« The Dual Agenda: April 2, 2015 Issue

Eldercare Voices

Medication Management Issues in Caring for Older Adults

Joseph T. Hanlon, PharmD, MS, BCP

Many older adults have multiple medical conditions, so it is not surprising that over 40 percent use four or more prescription medications. Of potential concern, is that as more medications are added to a person’s regimen, there is greater potential for unexpected new interactions. The result is that adverse effects may start to manifest, decreasing rather than adding to overall well-being. In addition, a growing list of medications can make adherence difficult, due both to the overall costs and the complexity of managing them. Good geriatrics practice includes a frequent, careful review of all prescribed and over-the-counter medications. This review may identify medications no longer indicated, important drug-drug or drug-disease interactions, and newly-indicated medications that are not yet prescribed. Medication reviews are particularly important for the frail, older adult on multiple medications and for adults with advanced illness. Careful consideration needs to be given to side-effects that become more relevant with advancing age, such as any medication that may affect alertness or balance, as the risk of falls becomes more significant over time. 

In the past decade, the concept of deprescribing for older adults has emerged due to a greater emphasis on trying to optimize quality of life, especially when the accrual over time of numerous chronic conditions increases the complexity of medication management. Deprescribing can be defined as the process of tapering, withdrawing, discontinuing or stopping medications to reduce multiple medication use. While each prescription was medically indicated, and made sense when originally prescribed, each needs to be revaluated continually with advancing age, and/or the addition of subsequent prescriptions. In caring for patients who are in very advanced stages of serious illness, and planning for end-of-life treatment, it is essential to identify unnecessary drugs that were once helpful, but that do not help make the dying patient feel better or more comfortable, in keeping with principles of palliative care.

To start this process, older patients, sometimes with the help of their family or friends, need to visit their primary care physician and bring with them all the prescription and nonprescription medications they are taking, in their original bottles and packages. He or she can ask the physician to review the medications to see if some can have the dosage reduced, or be discontinued entirely. Typically, the physician, sometimes in concert with a nurse or pharmacist, will consider the risks versus the benefits of continuing on the existing regimen. Experts have begun to agree that some medications such as blood thinners, anti-dementia medications, drugs to reduce cholesterol and medications to prevent bone fractures can be discontinued with very advanced age and frailty. The benefit is that these patients no longer have to be burdened by taking multiple medications that can expose them to unnecessary harms, in the form of understood risks – such as increased risk of internal bleeding, in the case of blood thinners, for example – that taking medications may entail.

Health professionals should always develop a deprescribing plan in concert with the patient and, when appropriate, his or her caregiver. For many medications, one will be able to just stop taking the medication. However some others (e.g., medications to help mood or treat high blood pressure), it is necessary to slowly withdraw the medication to prevent known adverse reactions that can occur with sudden cessation. In either case, it will be important for the older adult, his or her caregiver and health professionals to monitor together certain signs and symptoms to avoid the small chance of adverse effects from stopping or decreasing a given medication. Patients and caregivers who are tapering medications should get specific written information about when to decrease the dosage and can benefit from the use of an aide, such as a daily pill box, with compartments for administering pills several times in a day. Many pharmacies that are attuned to the needs of older adults and people with complex conditions are able to package prescription and non-prescription pills together on “blister” or bubble-packed weekly organizer cards, with several distinct times clearly marked for administering medications each day, to make the regimen as simple as possible for both patients and caregivers.

If swallowing medications becomes difficult due to advanced illness, many medications can be crushed and given with apple sauce or ice cream to make them easier to take. A pharmacist should always be consulted first, since some drugs should never be crushed, such as those with a special coating to protect the stomach or time-release the drug slowly. As alternatives to swallowing pills, many medications come in a skin patch form or can be given rectally. 

For late-in-life care situations, when the focus may be shifting strongly towards pain management and comfort care, the prescribing health professional can focus on carefully adding in new medications to manage pain and non-pain symptoms such as constipation, nausea and vomiting, difficulty breathing, anxiety and depression, to make the patient’s comfort the highest goal. Probably the safest and most effective medication for treating pain is acetaminophen (e.g., Tylenol ®).  One should use medications known as nonsteroidal antiinflammatory drugs (NSAIDS) such as ibuprofen, or naproxen with great caution as they can hurt the stomach, kidneys and heart. Their use should be primarily for inflammation pain and given for the shortest time possible. For nerve pain, there are some specific medications that can be used.

A very sensitive subject is the introduction of a narcotic/opioid such as morphine for pain and comfort management. Even in hospice situations, many older adults and their family members may be understandably afraid of, or concerned about suggestions from health professionals about starting such medications, even when death is anticipated in days or weeks, and such drugs can provide great palliative benefit. Concerns about addiction with these medications in such a situation can be sensitively put into perspective through honest communication from health professionals.

Managing medications for older adults regardless of what stage of life they are in is an important part of geriatric care management and quality of life for them and their families.

Joseph T. Hanlon, PharmD, MS, BCPS,  is a Professor of Medicine in the Division of Geriatrics and Department of Pharmacy and Therapeutics at the University of Pittsburgh and a Health Scientist in the Center for Health Equity Research and Promotion and Geriatric Research Education and Clinical Center at the VA Pittsburgh Healthcare System. Dr. Hanlon is a practicing clinical pharmacist who has been working with older adults to improve their medications for over 30 years, and frequently speaks to health professional meetings and groups of older adults.