Medication Use and Older Adults

A brown paper bag may hold the key to safer use of medications, according to health experts.

"A 'brown bag checkup' is the single best thing that patients can do to avoid medication mistakes and cut down on unnecessary medications," says Douglas Paauw, M.D., professor of medicine at the University of Washington in Seattle. "But I would estimate that only about 10 percent of people actually do it."

The checkup involves putting all of your medications and over-the-counter products in a brown paper bag and bringing them into your doctor's office. The bag should include any over-the-counter or prescription drugs, herbs, vitamins, dietary supplements, and topical treatments such as ointments and creams. "This kind of checkup is a good idea for anyone who takes medication, but particularly for older people who are the most likely to be taking several medications," Paauw says. The average 75-year-old has three chronic conditions and uses five prescription drugs, according to a report from the Merck Institute of Aging & Health.

Researchers at Pennsylvania State University found that when adults ages 65 to 91 were asked to bring in the brown paper bag containing their medicines, the list of medications in the bag was more complete than their official pharmacy records. And people with worse health consistently had poorer matches between the brown bags and the paperwork.

"If not a paper bag, then write out a list and bring that in," Paauw says. You could also share the information with your pharmacist, who can check for drug duplications, interaction problems, inappropriate dosing, and whether each drug is being given for the right indication.

The idea is to have at least one health care professional informed about everything that you take. "This should be done at least every year and preferably more often," Paauw says. "Some of my patients do it at every visit."

When the bottles and tubes are spread out on the table, the picture becomes clear. "When someone pulls out 10 bottles, then something might not be right and we can make adjustments," Paauw says. The doctor can also see that your multivitamin with iron is the reason your thyroid treatment isn't working. "Both iron and calcium supplements can interfere with the absorption of thyroid medicine," says Paauw, who gave a talk on common drug errors at the annual meeting of the American College of Physicians in April 2006.

Stephen Setter, Pharm.D., associate professor of pharmacotherapy at Washington State University in Spokane, says doubling up on therapy is another common problem. "Someone may be taking two products containing acetaminophen," which raises the risk of liver damage. Other common problems include expired medications and medications that are no longer needed, but were never reevaluated.

After you and your doctor settle on what you should be taking, then the next thing is for you to know the name of your medication and what it's for, says Karen Gunning, Pharm.D., associate professor of pharmacy practice at the University of Utah in Salt Lake City. "If an older person has memory problems or difficulty with comprehension, a family member or caregiver could help," Gunning says.

Setter cites an example in which one of his older patients mistakenly thought her glaucoma medication was for treating headaches. "So she was taking her eye medication only when she had a headache, but she should have been taking it every day to treat her eye disease," Setter says. Experts say that it's important to understand your medications because you are more likely to take the medicine correctly, more likely to know what to expect from the medication, and better able to report what you are taking to your doctors and pharmacist.

"Keep the list of medications in your wallet and let a family member know that you have it," Gunning suggests. "Patients should be able to take that list out at the dentist's office, an appointment with a specialist, or in an emergency," she says. "But it's not uncommon for an older patient to come to the hospital and say that their doctor gave them a white pill and that's all they know."

John Lowery, 87, Delphi, Ind., carries his medication list in his wallet, keeps it on his computer at home, and gives a copy of it to his primary care doctor every time he sees her. His oldest son, 65, lives nearby and also knows about the list.

Sticking With the Plan Setter, a pharmacist who helps older people manage their lives at home, says he often discovers that patients stray from their medication plan and that their doctor isn't aware of it. "I've seen a person's blood pressure go up because the patient hasn't been taking the medication, but the doctor thinks the drug isn't working," Setter says. "So a second medication is added or the dose is increased when the problem is really a compliance issue." Setter says that when this happens, he contacts the doctor and talks with the patient to reinforce the importance of two-way communication.

Robert Ferguson, M.D., chief of internal medicine at Union Memorial Hospital in Baltimore, says that intentional noncompliance with the regimen typically occurs because the patient can't afford the medicine or is worried about side effects. "When noncompliance is unintentional," Ferguson says, "it's usually because complying with the regimen became too difficult. It's so complex that it's too hard to keep it up."

Ferguson says he teaches medical residents that the regimen should be as simple as possible and effective, and should result in minimal side effects. "Sometimes, we can reduce the number of medications by treating two problems with one medication," Ferguson says. There also are ways to make the schedule simpler such as switching from a medicine that's given three times a day to another medicine that can be given once a day.

You can make sticking to a schedule easier by attaching the medications to meals or other daily activities. Lowery says this works for him. "The three medications that I need to take in the morning go on top of the refrigerator and I have them with breakfast," he says. "I take the others at night before bedtime."

For more complicated regimens, pill boxes with compartments can help. Pill boxes are also useful for people who have trouble opening pill bottles. Setter says, "You can ask for pre-filled pill boxes or request bottles without child-proof caps if no children live in or visit the home." Pharmacies usually charge a nominal fee for pre-filled pill boxes.

Everything from gadgets that beep to simple medication charts posted on the refrigerator can serve as reminders. "For some people, we color code the medication bottles or use a big picture of the sun to signal morning medications," Setter says.

Setter says he talks with many older people who are confused about the purpose of the drug and the instructions. "The typical scenario is that a patient has three new prescriptions and had to wait in the pharmacy for 30 minutes, so they just want to get the prescriptions filled and go," he says. "Health providers need to speak more slowly and take the time to explain, which can be a challenge," Setter says. "And patients should ask questions. But people get intimidated and don't want to ask or they feel like they don't have time to ask questions." Writing questions down is always a good idea, Setter says. "Family members and caregivers can help with this."

Examples of questions to ask about a new medication: What should I do if I forget a dose? Should I take the medicine before, during, or after meals? What should the timing be between each dose?

With some diseases, people may stop taking medication because they don't understand why they are taking it or don't feel that it helps. "But we don't want people to stop taking an osteoporosis drug and then have a fracture a year later," Setter says. "And with a diabetes drug, we are hoping to prevent blindness, amputation, and kidney disease."

Lowery, who has survived a heart attack and kidney failure, says he is diligent about managing his medications because he feels they improve his quality of life. From the pills that ease his joint pain to the drops that soothe his dry eyes, medications help him stay active. "I keep up a garden and go to bluegrass music festivals," Lowery says. He also visits Helen, his wife of 66 years, every day at the nursing home.

Managing Side Effects Most medication side effects are mild and may lessen over time. But if they are bothersome, you should discuss them with your doctor. The doctor may switch to a different drug or change the dose. "Neither patients nor physicians should shrug off side effects by chalking them up to old age," Setter says. "And side effects shouldn't be treated with more drugs."

Compared with younger people, older people can be more likely to experience some side effects, Ferguson says. Side effects may also be more troublesome than they would be for someone younger. There are no absolutes here. Some robust 85-year-olds can handle a medication better than a 50-year-old who has a lot of health problems. But generally, older people have a decline in liver and kidney function, which affects the way a drug is broken down and removed from the body. "The kidneys decline about 1 percent each year starting at age 40," Ferguson says. "Medication stays in the body longer and side effects can have bigger consequences in older people."

Examples of side effects that may affect older people more than younger people are dizziness, dry mouth, drowsiness, falls, depression, insomnia, nausea, and diarrhea. David Greeley, M.D., a neurologist at Northwest Neurological Institute in Spokane, says the effects of sedating antihistamines such as diphenhydramine can be disastrous in older people.

Diphenhydramine is commonly found in over-the-counter sleep aids such as Unisom Sleep Gels, Tylenol PM, and cold and allergy medicines such as Benadryl. Greeley says, "Whereas a younger person can take it at night and feel back to normal by morning, the medication can linger in the system of someone older, which may result in falls and confusion."

Paauw says diphenhydramine can also affect a man's prostate gland. "An older person who already has trouble urinating can end up in the emergency room with urinary retention," he says.

Another example is the drug Mirapex (pramipexole), a treatment for Parkinson's disease, for which there is an increased risk of hallucinations in people older than 65 compared with people younger than 65. "Quinolone antibiotics may also cause hallucinations," Paauw says. Examples of quinolone antibiotics include Cipro (ciprofloxacin), Levaquin (levofloxacin), and Floxin (ofloxacin).

In 2005, the Food and Drug Administration warned the public about the use of certain drugs called atypical antipsychotic drugs. The drugs are approved to treat schizophrenia and mania, but clinical studies of the drugs to treat behavioral disorders in older patients with dementia showed a higher death rate associated with their use when compared with patients receiving an inactive pill (placebo). The advisory applies to these antipsychotic drugs: Abilify (aripiprazole), Risperdal (risperidone), Zyprexa (olanzapine), Geodon (ziprasidone), Seroquel (quetiapine), and Clozaril (clozapine). Symbyax (olanzapine and fluoxetine), which is approved to treat depressive episodes associated with bipolar disorders, was also part of the advisory. The causes of death in older patients were varied, but most appeared to be related to the heart or pneumonia.

Reducing Errors Setter says that older adults sometimes inadvertently receive an initial dose of medication that's too high. "The dose may be totally appropriate for a younger adult," Setter says, "but with the aging process, an older adult is less able to tolerate the typical starting dose."

Health care providers try to find a balance that gives older people appropriate medications and appropriate doses. Experts say the philosophy has always been "start low and go slow" with dosing for older people because there are not enough clinical trial data in this age group for many drugs, especially in people ages 75 and older.

And because of the use of multiple medications, drug interactions are of concern. "Some interactions aren't necessarily harmful and can be easily managed," Setter says. "We want to prevent drug interactions that are dangerous."

Improving the knowledge base about how drugs work together is helpful, Setter says. "We have clinical guidelines that address individual diseases like Alzheimer's disease, Parkinson's, or diabetes. But there is a need for clinical guidelines with a geriatric slant--guidelines that can apply to a person who may have five co-existing diseases."

Drug-drug interactions occur when a drug may increase the effect of another drug or render it ineffective. Paauw says interactions involving warfarin (Coumadin) are the most common ones that result in hospitalization. Warfarin, a medication that thins the blood and helps prevent clots, is commonly prescribed to older people with an irregular heartbeat (atrial fibrillation) who are at risk of blood clots that can cause strokes.

Warfarin should not be taken with aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs because of the increased risk of gastrointestinal bleeding. Warfarin also interacts with the antibiotic Bactrim (sulfamethoxazole), which is commonly used in older people. This combination can result in severe increased bleeding. The supplements Ginkgo biloba, garlic, ginger, and ginseng can also interact with warfarin.

Many interactions can be prevented with more communication between doctors and patients, as well as better coordination between all the health care professionals who see a particular patient, says Nicole Brandt, Pharm.D., director of clinical and educational programs at the Peter Lamy Center for Drug Therapy and Aging in Baltimore. She and her colleagues are partnering with a managed care system to study medication management in older patients who have been discharged from five hospitals. As part of the study, a pharmacist visits newly discharged patients to conduct a medication evaluation.

"The goal is to create a more integrated social and health care support system to improve adherence and reduce errors," Brandt says. "Ultimately, we want to decrease readmissions to the hospital."

Sarah Ray, Pharm.D., ambulatory clinical coordinator of pharmaceutical services at Aurora Health Care in Milwaukee, says that technology is increasingly playing a role in improving patient safety. "We'll notice if patients are discharged from the hospital on a different dose than what they were on when they were in the hospital or before entering the hospital," Ray says. "I then have to clarify with the doctor, and the prescription may have been written incorrectly." Ray says she's able to catch that kind of error because she works in an integrated health care system and has access to computerized information about what the patient was taking in the hospital. But that kind of error might not be caught at an independent pharmacy that does not have access to hospital records.

Ray says she thinks electronic prescribing will make a big difference in reducing medication errors. Electronic prescribing allows doctors to transmit prescriptions to pharmacies electronically. This method decreases errors caused by hard-to-read handwriting and automates the process of checking for drug interactions and allergies. The Medicare Prescription Drug Improvement and Modernization Act of 2003 established standards for electronic prescribing. Final standards will be set by the U.S. Department of Health and Human Services no later than April 2008.

By Michelle Meadows
FDA Consumer Magazine
July-August 2006

Reviewed by athealth on February 5, 2014.