Medications are one of the most important health care technologies for improving longevity and quality of life for older adults.  Medications, including prescription drugs, over the counter medications and herbal products and dietary supplements, are prescribed or selected for self-treatment with the intent to cure, improve symptoms or prevent diseases.  Unfortunately, medications are a double-edged sword.  Medications can also result in problems such as side effects, drug interactions and other undesired outcomes.  Fortunately, many of these medication-related problems are predictable and therefore can be prevented.

What is a medication-related problem?

A medication-related problem is anything involving drug therapy that interferes with (or has the potential to interfere with) the desired outcome for a patient.  Some types of medication-related problems include:

• Untreated conditions.  In this case, needed medication has not been prescribed.  Examples include untreated pain or lack of calcium and vitamin D to prevent osteoporosis.

• Drug use without an indication.  In this case, medication is prescribed or used without a valid medical reason. 

• Improper drug selection.  This occurs when medications prescribed are not the most appropriate for the current medical condition due to the patient’s age, other health conditions or other medications.

• Dose too low.  Dose prescribed is too low to provide the intended therapeutic benefit.

• Dose too high.  Dose of the medication is too high resulting in higher risk for adverse drug reactions or side effects.

• Adverse drug reactions (side effects).  This occurs when the patient experiences a medical problem that is the result of taking a medication.  For older adults, adverse drug reactions can contribute to geriatric problems such as falls, urinary incontinence, constipation and weight loss,

• Drug interactions.  In this case, the patient experiences a medical problem that results from combining one medication with another medication, alcohol or food.

• Failure to receive medications.  In this case, a medical problem results from not receiving a medication as prescribed.  Many factors may play a role including incomplete instructions on how to use the medication, financial concerns, memory problems, and medication not available when needed.

What are the symptoms of a medication-related problem?

Medication-related problems can cause or worsen common geriatric problems including:

Medication-related problems are often mistakenly attributed to aging or underlying health conditions rather than medications.  These problems can lead to compromised quality of life, hospitalization, loss of independence or even death.

Why are older adults at higher risk for medication-related problems?

Older adults are at increased risk for experience a problem due to medication for several reasons.  They are more likely to suffer from chronic diseases requiring treatment with medications.  More medications increase the risk of drug interactions and other medication-related problems.  Physiologic changes associated with aging also result in higher risk.  The ability to eliminate medication from the body becomes less efficient with aging due to reductions in kidney and liver function.  Aging can also result in changes in the way the body responds to medication.

Another source of increased risk is ineffective coordination and information sharing within the health care system.  Multiple health care providers may be prescribing medications for the same patient.  When one prescriber is unaware of what other providers have prescribed, adverse drug events, drug interactions and duplication of therapy can result.  Using more than one pharmacy also reduces the opportunity for identifying medication-related problems if the pharmacists are unaware of all of the medications (prescription and over the counter) that patients are taking.  In addition to lack of coordination of care, the shortage of health professionals with specific training to work with older adults increases the risk of medication-related problems. 

Finally, even when health care is well-coordinated and health professionals are well-trained, medication-related problems may still arise due to lack of scientific evidence about what the best treatment might be for older adults.  Individuals over the age of 75 are under-represented in clinical trials for new medications, so information on dosing and appropriate use of medications is often lacking for the oldest patients.

What can you do to prevent medication-related problems?

• Communicate effectively with health care providers about medications.  One way to prevent medication-related problems is through communication.  Make sure that you know why medications are prescribed, how exactly to take it, how you will know if it is working, what adverse drug reactions to watch for and what follow up will be necessary to use the medication safely.  You can obtain this information from your doctor or pharmacist.  If you feel you are having problems that might be related to medications, including possible side effects or inability to afford medications, it is important to discuss your concerns with your health care providers.  Solutions are often available once a problem has been identified.

• Designate a medication manager.  Regular review of your medications (at least annually) can identify potential problems or less than optimal overall drug therapy.  It is a good idea to ask your primary care or other doctor that you see regularly to take on the responsibility of managing medications, especially when multiple prescribers are involved.  You can schedule an appointment specifically to review medications.  Your pharmacist is also a good resource for reviewing medications and communicating with multiple prescribers to resolve possible medication related problems.

• Keep a medication list.  One solution to help reduce the risk of medication problems is to keep a list of all of your medications, indicating exactly how you take them.  When new medications are added or medications are discontinued, you can communicate this to all of your health care providers by giving them a copy of the list.  A medication record form is available at http://www.ascp.com/consumers/tips/upload/My_Medication_Record.pdf .  You should also keep an ongoing record of any adverse reactions to medications you have experienced.

• Consult with a doctor or pharmacist before taking over-the-counter medication, alcohol or herbal supplements along with prescription drugs.  Over the counter and herbal medications, as well as alcohol, can interact with other medications or cause problems for individuals with certain health conditions.  Just because products are available without a prescription does not mean that they are safe for everyone.  For example, over the counter products containing diphenhydramine (such as Tylenol PM^®) should be avoided in older adults, particularly those with dementia.  Gingko biloba, an herbal product used to improve memory, interacts with anticoagulants (blood thinners) such as Coumadin^® and increases the risk of bleeding.

• Use common sense when using medications.  Avoid changing doses or discontinuing medications without consulting your doctor.  Medications are not always the best solution to resolve a health-related problem.  For example, many behavioral issues that arise during the course of a dementia illness are best managed using non-drug therapy approaches because the medications often cause additional side effects.  It is also important to avoid sharing medications with others or using someone else’s medications.  Medications no longer needed should be discarded.

• Obtain medication refills in a timely manner.  To avoid running out of medications, it is important to order refills before the current prescription is finished.  If getting to the pharmacy to pick up medications becomes an issue, find out if your pharmacy can provide home delivery.

Tips for administering medications to patients with dementia

• Use clear directions and simple language to communicate what you need the patient to do.  For example you could say “Here is your pill for your blood sugar.  Put it in your mouth and drink some water.”

• Developing a routine for medication administration may also help.  Giving medications at the same time of day in the same place may decrease conflicts.  If the patient refuses to take a medication, it may be better to wait and little while and then try again.

• Don’t assume that the patient will take medications on their own.  Sometimes patients will spit them out or hide them, so you want to be sure that they are actually swallowed.  As the dementia progresses, you will need to assume increasing responsibility for the administration of medications.  Watch for pills that are spit out or thrown on the floor, since these medicines could be harmful if consumed by children or pets.

• Keep medications organized.  It may help to keep a check list or use pill boxes or other packaging for medications.  It is easy to forget to give a medication so develop a system that works for you.  Your pharmacist can assist you in finding a solution that works for you.

• Adapt medication administration techniques for the person.  If the patient has difficulty swallowing pills, there are often alternatives.  Some medications can be crushed or are available in a liquid form.  It is essential to discuss alternatives with your doctor or pharmacist, since not all medications can be safely crushed.

• Store medications safely.  It is important to keep medications in a way that limits access by the patient.  Locked cabinets for medications may become necessary.  Patients can forget that they have already taken medications and take additional doses.  Keeping the phone number for the poison control center or emergency room near the phone in case of an emergency with medications.

Sources:

American Society of Consultant Pharmacists.  Seniors at Risk.  (http://www.ascp.com/publications/seniorsatrisk/upload/AtRisk.pdf).  Accessed 11/26/07.

American Society of Consultant Pharmacists.  Tips for Seniors.  (http://www.ascp.com/consumers/tips/index.cfm).  Accessed 11/26/07.

Alzheimer’s Association.  Medication Safety.  (http://www.alz.org/living_with_alzheimers_10486.asp).  Accessed 11/26/07.

NIH Senior Health. Taking Medicines (http://nihseniorhealth.gov/takingmedicines/toc.html). Accessed 11/26/07.

Shrank, Polinski & Avorn. J Am Geriatr Soc 2007;55:S373-S382.