Frieda Wiley, PharmD, BCGP, is a writer and pharmacist.
The specific medication challenges of seniors-and the tools and tricks to help them stay healthy.
An estimated 47 million adults living in the United States were age 65 and older in 2017, according to research conducted by SeniorLiving.org. The Population Reference Bureau projects that number will more than double to nearly 100 million individuals by 2060. The combination of the expanding elderly population taken together with an average lifespan of 78.6 years for men and slightly more than 81 years for women highlights the need to improve medication-related outcomes in this population. Facilitating how senior citizens manage their medications by engaging technology, support systems, healthcare providers, and other resources are good places to start.
Geriatric patients face many challenges in managing their medications, which is sometimes very complex due to their medical conditions,” says Jin Seon Kim-Paglingayen, MD, an assistant clinical professor of health sciences in the department of family medicine at University of Southern California, Riverside.
Experts have varying opinions when it comes to pinpointing the biggest hurdle in helping senior citizens manage their medications. However, polypharmacy appears to be a recurring theme-especially as prescription medication use continues to rise.
Prescription medication use among the geriatric population has more than doubled over the last 20 years. A 2015 study published in The Journals of Gerontology that evaluated data from 13,869 adults ages 65 and older in the National Health & Nutrition Examination Survey (1988-2010) found that older patients took a median number of two medications in 1988; by 2010, that number had doubled to four medications with 40% of the patients taking 5 or more medications.
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Jessica Triboletti, PharmD, assistant professor of pharmacy practice at Butler University College and ambulatory care clinical pharmacy specialist at Eskenazi Health in Indianapolis, notes the medication management is not exclusive to prescription medications. Comprehensive medication management should also include over-the-counter medications, dietary supplements, and herbal products.
According to Jacqueline Hagarty, PharmD, BCGP, an ambulatory clinical pharmacy specialist at Banner Pharmacy Services in Phoenix, taking multiple medications can have serious consequences. A high pill burden contributes to low adherence rates, but poor understanding or lack of education on the medications also hinders patient adherence.
“I find that many of my patients do not know the indications for all of their medications, so they do not understand the importance of taking them every day,” she observes.
Hagarty also finds that some patients may feel overwhelmed by managing their medications. Many patients are also worried about side effects and interactions, but they do not always express these concerns to their health care providers.
Polypharmacy, the need for increased collaboration among healthcare professionals, and improving communication are not the only challenges in the world of medication management. Kim-Paglingayen points out that particular circumstances such as language barriers, lack of transportation, and physical or mental disabilities require unique solutions.
Older patients who are disabled or without access to transportation may also lack social support, such as having a family or friend to pick up their medications and refill requests promptly. Those who have mental or physical disabilities may not be able to adhere to high-maintenance medication regimens, such as those requiring frequent glucose checks and stringent dietary restrictions to avoid dangerous drops in their blood sugar.
Age-related changes add another layer of complexity. Declining or compromised kidney and liver function may hinder the speed by which medications are cleared from the body, causing medications to last longer and increase the risk for side effects.
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Triboletti cites other age-related changes, such as additional sources of complexities. For example, factors such as increased fatty tissue, decreased bodily fluid, and overall weight-loss can alter the volume of distribution, warranting the need to adjust medication doses.
Special populations, such as homebound patients-both young and old-may face a greater risk for adverse drug events associated with complex medication regimens. Frequently, these individuals live with multiple chronic conditions and take multiple medications to treat each condition, increasing the risk for complications and costly medication regimens and poor medication adherence.
Collaboration Is Key
Melissa Morgan-Gouveia, MD, a geriatrician with Christiana Care Health System’s Department of Medicine who specializes in home-based primary care with Christiana Care’s Visiting Nurse Association says that open lines of communication between all healthcare providers involved-including caregivers-is imperative to improving the patient experience and outcomes.
She cites the increased potential for OTC drug interactions as an example. Many OTC medications are combination products with multiple different medications, which can increase the risk for unintentional overdoses of medications such as acetaminophen.
Triboletti agrees. “Communication is key, and pharmacists are in a unique position to provide accessible and consistent medication support,” she says. “Conversation with patients and caregivers are important to help identify concerns, barriers, and underlying causes for nonadherence.”
Hagarty emphasizes the importance of reviewing medications with the patient can help increase their understanding. Doing so could potentially improve patient adherence while facilitating the pharmacist’s ability to identify opportunities to optimize their medication therapy. Examples of this include discontinuing unnecessary medication and duplicate therapy, identifying new drug interactions, and finding solutions to barriers to access such as transportation or cost. Sometimes, healthcare providers must adjust the solutions to suit the patient’s environment.
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“Home health providers should identify the over-the-counter medications a patient is taking when conducting a medication review, including asking about medication bottles seen during the visit that the patient may forget to mention such as the over-the-counter sleep medication on their nightstand,” Morgan-Gouveia says. “They alert the patient’s primary care provider [and the pharmacist] about any over-the-counter medication a patient is taking that is not on their medication list.”
Technology: Help or Harm?
Healthcare is no stranger to new technologies designed to engage users-in this case, patients. While some stereotypes regarding senior citizen’s affinity for and ability to use technology persist, internet use among senior citizens is on the uptick. The number of senior citizens who own smartphones more than doubled from 23% in 2013 to roughly 50% in 2017, depending on the age range, according to a report from Pew Research. As many as 59% of senior citizens aged 65 -69 years reportedly owned smartphones and 49% of 70- to 74-year-olds owned smartphones in 2017. While lower, those numbers still remain relatively high for the 75+ group: 31% of 75-79-year-olds owned a smartphone and 17% of seniors aged 80 years and older having owned smartphones in 2017.
Similarly, internet use among this population has soared. Only 14% of senior citizens used the internet in 2000, but that number soared to at least 67% by 2017. Furthermore, the usage statistics pattern those of geriatric smartphone owners, with the 65-69-year-old-age groups being the most robust internet user, followed by those in the 70-74-age group; usage drops off after that point. However, recruiting technology to solve medication management problems may require insight that transcends the gadget and the application.
“These hurdles are not just technological-they’re life hurdles,” says Maureen Williams, marketing solutions manager, consumer and physician experience for Meditech. For Williams, a healthcare technology industry professional who also cares for her aging mother, the reality hits home. “Any technology that gets deployed needs to be easy-to-incorporate into that patient’s daily life.”
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For patients who might benefit from technological interventions, Williams recommends that healthcare professionals work with patients to ensure the technology is something the patient finds easy-to-use, easy-to-understand, and easy-to-incorporate into their daily life. It is also crucial that the patient finds the technology both meaningful and useful enough to continue using it.
“If an alarm is going off every 2 minutes, the patient is just going to cut it off,” Williams cautions, referencing a phenomenon known as alert fatigue.
In addition to addressing the patient’s ability to manage medications, Williams says that providers frequently encounter challenges helping patients address costs. Meditech has a patient portal that facilitates real-time communication between all interested parties. Both printable and downloadable, patients can access the list to share with healthcare providers and family members.
However, not all platforms offer the same features. Williams’ mother must phone in refill requests for certain prescriptions, and subsequently, call the pharmacy to ensure the script went through. For patients who have a portal to refill prescriptions (as well as their care providers that leverage real-time benefit check and Electronic Prior Authorization), the refill process is much more efficient and smoother.
Kim-Paglingayen says that, while technology offers an opportunity to help seniors better manage their medications, it may not be a suitable choice for every member of the golden-years community.
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“There are tech-savvy elders who have a list of their medications and dosages in their smartphone ‘note’ section,” says Kim-Paglingayen. “But most elders I know would rather have a handwritten list in their wallet or note pad that they bring along with them to the hospital or the clinic.”
In cases where a patient’s medication list is unclear, Kim-Paglingayen’s staff usually places a call to the patient’s family, pharmacy, or PCP for collateral information. However, there are times when phones come in handy, as she says some patients come in with pictures that they took of their pill bottle.
Ultimately, using technology depends on the patient’s reception, comfort level, and access to specific resources.
“Depending on the person, apps and online resources can be a great tool to keep patients engaged in their own health care,” says Triboletti.