Medications in Older Persons Introduction
As life expectancy continues to rise, the aging population represents a growing segment of healthcare consumers. Older adults often face multiple comorbidities, necessitating the intake of several medications over prolonged periods. This phenomenon, known as polypharmacy, presents unique challenges for healthcare providers and older individuals alike, especially concerning medication adherence and management. This article delves into various aspects of medication management in older persons, including polypharmacy, nonadherence, cognitive decline, and compliance-enhancing interventions, and proposes strategies for successful management.
Medications in Older Persons
The increased life expectancy in the global population has resulted in a higher prevalence of chronic conditions, such as congestive heart failure, chronic obstructive pulmonary disease (COPD), and diabetes mellitus among older adults. These conditions frequently necessitate lifelong medication use, leading to the phenomenon of polypharmacy, which is defined as the simultaneous use of multiple medications.
Polypharmacy is particularly concerning in older adults due to the increased risk of adverse drug events, which can significantly impact their physical and psychological health. Additionally, polypharmacy often results in nonadherence to therapeutic regimens, further complicating the management of chronic illnesses. Consequently, monitoring adherence to medication is crucial and should be considered an essential clinical parameter in every patient encounter. A comprehensive geriatric assessment, including an evaluation of an individual’s capabilities and risk factors, is pivotal in successfully managing medication regimens.
Nurses play a vital role in this process by assisting older adults and their families in managing medication regimens and ensuring adherence to prescribed therapies.
Older People as a Large Population in Health Care
Older adults are the largest consumers of medications per capita. International studies indicate that individuals over the age of 65 account for 15-18% of the population but consume 40-50% of prescribed drugs (Klauber, 1996; Linjakumpu et al., 2002; Swafford, 1997). Polypharmacy prevalence increases with age and the number of coexisting comorbidities (Linjakumpu et al., 2002; US Agency for Healthcare Research and Quality, 1996). Recent large-scale studies report that 11-25% of older adults use five or more medications simultaneously (Chen, Dewey, & Avery, 2001; Linjakumpu et al., 2002).
Polypharmacy and View of Health
Polypharmacy poses a significant risk of adverse drug events, which can lead to poor physical and psychological outcomes. Older adults are particularly vulnerable to pharmacokinetic, pharmacodynamic, and homeostatic changes due to age or multiple chronic diseases (Raik, 2001). These changes make them more sensitive to adverse drug interactions and toxicity. Furthermore, inappropriate prescribing is more likely in older adults due to a lack of comprehensive knowledge regarding potential drug interactions and limited communication among multiple healthcare providers, leading to complex therapeutic regimens. Each additional medication increases the risk of adverse outcomes (Raik, 2001).
Prescribed Medication
Suboptimal use of prescribed medications is a common issue among older adults, often resulting in unplanned hospitalizations. It has been noted that 28.1% of emergency department visits are medication-related, and 63.35% of hospital admissions due to adverse drug reactions could have been prevented (McDonnell & Jacobs, 2003). The risk of medication errors is higher among older adults due to visual and cognitive impairments, illiteracy, high medication costs, the complexity of medication regimens, the duration of treatment, and side effects (Raik, 2001).
Adherence is defined as the extent to which a person’s behavior (taking medications, following a recommended diet, and/or executing lifestyle changes) aligns with the recommendations of a healthcare provider (Haynes, McDonald, Garg, & Montague, 2003). In persons aged 60 years or older, nonadherence with medication regimens varies from 26% to 59% (Van Eijken, Tsang, Wensing, de Smet, & Grol, 2003), similar to rates observed in younger populations. Contrary to popular belief, nonadherence is not more prevalent among older adults without cognitive impairment.
Non-Adherence to Outcomes
Nonadherence to medication regimens is associated with poor health outcomes. Thus, it is essential to monitor adherence as a clinical parameter during every healthcare encounter. Adherence can be assessed using both direct and indirect methods. Direct methods include assays of medication, medication by-products, or tracers in bodily substances (e.g., digoxin, phenobarbital), and observation of medication administration. Indirect methods include self-reports, collateral reports, prescription refills, pill counts, and electronic event monitoring (EEM).
There is no gold standard for evaluating adherence, as each method has specific drawbacks, such as underestimating nonadherence or failing to capture medication-taking dynamics. EEM, which involves a pill bottle fitted with a microelectronic circuit that records the date and time of each opening and closing, has emerged as the most valid and reliable method to date (De Geest, Abraham, & DunbarJacob, 1996). This method allows for a continuous and multidimensional assessment of noncompliance.
Processes Associated with Older Persons
Several processes associated with aging can negatively impact an older person’s ability to independently and correctly manage medications, thus affecting adherence. Knowledge of risk factors for nonadherence allows healthcare providers to identify older patients at risk for inadequate medication management and target modifiable factors for adherence-enhancing interventions.
Aging as a Factor
Aging is associated with declines in auditory, visual, cognitive, and functional capacities. These declines can make it more difficult for older adults to handle childproof caps, blister packages, or nebulizers, or to swallow large pills. Adherence to medication regimens requires, among other abilities, reading labels and distinguishing tablets by color. A significant percentage of older adults have visual or hearing impairments, which may affect their ability to manage medications effectively (Desai, Pratt, Lentzner, & Robinson, 2001). Additionally, a substantial proportion of older adults have inadequate functional health literacy, making it challenging to process the health information and instructions provided.
Cognitive Decline and Aging
While cognitive decline is associated with aging, it does not necessarily impede older adults’ ability to manage their medications independently, unless accompanied by pathophysiological conditions such as Alzheimer’s disease. Forgetfulness is a common reason for nonadherence among older adults, but severe cognitive impairment significantly compromises the ability to manage treatment regimens. Cognitively impaired individuals are more likely to require assistance with medication management (Conn, Taylor, & Miller, 1994).
Treatment Associated with Aging
Treatment-related factors such as the duration, complexity, and cost of medication regimens can also negatively impact adherence. Medication restriction, where seniors take fewer medications than prescribed, is common among those lacking prescription coverage, especially in vulnerable populations (Steinman, Sands, & Covinsky, 2001). Moreover, many older adults live alone and are socially isolated, depriving them of essential social support and increasing the risk of depression, both of which are known risk factors for medication nonadherence (De Geest, von Renteln-Kruse, Steeman, De Graeve, & Abraham, 1998).
Compliance Enhancing Interventions
To improve medication adherence among older adults, compliance-enhancing interventions should be based on empirical evidence of modifiable risk factors. Studies have shown that multifaceted, tailored, and continuous interventions are more effective in improving medication adherence than single, generalized, and short interventions (Haynes, McDonald, Garg, & Montague, 2003; Peterson, Takiya, & Finley, 2003; Roter et al., 1998; Van Eijken, Tsang, Wensing, de Smet, & Grol, 2003).
These interventions should combine educational, behavioral, and social support strategies tailored to the specific circumstances of each individual and their family within a biopsychosocial care paradigm. Furthermore, it is essential to involve older patients and their families as partners in developing tailored and multifaceted medication management interventions.
Successful Management
Successful management of medication regimens in older adults requires an understanding of the risks associated with polypharmacy and the specific factors related to aging that contribute to nonadherence. Interventions to support older adults and their families in medication management should be multifaceted and tailored to the continuum of chronic illness management. This approach will help mitigate the risks associated with polypharmacy and improve adherence, ultimately enhancing the quality of life and health outcomes for older individuals.
Conclusion
Managing medications in older adults presents significant challenges due to polypharmacy, cognitive decline, and various factors associated with aging. By understanding these challenges and implementing tailored, multifaceted interventions, healthcare providers can enhance adherence, reduce the risk of adverse drug events, and improve health outcomes for older patients. Collaboration between healthcare providers, patients, and their families is critical to achieving successful medication management in this vulnerable population.