Recommendations for the elderly, their caregivers, and health professionals
As people age they face growing health problems, mainly from chronic diseases (such as hypertension, diabetes and cancer, among others) that require ongoing treatment. Since these conditions tend to occur simultaneously, polypharmacy i (the consumption of multiple drugs by one patient) is almost unavoidable, which can lead to an increase in unwanted or dangerous interactions. In addition to these risks, problems may arise due to changes in body, possible errors of improper prescription and self-medication.
To prevent these complications, pharmaceutical services should provide differentiated care to older adults to contribute to better treatment, either through promoting their participation or through special pharmaceutical care.
Actions for older adults to help ensure differentiated careii
- Make a list for your physician of all the drugs that you routinely or occasionally take.
- Tell your physician or pharmacist about any condition that may affect your ability to take certain drugs, such as allergies, heart attack, hypertension, acute heart disease, or liver or pulmonary problems.
- Ask questions and try to clarify any doubts you may have.
- Whenever possible, request information in writing.
- Organize your prescription drugs so you know where they are, what they are, and when to take them.
- Periodically review your medications and discard those that have passed their expiration date.
- Access to drugs may be restricted due to cost and sometimes older adults cannot afford to pay for their medication. Older adults can discuss their concerns about cost with their doctor so that the doctor can prescribe a less expensive drug, such as a generic. The patient can also inquire if there are any special national discount policies for the elderly. Another good practice is to look for a pharmacy that provides good service at a reasonable price.
Actions of pharmaceutical service professionals to minimize problems with drug consumption in older adults:
Pharmaceutical service professionals play an essential role in helping older adults minimize the problems arising from drug use. Tanziiii suggests ten recommendations for elderly care, based on the most common difficulties. These recommendations, adapted to the reality of the Americas, are:
1. Minimizing patients' confusion. Although many older patients do not have any physical or cognitive impairment, some have problems with hearing, vision, or speech. In order to minimize confusion for older patients, offer simple, step-by-step instructions and present directions in a positive manner. In addition, always repeat instructions and give patients ample time to respond before moving to the next step. Speak slowly in a low-pitched tone to patients with a hearing impairment. Offer large-print labels and materials to patients with a visual impairment.
2. Medication Appropriate Index (MAI). The Medication Appropriate Index is a tool used by a geriatrician or clinical pharmacist to assess the suitability of a prescription in an older patient, using ten criteria.iv Because polypharmacy is a concern in this patient population, pharmacists can use the MAI to determine if duplicate medications can be discontinued or to identify drugs with complicated dosing schemes that can be simplified.
3. Apply the Beers criteria. Pharmacists should review medication lists thoroughly to ensure that older patients are not receiving agents on the Beers list,v which includes muscle relaxants, antispasmodics, antihistamines, and other medications that have the potential to produce adverse effects such as sedation and impaired driving. The list also includes amphetamines and anorexics because these drugs have the potential for causing dependence, hypertension, angina, and myocardial infarction.
4. Reduce fall risk. Some medications can cause sedation and weakness, which may increase the risk of falling in older patients.vi Pharmacists should review medication lists to identify these agents and attempt to discontinue them or recommend safer alternatives in this patient population. In addition, educate patients on fall prevention tips such as wearing suitable, removing home hazards such as electrical or telephone cords from walkways, securing loose rugs, and adding light to living spaces to highlight objects that may be in the patient's way.
5. Avoid anticholinergics. Most medications with anticholinergic effects should be considered inappropriate for older patients. These agents produce effects such as dry mouth, constipation, and blurred vision, and in more serious cases can result in tachycardia, cardiac arrhythmias, urinary retention, and confusion. Review medication lists to identify these agents and attempt to discontinue them or recommend safer alternatives.
6. Antipsychotics and dementia. Data have shown that use of second-generation antipsychotics in older patients with dementia-related psychosis is associated with an increased risk of death, primarily related to cardiovascular or infectious complications.vii Pharmacists need to screen medication profiles carefully to determine if patients using antipsychotics are also being treated for dementia. If so, contact their attending physician to discuss this risk.
7. Anticoagulant considerations. Patients older than 75 years have an increased risk of bleeding with anticoagulant therapy, and data indicate that older patients may be more sensitive to the effects of warfarin.viii Ensure that lower initial doses of warfarin (3–5 mg/day) are used in older patients to prevent over-anticoagulation. In addition, educate patients receiving anticoagulation therapy about their increased risk of bruising and bleeding.
8. Over-the-counter (OTC) concerns: Agents with anticholinergic effects and those that increase the risk of bleeding can be dangerous for older patients. If older patients purchase antihistamines or nonsteroidal anti-inflammatory drugs (NSAIDs), for example, educate them on why these agents are dangerous and recommend safer alternatives. Since older patients tend to be polymedicated, potential interactions should be investigated, to avoid or minimize their effects, for example, by adapting the dosage scheme.
9. Packaging: If the packaging does not have child-safety devices, patients should be educated on proper storage and the importance of keeping the medication out of children's reach. In addition, older adults may need support in handling some packaging or distinguishing different medications without making mistakes.ix,x
10. Look-alike and sound-alike drugs: Patients should be alerted by pharmacists on the existence of different drugs that look alike or whose names sound alike.xi,xii Special care should be given to those products most commonly used by older adults.
Links of interest:
- World Health Organization, Rational Use of Drugs
- Pan American Health Organization, Pharmaceutical Services Based on PHC
i Brazil, Ministério da Saúde, Secretaria de Atenção Básica, Departamento de Atenção Básica. Cadernos de Atenção Básica no 19: Envelhecimento e Saúde da pessoa idosa. Brasília-DF: Ministério da Saúde, Brazil; 2006.
ii FDA, (Food and Drug Administration). As You Age...A Guide to Aging, Medicines, and Alcohol. Silver Spring: FDA; 2010; Available at: http://www.fda.gov/Drugs/ResourcesForYou/ucm079522.htm.
iii Tanzi MG. Ten tips for counseling older adults. Pharmacy today [serial on the Internet]. 2011; 17(11): Available at: http://www.pharmacist.com/AM/TemplateRedirect.cfm?template=/CM/ContentDisplay.cfm&ContentID=273622
ivRibeiro AQ, Araújo CMdC, Acurcio FdA, Magalhães SMS, Chaimowicz F. Qualidade do uso de medicamentos por idosos: uma revisão dos métodos de avaliação disponíveis. Ciência & Saúde Coletiva. 2005;10:1037-45.
v Aparasu R, Mort. Inappropriate prescribing for the elderly: beers criteria-based review. The Annals of Pharmacotherapy. 2000 March 1, 2000;34(3):338-46.
vi Hamra A, Ribeiro MB, Miguel OF. Correla√ß√£o entre fratura por queda em idosos e uso pr√©vio de medicamentos. Acta Ortop√©dica Brasileira. 2007;15:143-5.
vii Jeste DV, Blazer D, Casey D, Meeks T, Salzman C, Schneider L, et al. ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with Dementia. Neuropsychopharmacology. 2008;33:957-70.
viii Torn M, Bollen WLEM, Meer FJMvd, Wall EEvd, Rosendaal FR. Risks of Oral Anticoagulant Therapy With Increasing Age. Archives of Internal Medicine. 2005;165:1527-32.
ix van Geffen EC, Meuwese E, Philbert D, Bouvy ML. Problems with Medicine Packages: Experiences Reported to a Dutch Medicine Reporting System. The Annals of Pharmacotherapy. 2010 June 1, 2010;44(6):1104-9.
x Atkin PA, Finnegan TP, Ogle SJ, Shenfield GM. Functional Ability of Patients to manage Medication Packaging: A Survey of Geriatric Inpatients. Age and Ageing. 1994 March 1, 1994;23(2):113-6.
xi Filik R, Purdy K, Gale A, Gerrett D. Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion. Hum Factors. 2006;48(1):39-47
xii Hoffman J, Proulx S. Medication errors caused by confusion of drug names. Drug Saf. 2003;26(7):445-52.