The number of people whose lives have been saved or improved by the use of prescription medications is countless, but older adults have especially benefited. According to Holly Divine, a clinical pharmacy professor at the University of Kentucky, 75 percent of older Americans take at least one prescription medication. Among these, the majority take drugs to treat heart and kidney diseases and high blood pressure. Other commonly used prescription drugs are those that help lower cholesterol, thin blood, treat diabetes and acid reflux, and manage depression.
The benefits of medication come at a price, however, because when used improperly, medicine loses its effectiveness and can even become harmful. Older adults are at risk of over- or under-dosing for a variety of reasons, including errors on the part of physicians and/or pharmacists, patient confusion caused by having to manage too many medications, or the conscious decision not to take medications as prescribed. Interactions between prescribed drugs and diseases, food, beverages, or other substances are another major cause for concern.
Drugs also have a powerful effect on how people interact with their environments. They can contribute to sensory deprivation, mental health problems, dietary changes, and compromised immune systems. Additionally, the growing number of older adults who abuse prescription medicines means that greater vigilance from caregivers and providers is required.
An estimated 99,628 emergency hospitalizations for adverse drug events occurred each year between 2007 and 2009 among older adults, who are nearly two to four times more likely than younger persons to have adverse drug events requiring hospitalization. Yet, excluding abuse, it’s estimated that 90 percent of adverse drug reactions are preventable, according to a Merck Manual report. With a coordinated effort from patients and providers, and by combining new technologies with education, older adults can safely take medicines that perform as they are intended.
Too Much, or Not Enough
The US Food and Drug Administration (FDA) requires pharmaceuticals to undergo rigorous testing to ensure the correct dose is delivered at the right time. Medicines taken improperly not only are ineffective, but can also lead to catastrophic consequences. Older adults can require hospitalization for the wrong medication, too much of a given medication, or not enough of the medication they were prescribed.
Improper dosages of warfarin, oral hypoglycemic agents, insulins, oral antiplatelet agents, benzodiazepines, and NSAIDs are all problematic, and they often result in a patient’s hospitalization. Incorrect dosing can occur at home or at an assisted care facility; studies have shown that dosage errors are a common occurrence in nursing homes. Narcotics overdose, prevalent among younger adults, is also an increasing cause of hospitalization among seniors. Given the expected surge in chronic diseases, this information suggests greater attention should be focused toward managing antidiabetic and antithrombotic drugs.
Adverse drug effects from dosage errors don’t always lead to hospitalization. Many people live with the effects of over- or under-medicating. Ascribing their side effects to other causes, they can experience a wide variety of sometimes dangerous symptoms.
There are many causes of drug dosage problems, but the most common among them is patient error. According to a New England Journal of Medicine report, 40 percent of adults age 65 and older take between five and nine prescription medicines. Taking so many prescriptions at different time intervals (polypharmacy) is confusing, and it greatly enhances the odds of a patient making a dosage error. Compounding the problem is forgetfulness, which can be caused by dementia or confusion brought on by some drugs’ side effects.
Solutions to dosage errors require extra effort on the part of seniors and their caregivers. To help manage multiple medications, charts are available to guide the loading of pillboxes. Products that automatically dispense medicines at the correct time and dose are also available. The Philips Medication Dispensing Service, for example, can be pre-programmed to send an audio alert to a patient when it’s time to take a medication, while dispensing it at the same time.
It may not be practical to check medications at the pharmaceutical counter, but encourage patients or their caregivers to see if the medicine looks different, and if so, ask why. You can also encourage them to look at their doctor’s discharge instructions, which should always be provided, and compare what was ordered with what was filled. Later, they should count the medicines to ensure that they have the proper amount.
Dosage errors are sometimes caused by physicians and pharmacists. Communication issues lead to the majority of physician errors, while pharmacies sometimes mislabel a product or make counting errors. Through a cooperative effort among patients, physicians, pharmacists, and hospitals, provider errors can be significantly reduced. Patients should take their medicine with them when visiting their doctors. By comparing labels with what’s actually in the bottle, physicians and pharmacists can catch any discrepancies. Medical practitioners and hospitals are converting to electronic health records, which is expected to reduce provider-initiated dosage errors.
For a variety of reasons, patients may not follow medication instructions properly. The most common of these reasons include memory impairment, problems related to polypharmacy, a wariness of unpleasant side effects, or the inability to afford medications. Failure to follow medical instructions can lead to adverse effects, no matter what a patient’s intentions had been.
Because a significant number of older adults live with memory impairment, some simply forget to take their medications. To compensate, they may skip or take an extra dose. The sheer number of drugs some people have to take can present a confusing array of medications, and mistakes can easily be made. Automatic pill dispensers can address both problems.
Some people may take lower doses or none at all after experiencing unpleasant reactions to their medications. In addition, when different medications interact, their side effects can often become magnified, especially among older adults. Attributing these side effects to other causes, a significant number of patients fail to report them to their medical providers.
Many reactions are serious, even fatal. It’s imperative that older adults be carefully instructed on what side effects can occur with each medication and in combination with other medicines. Patients should notify their healthcare providers or go to the emergency room when they experience unusual symptoms.
Despite prescription drug assistance programs, some people simply can’t afford their medications. The average monthly Social Security benefit is approximately $1,200; when relying on such a small income, buying food often takes precedence over medication. The Affordable Care Act requires that all insurance carriers provide prescription drug benefits, but out-of-pocket expenses vary by plan levels. Even for seniors who have Medicare D (prescription benefits) coverage, prescription co-payments may be beyond their means.
To cope, some people divide their medications, skip doses, buy them online, or seek alternative treatments. Older adults should be informed of the consequences of resorting to these measures and be referred to programs that will help pay for their medicines. Most pharmaceutical companies provide income-based assistance, and many states have assistance programs. The Partnership for Prescription Assistance is an excellent resource for other sources, and Social Security recipients may be eligible to seek additional help. Additionally, eligible veterans can contact any Veterans Affairs hospital, and local United Way branches serve as community directories that include emergency medication assistance services offered by charities and free clinics.
Because physiological factors among older adults can vary greatly, drug interactions among seniors are an especially complex problem. Information on the interactions between all medications approved by the FDA is available on their website. Effects of interactions can range from reduced or heightened efficacy to a whole range of serious physical reactions. The American Geriatrics Society produces a handy pocket card listing medications that should not be given to older adults at all or that should be used with extreme caution.
Prescription drug interactions aren’t limited to other prescribed medicines. Certain medical conditions, foods, and beverages — especially alcohol — influence drug effectiveness. Grapefruit juice, for example, can interact adversely with a variety of medications. Interactions between prescribed drugs and those obtained over-the-counter are also common.
Older adults or their caregivers should read the printed material that comes with every prescription drug. This material includes specific interactions between medications and lists potential side effects. Other useful resources include the US Centers for Disease Control and Prevention, which maintains a website with helpful information on adverse drug effects, and the FDA website, which lists specific interactions between classes of drugs and other substances.
Medications and the Environment
Medication can dramatically impact how older adults interact with the environment and other people. An unfortunate consequence of ageism is to mistake an adverse drug effect on an older adult as an age-related problem. Depending on what medications are interacting, bodily functions can be limited or even altered. Among the many other effects, pharmaceuticals can:
- Distort vision and enhance sensitivity to light;
- Lead to hearing loss and tinnitus;
- Limit a person’s tactile sensations, especially in the extremities;
- Alter how things taste and smell, contributing to dietary problems;
- Change mood and behavior;
- Cause dizziness and vertigo, leading to an increased risk for falls;
- Render an individual immunocompromised; or
- Cause incontinence and GI issues that mimic diseases.
Addressing all of these possibilities seems daunting, but risks associated with side effects can be reduced. For starters, any new symptom an older adult experiences should be considered a potential side effect of medication. Patients should be clearly instructed on how their medicines will alter their lives and on what kinds of symptoms to expect. Adaptive technologies may sometimes be necessary — from hearing aids and canes to medications that address certain side effects. Great care must be taken, however, to avoid a prescribing cascade: when a cycle of drugs applied to treat side effects create their own problems, which in turn are treated with additional pharmaceuticals.
Prescription Drug Abuse
Although the percentage of adults abusing prescription medicines is far below the average for younger age cohorts, their rate of increase is alarmingly high. Prescription drugs most likely abused by older adults are psychoactive opioids and benzodiazepines. Alcohol greatly compounds the dangers associated with these types of medicines. According to an Administration on Aging Report, the principle risk factors for psychoactive prescription drug abuse are:
- If the patient is female,
- If the patient is socially isolated,
- If the patient has a history of substance abuse, or
- If the patient has as a mental health disorder, especially depression.
Continued use of psychoactive drugs can lead to a host of serious problems. Social interaction can turn into outright withdrawal — often mistaken for dementia — marriages can break up, and personal hygiene may decline.
Other consequences include:
- Increased risk of falling
- Memory problems
- Increased sedation
If any of these signs and symptoms present themselves, drug abuse should be considered. Prevention is the best way to combat drug abuse among older adults, making early education vitally important. Healthcare professionals can rely on an evidence-based program called SBIRT (screening, brief intervention, and referral to treatment providers) to identify and help patients with a drug abuse problem.
In addition to abuse of prescription medicines, there’s a steady increase in the use of illicit substances, especially cannabis, among older adults. In most cases, these drugs are not new to users, many of whom have developed excellent mechanisms to mask usage. Nevertheless, identifying this kind of drug use is important, as cannabis and such drugs as heroin, cocaine, and amphetamines can wreak havoc on an individual.
Educating and assisting patients and caregivers; improving communication between patients, doctors, and pharmacists; and overall heightened vigilance will go a long way toward reducing the dangers prescription drugs pose. It is imperative that healthcare workers, especially those who work directly with older adults, become familiar with the dangers of prescription and illicit drugs. Only a partnership between patients, families, caregivers, and healthcare providers will reduce the risks of medications designed to help, not hurt, older adults.