Nursing Care and Medications in Older Persons

Medications in Older Persons

     Due
to increased life expectancy, older age is associated with the prevalence of
multiple comorbidities (eg, congestive heart failure, chronic obstructive
pulmonary disease, diabetes mellitus), which often necessitate life-long and
multiple medication intake. 

    Consequently, older people are the largest
consumers of medication. Polypharmacy is worrisome in the elderly because of
the increased risk for adverse events. Furthermore, polypharmacy may result in
nonadherence to the therapeutic regimen, a factor found to be associated with
poor outcomes in view of physical and psychological health. 

    Adherence needs to
be monitored as a clinical parameter during each clinical encounter. Evaluating
older person’s capabilities and risk-factors for successful management of the
medication regimen should be part of a thorough geriatric assessment as a
cornerstone of chronic illness management. 

    Nurses play an important role in
this assessment and assist older persons and their families in the management
of and adherence to their medication regimen.

Older People as a Large Population in Health Care

    Older
people are the largest per capita consumers of medications. Several
international studies show that persons older than 65 years account for 15%-18%
of the population, but consume 40%-50% of prescribed drugs (Klauber, 1996; Linjakumpu
et al., 2002; Swafford, 1997). 

    Prevalence of polypharmacy increases with higher
age and number of concomitant comorbidities (Linjakumpu et al., 2002; US Agency
for Health care Research and Quality, 1996). In two recent large-scale studies,
it was noted that 11%-25% of older people use five or more medications
simultaneously (Chen, Dewey, & Avery, 2001; Linjakumpu et al., 2002).

Polypharmacy and View of Health

    Polypharmacy
is worrisome in view of the increased risk for adverse events as this may be
associated with poor outcomes in view of poor physical and psychological
health. 

    It has to be noted that, secondary to higher age or multiple chronic
diseases, older persons are most vulnerable to pharmacokinetic,
pharmacodynamic, and homeostatic changes (Raik, 2001). These changes make them
particularly sensitive to adverse events, interactions, and toxicity of
medications. 

    Older persons are also at greater risk for inappropriate
prescribing. The average clinician often lacks sufficient knowledge regarding
possible drug interactions. In addition, a lack of information regarding
medication prescriptions: ordered by other providers serves as a significant
factor in increasing the complexity of the therapeutic regimen. 

    Every new drug
added to the medication regimen will increase the risk for adverse outcomes
(Raik).

Prescribed Medication

    Suboptimal
use of prescribed medications is often associated with unplanned
hospitalizations among the chronically ill: 28.1% of visits in an emergency
department were due to medication-related visits, and 63.35% of hospital admissions
due to drug reactions could have been prevented (McDonnell & Jacobs, 2003). 

    Furthermore, the risk of medication mishaps is higher in the older population
due to errors in self-administration, caused in part by visual and cognitive
impairment, illiteracy, high medication costs, the complexity of the medication
regimen, duration of treatment, and /or side effects of the medications (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) corresponds
with the agreed recommendations of a health care 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), numbers that are very similar to those of younger
populations. 

    Nonadherence with drug treatment is highly prevalent in all
chronic patient populations among different age groups and is not more prevalent
in older normally aging persons, as is sometimes wrongly stated.

Non Adherence to Outcomes

    Because
nonadherence has been found to be associated with poor outcomes, adhesion needs
to be monitored as a relevant clinical parameter during each clinical
encounter. Clinicians can use direct as well as indirect methods to assess
adherence with medication regimens. 

    Direct methods refer to assay of
medication, medication by-products or tracers in bodily substances (eg,
digoxin, phenobarbital), and observation of medication administration. Indirect
measurement methods are self-report, collateral report, prescription refills,
pill-count, and electronic event monitoring. 

    Yet there is no gold standard to
evaluate adherence with a medication regimen, as all methods have specific
drawbacks in view of underestimating nonadherence or the lack of revealing
medication-taking dynamics. Electronic event monitoring (EEM) has emerged as
the most valid and reliable method to date.     

EEM consists of a pill bottle
fitted with a cap that contains a microelectronic circuit. The date and time of
each bottle opening and closing are recorded as a presumptive dose. 

    Recorded
data can be downloaded to a computer that lists and graphically depicts
individual medication taking dynamics. Indirect, electronic event monitor ring has
superior sensitivity compared to other direct and indirect methods, as it
allows assessment of noncompliance at a continuous level and in a
multidimensional manner (De Geest, Abraham, & DunbarJacob, 1996).

Processes Associated with Older Persons

    A
number of processes associated with aging may negatively influence older
persons” ability for independent and correct medication management and
prevent adherence. 

    Knowledge of risk-factors for nonadherence will allow
identification of older patients at risk for inadequate medication management.
Modifiable factors can be targeted for Adhesion enhancing interventions A
selection of factors with special relevance for the older population will be
discussed next.

Aging as a Factor 

    Aging
is associated with decline in auditory, visual, cognitive, and functional
capacities. It can be more difficult for older persons 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 according to their color. Nineteen percent of persons
aged 70 years and older have visual impairments, including blindness; one third
have hearing impairments (Desai, Pratt, Lentzner, & Robinson, 2001). 

    Labels
may be misread and colors of pills may not be recognized. Reading difficulties
with regard to prescription labeling was not significantly related to
nonadherence in seniors, although 38.8% were not able to read all the
prescription labels and 67.1% did not fully understand all information (Maison,
Gaudet, Gregorie, & Bouchard, 2002), admittedly restricting options for
adequate medication management.     

    Older persons have to be aware of the intended
effect of the medication, how to administer it, possible side effects, and
other relevant aspects of the medication regimen. A significant proportion of
the older population has inadequate or marginal functional health literacy,
making it difficult to process the health information and instructions given to
them.

Cognitive Decline and Aging 

    Although
cognitive decline is associated with aging, in the absence of
pathophysiological decline such as Alzheimer disease, cognitive functioning of
older persons is normally sufficient to independently manage their own
medication regimen (Park et al., 1999). 

    Forgetfulness is a common reason for
nonadherence in older persons; however, severe cognitive impairment most
compromises patients’ abilities to independently manage their treatment
regimen. Cognitively impaired persons are more likely to receive assistance
with medication management compared to cognitively intact subjects (Conn,
Taylor, & Miller, 1994).

Treatment Associated with Aging 

    Treatment-related
factors such as duration, complexity, and cost of medication regimens can also
negatively affect adherence. Medication restriction, ie, taking less
medications than prescribed, is common in seniors who lack prescription
coverage, particularly among certain vulnerable groups (Steinman, Sands, &
Covinsky, 2001). 

    The fact that many older persons live alone and are relatively
socially isolated deprives them of necessary social support and places them at
risk for depression, both of which are known risk factors for medication
nonadherence (De Geest, von Renteln-Kruse, Steeman, De Graeve , & Abraham,
1998).

Compliance Enhancing Interventions

    Compliance-enhancing
interventions should be built on the available empirical evidence of modifiable
risk-factors and intervention studies. 

    Evidence shows that compared with
single, generalized, and short interventions, multifaceted, tailored, and
continuous interventions result in improved medication adherence (Haynes,
McDonald, Garg, & Montague, 2003; Peterson, Takiya, & Finley, 2003;
Roter et al. al., 1998; Van Eijken, Tsang, Wensing, de Smet, & Grol, 2003). 

    This implies a combination of educational, behavioral, and social support
strategies tailored to the specific situation of each individual older person
and his family within a biopsychological care paradigm. 

    Furthermore, it is
important that older patients and their families are seen as partners in the
development of tailored and multifaceted medication management interventions.

Successful Management 

    Successful
management of medication regimens in older persons requires an understanding of
the risks associated with polypharmacy and specific factors associated with the
aging process that put patients at risk for nonadherence. 

    Interventions aiming
at supporting older persons and their families with regard to medication taking
further should be multifaceted and tailored along the continuum of chronic
illness management.