiratory disorders, and thrombotic disorders in patients who may require five of more medications to achieve therapeutic endpoints, as outlined in the 7th Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7),10 the American Diabetes Association (ADA),11 the 3rd National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III),12 National Heart, Lung, and Blood Institute (NHLBI) and National Asthma Education and Prevention Program (NAEPP),13 and the American College of Chest Physicians (ACCP) 7th Conference on Antithrombotic and Thrombolytic Therapy14 guidelines, respectively.
TEAM MANAGEMENT
A variety of teams can be assembled to help with medication management. The best are put together to have each member practice at their maximal level of licensure. A variety of interventions have utilized pharmacists. One study in England used a pharmacist to review repeat prescriptions through consultations in general practice with elderly patients. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient, 2.2 v 1.9).15 Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group. Such reviews resulted in significant changes in patients’ drugs and saved more than the cost of the intervention without affecting the workload of the general practitioners.15 Many office practices now instruct patients to bring their medications in at every visit.
However, today’s polypharmacy has a new potential villain at every clinical encounter: the electronic medical record. For all its benefits, it has the potential to reproduce and reinforce errors of commission and errors of omission. Errors once made on an electronic list can just be duplicated with a single keystroke. There may be no true repository for an always-accurate drug list, just the belief that “what you see is what you get.”
RECONCILING MEDICATIONS ACROSSPRACTICE SITES
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Goal 8 mandates medication reconciliation across practice sites. This is a process step now occurring at both inpatient and outpatient reviews by JCAHO. Goal 8 requires an accurate and complete reconciliation of medications across the continuum, but the requirements relate only to obtaining and communicating a complete list of medications. The intent of the goal is that whenever a patient/client/resident moves from one “setting, service, practitioner, or level of care within or outside the organization,” the complete and current list of that patient/client/resident’s medications—as obtained on admission/entry and updated during that episode of care—will be communicated to the next provider of service to be compared (reconciled) with the medications to be provided in/by the new setting, service, practitioner, or level of care. Reconciliation is the process of comparing what the patient/client/resident is taking at the time of admission or entry to a new setting with what the organization is providing to avoid errors of transcription, omission, duplication of therapy, drug-drug and drug-disease interactions, etc. It is up to each organization to determine how this process takes place. Whenever and however the comparison takes place, it should take place early enough to improve the safety of the organization’s medication management processes, and hence, patient safety. Prescription and nonprescription drugs come at our patients from the global marketplace. Pharmacies fill whatever prescription a physician, nurse practitioner, or other appropriately licensed provider calls in. Insurance companies, managed care organizations, and even fee-for-service practitioners have a difficult time understanding what medications patients take, while the Internet—with its offshore providers, cheaper drugs, and a dizzying array of nontraditional therapies—adds to the complexity. The Medicare Part D drug benefit should force patients into a single plan; one hope is that the formulary will not just be controlled, but that drug-drug interactions, omissions, and commissions will be electronically monitored. A medication master list has great appeal. There would be only one pharmacy to adjudicate drug-drug interaction and potential complications. When a medication was changed or a dose adjusted, the corrections would find their way into every nook and cranny of patient compliance—from the drug cupboard at home, to the drug cart at the nursing home, to the bedside at the hospital, to the medical record at all locations and to the pharmacy.
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PATIENT COMPLIANCE
Much has been considered in patients taking and staying on their medications. Adherence requires that both the patient and the practitioner are on the same page. Many factors are associated with medication adherence and related health outcomes in older adults. Although the cognitive processes needed to manage and take medications declines with aging, the number of prescription and nonprescription medications consumed increases. Providers must be mindful of vision, hearing, health literacy, disability, and social and financial resources as intrusions that may complicate the ability of older adults to adhere to the pharmacologic prescription.16 Noncompliance results in decreased quality of life, increased health care costs, and both acute and long-term care admissions. Only 50% of older adults adhere to medication treatment. Reasons are complex and varied but include cost, adverse effects, poor instruction, or a poor therapeutic relationship with the primary provider.17 Patients also have their own belief systems, with rituals and drugs for sleep, pain, and bowel function. Any over-the-counter therapy with a “PM” suffix has both an antihistamine and placebo effect. It has been estimated that approximately 90% of older adults take over-the-counter medications, at least occasionally.18 As a result, perhaps 3 million adults age 65 years and older may be at risk for herb/vitamin/medication interactions.19
Drugs are expensive, and patients have learned that treatment decisions are as much based on physician experience as they are on clinical evidence. During hospitalizations for acute illness, drugs are often added or discontinued, and the dosages are frequently changed.20,21 What is discontinued after one hospitalization can easily get restarted the next. Physicians often change medications to fit their own comfort zone and construct for care when the patient will never see them again. This happens all too frequently in the hospital setting. Hospital lists and discharge medications are rarely completely correct. Most of the time the problem is just a dosage change, but occasionally there are total omissions or substitutions of completely different drugs. The hospital is a very sophisticated place where we can give medications around the clock, by skilled professionals and with a pharmacy backup that can break pills in half or adjust preparations to almost any dose. As an example, the 60-mg dose of furosemide has more risk than benefit in the nursing home or in the home setting. The drug comes as a 40-mg or 20-mg tablet. Any time we resort to half-pills or two pills instead of one, we have more than doubled the complexity of the task and increased the opportunity for error.
“HIGH-TECH” SOLUTIONS
Increasing medication compliance has had a variety of “high-tech” solutions over the years. A variety of targeted interventions (eg, phone calls, electronic devices) have provided evidence that there can be a positive impact on community-dwelling older adults and their compliance with prescribed medications.22 In the 1980’s, blister packs were de rigueur as the novel approach to delivering medications and improving compliance.23 Newer applications, including electronic dispensing systems, have recently been touted, but these require cognitively-intact caregivers to operate.24 Telemedicine applications utilizing “virtual visiting nurses” have been used around the world, including attempts at Mayo Clinic for patients with mild dementia.25 Diabetes management has been shown to be effective at a Veterans Affairs (VA) patient-centered care coordination/home telehealth program, as an adjunct to treatment for veterans with diabetes.26
Currently, there is no strong evidence to support the use of any one intervention type. Future research should use combinations of approaches, as there is some evidence that these are more likely to be successful.27 The only way we have any assurance that drugs are delivered appropriately to home patients is to establish a home visit program with the consultant pharmacist or a visiting nurse. Even then, there are discrepancies as to what is actually being taken and what is documented in the record. Compliance remains a problem even when drugs are being directly administered. Accuracy in the record is the first step toward improved patient care. These are goals within our electronic reach, and they are still consistent with the Institute of Medicine’s vision for the future.28,29
In the nursing home, one might expect that medication management with oversight by a consultant pharmacist would be improved, and, in fact, it is (at least as far as the drugs administered by the pharmacy to the resident). However, what gets documented in the various clinical records can be another story altogether. As mentioned previously, the electronic medical record gives one many opportunities to fill in space with inaccurate information. The most common inaccuracies are to bring forward drug lists from previous notes when rushed at the bedside rather than to dictate the new drug list, either at the bedside with the chart at your side or in the office with pill bottles scattered across a desk. Never is there only one list, because rarely is there only one practitioner. As patients transition across settings there are also multiple lists. The pharmacy keeps a record, a patient may have a list, the nursing home has its orders, and medical practices keep yet another set of books.
COMBINATION THERAPIES
Combination drug therapy now offers physicians the opportunity to better work within Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87) and the nine-drug limit imposed by federal regulation.30 The Centers for Medicare & Medicaid Services (CMS) has recently released a draft of the revised Guidance to Surveyors of Long Term Care Facilities covering Unnecessary Drugs.31 The new guidance focuses on avoidance of medications known to interfere with each other and, more importantly, underlying conditions. The updated Beers drug list is included, as are numerous other medications for which safer alternatives exist.32 Use of combination drugs indicates mindfulness of these recommendations and can further simplify treatment schedules in a variety of circumstances, not just limited to skilled care facilities. However, a few combination products on the Beer’s list remain on the market and continue to be used today despite clear association with adverse outcomes. Propoxyphene/acetaminophen is one such example that causes an increased incidence of dizziness and falls in the elderly, and has not been shown to be a more effective analgesic than acetaminophen alone.33
The same issues are more manifest for atypical antipsychotic drugs—and even antidepressants. Although psychiatrists can spend weeks adjusting medications for their younger patients, primary care providers have a narrow window of opportunity with their geriatric patients. Many of our ambulatory patients have reduced capacity to fuss with a lot of adjustments. Drugs given four times a day have more than four times the error rate as a similar therapy that can be given once a day. Geriatricians negotiate with patients and their families just what they will tolerate, and there usually is a pill count limit. Patients knew the nine-drug limit before it was every codified in the Federal Register. Current therapies are also designed better with a greater therapeutic window and more safety. Ideal pharmacokinetic characteristics of drugs in the elderly are water solubility for ease in absorption, short-to-intermediate half-life for once-daily administration, moderate protein binding, and combined elimination by hepatic and renal routes with an emphasis on glucuronidation and sulfation, rather than oxidative metabolism.34,35
OUR PATIENTS’ BEST INTERESTS
Our task is to keep medications simple—both for the patient and for the medical record. The fewer and the more effective the therapies, the safer it will be for our patients. The December 2005 White House Conference on Aging also addressed medication management in Resolution 54, “Optimize Medication Management Programs.” The resolution read:
Delegates were provided information that “Medication-related problems, including underutilization of medications, polypharmacy, adverse drug events and inappropriate prescribing, would represent the fifth leading cause of death in the U.S. if classified as a disease. Medication therapy management targets those with multiple chronic diseases. Additionally, frail older adults with multiple co-morbidities are often sub-optimally treated for chronic conditions around which clear therapeutic guidelines exist. If followed, these guidelines would reduce morbidity and cost. Patient injury and unnecessary costs to the health care system may be avoided when prescribers adhere to evidence-based treatment guidelines.”
Whether or not this resolution’s intent finds its way into policy over the next few years, our job as primary providers is to remain mindful that even good drugs can go bad, and that medication misadventures will confront us at regular intervals. First and foremost, we must watch out for the best interests of our patients. Adjudicating the medication list and the drugs we prescribe remain a top priority.
Dr. Tangalos has been a consultant for Janssen, Forest Pharmaceuticals, Amgen, and Pfizer/NCQA. Dr. Zarowitz reports no relevant financial interests.
