October 03, 2016
Older patients account for about a third of all inpatient care, but they are involved in approximately half of hospitalizations marred by adverse drug events, according to the US Department of Health and Human Services. The elderly offer unique medication safety challenges, partly because of the sheer number of agents they take and the natural physiological effects of aging. Dr. Zaldy S. Tan, the director of the UCLA geriatric workforce enhancement program and associate chief of the division of geriatric medicine at UCLA’s David Geffen School of Medicine, recently spoke with us about the issues health care professionals face when caring for the elderly, and how breaking down communication barriers between is one of the keys to reducing the risks of drug-drug interactions in this challenging patient population.
PLN: Why is it difficult to manage medication use in older patients?
Dr. Tan: Many elderly patients are on numerous medications, and studies show that the more medications patients take, the higher the risks of drug-drug interactions and medication-related complications. Renal and hepatic metabolisms are inefficient in older individuals, so drugs might not clear as quickly as they do in younger individuals. Compliance with prescribed therapies is also an issue, and it’s a multifactorial problem. Elderly patients are prone to more drug-related adverse events, and therefore are more likely to skip a dose or to stop therapy all together because they don’t like the associated side effects. Many older patients are also on a fixed, limited income and may not take medications as frequently as they should or chose to not take medications at all, because they want to save money. Finally, a lot of older patients have some degree of cognitive impairment, which may impact their abilities to take prescribed therapies as directed, or they may not have the health literacy younger people have in terms of being proactive about their medications and questioning or assessing the drugs they’re taking. The elderly must be empowered to take ownership in their own care and in managing the medications they’re prescribed.
PLN: Do prescribers fully appreciate the problem of medication-related issues among the elderly?
Dr. Tan: General physicians often don’t appreciate the enhanced effects medications have on their older patients. But that’s only part of the issue. Caregivers at home hesitate to intervene when they suspect their loved ones are having issues with medication compliance. A lot of medication-related risks are missed because prescribers don’t grasp the potential dangers as much as they should, and caregivers aren’t equipped to manage medication use of family members.
PLN: What adverse events can polypharmacy cause in elderly patients?
Dr. Tan: We often see older patients being started on anticholinergic medications, such as oxybutynin for urinary incontinence. They then have related side effects—dry mouth or constipation—which lead to poor tolerance. We also often see patients on blood thinners being started on antibiotics, commonly to treat urinary tract infections or pneumonia, which can lead to bleeding and supratherapeutic anticoagulation. Over-the-counter nonsteroidal anti-inflammatory drugs can cause gastritis and, if combined with a blood thinner, could lead to catastrophic gastrointestinal bleeding.
PLN: Is a lack of overall communication among providers to blame for some of these medication-related issues?
Dr. Tan: That’s part of the issue. Medical record systems don’t typically communicate with each other, and not just between hospitals and outpatient clinics, but also with pharmacies. Points of care have their own medication databases that are inaccessible to providers in different locations. That’s why at UCLA we emphasize the use of brown bag medication reconciliations, one pill bottle at a time, to determine exactly which medications patients are taking, and what they’re taking them for. We find that some patients are prescribed medications they shouldn’t be on or are on therapies they should have stopped long ago.
PLN: What role can health-system pharmacists play in ensuring safe medication delivery to elderly patients?
Dr. Tan: Many electronic health records have systems that remind prescribers of potential drug interactions are quite helpful. But in the bigger view, besides specific interventions, interprofessional communication needs to improve. Healthcare professionals—physicians, nurses, pharmacists, social workers—need to communicate better with each other. Medication safety is not just a pharmacy problem or a physician’s problem or a nursing problem—scopes of practice overlap. If you see something, say something. Pharmacists who suspect a patient has no understanding of the medication they’re taking or how to take it should contact the prescribing doctor. Patients fall between the cracks when health care professionals don’t feel it’s their place to voice concerns. There has to be some sort of system in place to facilitate that communication.