Factors Affecting Medication Risk in Elders

Elders consume the majority of prescription and over-the-counter (OTC) medications in the United States. Because of the aging population and individuals are living longer, often with chronic diseases that require medication therapy, it is no surprise that over 40% of elders in the community take at least five prescription medications.¹ When OTCs are included, the number of medications consumed per day often exceeds 10 or more. It is important to note that natural products (such as health foods, supplements, and vitamins) may also be consumed by this population. Yet because they are erroneously not considered medications by some, they may not be reported when an elder is questioned about medication use.

Polypharmacy

Several components contribute to the incidence of polypharmacy (use of multiple medications in a single individual). Sometimes the use of many medications is the right thing for patients to control their diseases and ensure a better quality of life. However, there are risks associated with polypharmacy. Drug interactions happen with increased frequency the more drugs that a person consumes. These interactions may include the increase or decrease in effectiveness of one drug caused by another or a more pronounced manifestation of an adverse event due to the elder taking two drugs that have a similar side-effect profile. In addition, sometimes new medications are introduced for the specific reason of offsetting a troublesome effect caused by another. Providing new medications may be appropriate, but this scenario often occurs because the problem is not recognized as drug-induced. Risk factors that contribute to polypharmacy include the use of multiple physicians with different specialties who may prescribe similar medications, the use of multiple pharmacies, inappropriate medication reconciliation upon discharge from the hospital, and the fact that elders often have multiple conditions requiring medication therapy.

Physiology and the Aging Process

Many factors are involved in the increased incidence of medication-related adverse events in elders. With aging, kidney and liver functions decline. Many medications are excreted by the kidney and metabolized, or degraded, by the liver. Therefore, changes in organ function may frequently lead to drug accumulation in the body. This accumulation may result in toxic levels of drugs. To avoid drug accumulation, it is imperative that consideration be given to modifying doses for older individuals.

Although not all of the reasons are well understood, older persons tend to be more sensitive to the effects of certain medications. Body composition (lean tissue to fat ratio) changes as we age. Changes in body composition may result in alterations in how the body distributes a medication, making more or less of the drug available to have an effect. This is true for both the desired effects and for unwanted side effects. The adage “start low, go slow” should generally be used when initiating a new medication therapy in an older person.

Elder Medication Use and Implications for the COTA

When medical records are available, COTAs should always check the medication section to determine which medications are being used. This information helps COTAs be aware of possible side effects and drug interactions that might be observed with clinical intervention. COTAs should contact the elders’ physicians and pharmacies with any medication-related concerns or questions. (Common drug-related abbreviations and definitions are listed in Table 13-1. Medications commonly used by elders are listed in Table 13-2. Note that this is not an all-inclusive listing of medications used by elders or those that may contribute to side effects. Only generic names are listed, and they should be cross-referenced with trade names when necessary.)

TABLE 13-1 Common Drug-Related Terminology

TABLE 13-2 Disease States, Medications, and Common Side Effects

Cardiovascular diseases (high blood pressure, congestive heart failure, irregular heart rhythm, chest pain, heart attack, and stroke) are common in the older population. Medications used to treat these diseases may alter a patient’s blood pressure and/or heart rate, resulting in dizziness and the potential for falls. One class of medication, the diuretics, may cause excessive urination. As such it is recommended that nighttime dosing be avoided because of the risk of falls and interruption in rest. COTAs may notice that the client needs frequent breaks during therapy to use the restroom, and that the timing of the medication dose may need to be altered to avoid this. Persons taking one or more of the medication types mentioned previously should be closely monitored during therapy for the emergence of side effects, and consideration should be given to routine monitoring of blood pressure by the COTA. In addition, many of these same clients will be using medications to treat high cholesterol. Some of these drugs may cause diffuse muscle pain when they are started, with a dose increase, or with the addition of another medication, which may increase blood levels of the former. The COTA can help identify this type of drug-induced musculoskeletal pain and see to it that it is addressed by the appropriate individual because, in some cases, the consequences of this side effect can be severe and even life threatening.

Drugs that affect the blood’s ability to clot are also frequently used in persons with cardiovascular diseases. The COTA must be aware that the client is using one of these agents as the risk of a serious bleed is increased and therapy may have to be adjusted. One sign associated with the use of these medications is easy bruising. This is not necessarily unexpected, but if the COTA believes that the amount of bruising is excessive, he or she may wish to refer the patient to have the medication therapy evaluated.

Another common complaint of elders is pain, which can be either chronic (such as arthritis pain) or short-term because of an acute injury. The use of OTC pain medications is common when elders choose to self-treat. These medications include acetaminophen, aspirin, ibuprofen, and naproxen. Commonly observed side effects associated with these agents include gastrointestinal distress (which may be a symptom of a more serious condition such as a stomach ulcer) and increases in blood pressure because some of these medications can cause fluid retention. With more severe pain, prescription medications are used. Most prescription pain medications (primarily narcotics such as codeine, hydrocodone, oxycodone, and morphine) exert their action in the central nervous system and therefore may cause dizziness, drowsiness, and confusion. These symptoms add to the risk of falls and may make successful therapeutic intervention by the COTA a challenge if the client is unable to fully participate because of cognitive impairment.

Many older persons experience a variety of psychosocial, psychiatric, and cognitive disorders. Drugs that may be used to treat such diagnoses include antipsychotics, antidepressants, anti-anxiety agents, and medications used to slow the progression of cognitive impairment, such as those used in the treatment of Alzheimer’s dementia. These medications are all active in the central nervous system and therefore have the potential to affect sensorium, alertness, and balance. Additionally, some of them may have effects on other body systems causing disturbances in sleep and bodily functions (dry eyes, dry mouth, urinary retention, constipation, elevated heart rate, and the inability to perspire). Some of the agents used to treat psychosis also cause extrapyramidal symptoms that may manifest as abnormal movements of the limbs, head, neck, and the tongue. Sometimes these symptoms can be controlled with another medication or by discontinuing the offending agent. However, other times the benefit of continuing the medication may outweigh the risk associated with developing these symptoms, and the client and COTA may need to find a way to work around them. Furthermore, use of these medications is likely to aid the COTA in working with a client when symptoms of these types of disorders are controlled.

Sleep disturbances are frequently encountered by the older person. Such disturbances include the inability to fall asleep, early morning awakening, and daytime drowsiness. Sleep-inducing medications are often used to help older persons sleep. However, it is important to note that as people age, they need fewer hours of sleep, and education of elders is necessary to help them differentiate between insomnia and the normal aging process as it pertains to sleep. Some sleep agents may cause clients to be drowsy during the morning hours, which may interfere with the therapy process. Proper sleep hygiene (going to bed and getting up at the same time each day, minimizing daytime napping, using the bed for sleep and sex only, and avoidance of caffeine and exercise late in the day) can make a large difference in the client’s ability to fully participate in therapy. If daytime drowsiness is a concern, the COTA may wish to inquire about the use of sleep agents (both prescription and OTC) to determine whether a change needs to be made.

As persons age, the diagnosis of diabetes becomes more common. Drugs used for the treatment of elevated blood glucose are associated with several side effects that may be observed by the COTA. The most common of these is hypoglycemia, or low-blood glucose. Symptoms associated with hypoglycemia include sweating, dizziness, weakness, tremor, elevated heart rate, and confusion. These symptoms may be more common if the client has not had a normal amount of food before therapy. Additionally, diabetes can cause impaired sensation in the extremities, also known as neuropathy. This can result in numbness or extreme pain and may present a substantial challenge for the COTA. It is important that therapy be tailored for elders with impaired sensation to ensure that they remain safe during therapy and in their living environment. Medications are available to help with the pain of neuropathy, and the COTA may wish to refer patients if the pain interferes with quality of life.

Although not a normal part of aging, urinary incontinence may be frequently encountered in the elderly population. Incontinence presents its own challenges such as those associated with frequent toileting and skin breakdown as a result of excessive exposure to moisture. Medications used to treat one type of incontinence, overactive bladder or “urge” incontinence, can cause a multitude of side effects similar to those mentioned as associated with the psychoactive medications (dry eyes, dry mouth, urinary retention, constipation, elevated heart rate, and the inability to perspire).

Strategies for Minimizing Medication Problems in Elders

There are multiple reasons why older adults may be at higher risk for medication problems than younger persons. It is imperative that health care providers ensure that clients can safely manage their medications. Psychiatric diagnoses, such as dementia and depression, are common in this population and may affect the client’s ability to manage drug therapy without assistance. Often the first indication that there may be a problem in this area is the inability to manage other daily tasks such as keeping good finances or managing basic household responsibilities.

The older generation is often apprehensive when it comes to questioning health care providers, and this may lead to a lack of active participation in their own care. In many cases, a medication regimen can be simplified, but if the health care provider is not asked to do this, it is unlikely to occur. Additionally, if information about medications or their side effects is not readily offered, an older person might not directly ask about such things, and this may lead to underrecognition of side effects. It is also important that clients understand why they are taking each medication and its intended purpose so that they may self-monitor for problems.

There are many reasons that clients may not adhere to a medication regimen as prescribed. Over-adherence may occur, either by mistake because clients cannot remember whether a medication has already been taken, or because they may believe that “if a little is good, more must be better.” On the other hand, under-adherence also occurs for various reasons. Avoidance of side effects may lead a client to skip doses. Additionally, if money is a concern, clients may choose to alter their regimen by deliberately taking a medication less often than recommended. Cutting pills in half and taking partial doses is another common occurrence when saving money is an issue.

Self-treatment of symptoms or side effects with OTC medications may also result in problems. Although OTC medications are available without a prescription, it is incorrect to believe that they are without risks. Drug interactions may occur with medications that have previously been prescribed. It is also incorrect to believe that “natural” products are inherently safe because they, too, may interact with other drugs and cause side effects that may be more difficult to recognize because of a lack of regulation and standardization.

Application of the Occupational Therapy Process to Self-Medication

Medication routines of clients are often not addressed by OT.² This is evident in the lack of literature on self-medication programs and OT interventions with medication routines. Medication routines are instrumental activities of daily living (IADL). According to the Occupational Therapy Practice Framework: Domain and Process (second edition), medication routines are classified as a health management and maintenance IADL.³ Thus, assessment of routines and instruction in proper use of medication should be dealt with as part of activities of daily living (ADL) routines.⁴ Participation in one’s medication routine includes obtaining medication, opening and closing containers, following prescribed schedules, taking correct quantities, reporting problems and adverse effects, and administering correct quantities by using prescribed methods.

Client Factors

Values, beliefs, spirituality, body functions, and body structures that reside within the client and may affect performance in medication routines should be analyzed by the registered occupational therapist (OTR) and COTA. This section overviews how each of these client factors can potentially impact one’s medication routine.

Sensory Functions and Pain

Visual perception skills may be required by elders who take multiple medications. Visual perception skills include color discrimination, depth perception, and figure-ground perception. Visual acuity and perception are required to distinguish between different containers of medication and to read instruction labels. If needed, glasses should be worn when elders self-medicate. Adaptations may be used to assist elders who have visual impairments (Figure 13-1). Magnifying lenses and large type or contrasting print may be helpful. For severe visual impairments, different size, different shape, or multicolor containers can be used for medication storage. Instructions for administration can be tape recorded to relay information that cannot be read. Depth perception skills are needed to obtain pills in a multipartition container. Figure-ground perception also is needed to see white pills in a white pill box. COTAs should suggest that elders use colored pill containers for white pills.

FIGURE 13-1 This magnifier device consists of a plastic cylinder in which the medication and syringe fit at each end and permits elders with visual impairments to view amounts easily.

According to the Deafness Research Foundation, there is a relationship between age and hearing loss. For example, 30% of adults who are ages 65 to 74 years and 47% of adults age 75 years and older have a hearing impairment.¹⁷ COTAs should remember this when educating elders, family members, and caregivers. The ability to hear is important for elders to understand patient education, medication dosages, and changes. COTAs should provide both verbal and written instructions when educating elders. For example, Kathy, a COTA, meets with Vladimir, who has difficulty hearing, to review his discharge program. She first checks to make sure Vladimir is wearing his hearing aid and then reviews the information in his client education packet. Kathy speaks slowly and clearly and is sitting directly at eye level with Vladimir. She also frequently asks Vladimir whether he has any questions and encourages him to repeat back to her what he understands (see Chapter 16).

Activity Demands

Medication routines involve activity demands. According to the Occupational Therapy Practice Framework, activity demands are “aspects of an activity, which include the objects and their properties, space, social demands, sequencing or timing, required actions and skills, and required underlying body functions and body structure needed to carry out the activity” (p. 638).³ Aspects of activity demands include the following:

Table 13-3 offers examples of activity demands typically involved in medication routines.

TABLE 13-3 Activity Demands and Examples Related to Medication Routines

Occupational Therapy Process

According to the Occupational Therapy Practice Framework,³ evaluation, intervention, and outcomes comprise the process of occupational therapy. Evaluation includes the occupational profile and analysis of occupational performance. Intervention constitutes the plan, implementation, and review. Finally, the outcomes are the determination of success of the desired outcomes. The following outlines the process as applied to medication routines.

The occupational profile is “the initial step in the evaluation process that provides an understanding of the client’s occupational history and experiences, patterns of daily living, interests, values, and needs. The client’s problems and concerns about performing occupations and daily life activities are identified, and the client’s priorities are determined” (p. 646).³ COTAs often assist in gathering information from the client during the profile. Questions and items to be used as part of the occupational profile related to medication routines include the following:

Depending on the issues that arise from the occupational profile, the therapist may determine to analyze the person’s performance related to the medication routine. Analysis of occupational performance is “the step in the evaluation process during which the client’s assets, problems, or potential problems are more specifically identified. Actual performance is often observed in context to identify what supports performance and what hinders performance. Performance skills, performance patterns, context or contexts, activity demands, and client factors are all considered, but only selected aspects may be specifically assessed. Targeted outcomes are identified” (p. 646).³ For example, a therapist may suspect that the elder’s grip strength is insufficient to open a medication container and thus test grip strength using a dynamometer or asking the person to open his or her medication container(s). Based on the analysis of occupational performance, the therapist is able to plan intervention.

The intervention plan consists of “a plan that will guide actions taken and that is developed in collaboration with the client. It is based on selected theories, frames of reference, and evidence. Outcomes to be targeted are confirmed” (p. 646).³ For example, the therapist may use a rehabilitative frame of reference and focus on the person’s abilities and compensate for disability. Thus, the therapist may decide that the person’s grip strength is not sufficient to open childproof medication containers and has the client practice opening a container that is not childproof. The therapist may provide information on how to request such containers for future prescriptions. This action is the intervention implementation, or the “ongoing actions taken to influence and support improved client performance. Interventions are directed at identified outcomes. Client’s response is monitored and documented” (p. 646).³ The therapist will then review “the implementation plan and process as well as its progress toward targeted outcomes” (p. 646).³ The following section addresses ideas for medication intervention with elders.

Assistive Aids for Self-Medication

Many commercial or homemade aids can assist individuals with self-medication.¹⁹ Each aid has advantages and disadvantages.

Commercial Aids

Calendars

Calendars are helpful for tracking medication schedules. A pocket calendar or a calendar hung near the place where medication is taken can be used to mark each time medication is taken. At the end of the day, marks are counted to make sure that the medication schedule was followed. The advantage of using calendars is that the medications are stored in their original containers and remain properly labeled. Calendars are also inexpensive and readily available. The disadvantage of using a calendar is that it requires some basic reading, comprehension, and memory skills to mark the calendar each time medications are taken.¹⁹

Pill storage boxes/storage boxes

For people who take medications on a regular basis, a pill box or pill reminder is a useful item. Pill storage boxes are containers with compartments in which to put medications (Figure 13-2). Pill boxes are easy to use and can be useful to adhere to one’s medication schedule regardless of whether one is at home or traveling. Pill boxes are organized daily, weekly, or monthly. Some have the capacity to organize medications throughout the day (e.g., breakfast, lunch, and dinner). Added features such as locks or timers and alarms can be ideal when safety is a concern or when a cognitive reminder is needed. Some boxes are made to look like jewelry. There is certainly one likely to be available to suit one’s needs and style.

FIGURE 13-2 Various pill boxes are available with compartments for single or multiple daily and weekly doses.

Pill boxes require manual dexterity skills to open and close and to manipulate pills. Visual discrimination also is required to identify desired pills. Pill boxes usually do not provide tight storage for medications that require tight containers, such as nitroglycerin. In addition, the pills are no longer in labeled, childproof containers.

There are advantages and disadvantages for using daily and 7-day pill boxes.¹⁹ An advantage of a daily pill box is a better chance of taking all daily doses. Any errors made in setting up this pill box would be experienced for one day only. A disadvantage of a daily pill box is that each compartment could contain several unlabeled pills. The elder would have to identify the medication(s) by physical appearance. This is a serious safety concern if pills are similar in size, shape, or color, especially if the elder has impaired vision or is easily confused.

Weekly pill boxes store medication for 7 days. The design of some pill boxes allows the separation of multiple daily doses. These boxes often consist of four rows and seven columns. The four rows are marked with times of the day (morning, noon, evening, and bedtime), and the seven columns are marked with the day of the week. The advantage of using a 7-day pill box is that setup is required once a week only. The disadvantage is that setup requires more accuracy.¹⁹ If there is a mistake, it may occur seven times.

A pill box with an alarm is an option for elders who must take their medication at specific times. The advantage of this type of pill box is that it alerts elders of the medication schedule. A disadvantage is that elders must be able to read, understand, and follow in-depth instructions. These devices often need to be programmed and may require very fine manipulation to set the clock or the alarm. If the device breaks, repairs may be difficult and expensive. Another disadvantage is the risk of not hearing the alarm when it sounds.

Insulin holders

Insulin holders are intended for one-handed use. The device holds an insulin bottle so that a person can manipulate a syringe to obtain the proper amount of fluid. Often the device has suction cups or a nonskid surface to prevent the device from sliding on a table top.

Pill splitters

Pill splitters are useful devices when a pill must be split for proper dosage or to reduce the pill size for easier swallowing (when appropriate). Pill splitters are often lightweight and use a leverage design to reduce the amount of strength needed to use it. As previously stated, a razor blade should never be used to cut a tablet.

Pill crushers

A pill crusher is a device used to pulverize tablets into a fine powder. Similar to the design of pill splitters, pill crushers use a leverage system so that an abundance of strength is not required. Pill crushers can be beneficial when individuals have difficulty swallowing whole tablets. (Remember that not all tablets can be crushed or split.)

Talking and shaking alarms, watches, and prescription bottles

For elders who experience difficulty remembering to take their medications or what their medication routine is, several devices such as talking or shaking alarms and talking prescription bottles may be beneficial. Talking alarms are devices that are programmed to send a “beep,” voice message, or visual cue when it is time to take a medication. Shaking alarms can be clipped to the bedding to wake elders when it is time to take their medication. The device can be put in one’s pocket when in public and it will provide a quiet vibration to indicate the medication time. A talking prescription bottle is a device attached to a prescription bottle. A pharmacist or physician records the prescription information into the device. To operate, one pushes a button on the device to play a recorded message about the contents; how many pills to take, when, and what for; and any warnings. The talking prescription bottle is intended for those who have low vision or hearing impairments. It is also beneficial for elders for whom English is a second language or for elders who have difficulty reading.

Homemade Aids

Medication diary

A medication diary is another aid for tracking medication use (Table 13-5).

TABLE 13-5 Contents of a Medication Diary

Section	Information
1: Demographics	Name Date Address Phone number Date of birth Medication allergies: date of occurrence and type of reaction Vaccinations (year, date) Flu shots (year, date)
2: Health care providers	List names and phone numbers of all health care providers (tape their business cards here).
3: Past medications	List all medical conditions that required treatment with medication over the years. List all medical conditions that currently require treatment with medication.
4: Special equipment	List all adaptive or special equipment required (such as a nebulizer, ostomy products, and incontinence products). Include the brand, size, and model, and the supplier’s name and phone number.
5: Recent medications	Enter the name of new medications used, the date, the reason the medication is being used, the strength of the medication, and how often the medication is taken each day. Keep track of any dosage changes, discontinuation, the date, and the reason for the change or discontinuation.
6: Over-the-counter medications	List any over-the-counter medications used for the eyes, ears, skin, and other organs and tissues. Enter how often the medications are used.
7: Questions for health care providers	List any questions to ask the doctor or pharmacist.

COTAs may assist elders in making a diary, which can be kept in a notebook. This information can then be shared with other health care professionals, as needed.

Storage cups

Storage cups can be made at home by using small plastic or paper cups that are stacked and ordered according to the number of times the medication must be taken throughout the day. The cups should be marked in relation to when medications are taken (for example, morning, noon, dinner, and bedtime) (Figure 13-3). After the morning medication is taken, the “morning” cup is moved to the bottom of the stack. This allows the next medication dose to be on the top. This system requires that elders have good manual dexterity, visual-perceptual, and memory skills. A similar system can be made using egg cartons. For liquid or powder medications, a system can be set up using small, labeled, airtight containers. Using a homemade system is simple and inexpensive. However, using a homemade system may cause medication to be exposed to improper storage conditions.¹⁹ Also, pills in open view may tempt small children who live in or visit the elder’s home. This risk can be reduced by storing the medication out of view and reach.

FIGURE 13-3 Storage pill cups can be made at home by simply using small plastic or paper cups.

Self-Medication Program

A formal self-medication program may prevent problems with polypharmacy.² The program is designed to (1) use an interdisciplinary team approach, (2) educate elders about their medications, (3) develop elders’ motor skills for proper administration, (4) offer practice opportunities to elders, (5) assess elders for any adaptive devices that may be useful, and (6) evaluate elders’ skills in medication administration before discharge.

The elders’ intervention plan should include interventions to maximize independence with self-medication. Depending on elders’ limitations and deficits, COTAs should engage them in simulated medication tasks. An example of such a task is using small, colored candy pieces to practice color discrimination and fine prehensile patterns. Reading and comprehending general labels can aid in reading medication labels. Opening and closing medication containers should be practiced. In addition, elders should master any adaptive aids before being discharged from OT.

Relatives, friends, and home care personnel who assist in the delivery of medications often have not been included in discussions of medications.²⁰ Family and caregivers should be able to name the elder’s medications, describe the purpose of each medication, and describe any precautions associated with each medication. COTAs can refer to Box 13-1 to help educate family and other caregivers. Box 13-2 addresses safety issues for COTAs’ consideration.

Case Study

Pat is an 83-year-old woman living at home with her 85-year-old husband. Pat is currently under the care of two physicians: her primary medical physician and a psychiatrist. Pat has a recent history of falls and has significant bruising on her forehead. One of her falls occurred in the middle of the night while she was attempting to walk to the bathroom. Additionally, she complains of dizziness and pain in her knees, which affects her ability to participate in events outside of her home.

Two weeks ago Pat fell and fractured her hip. Her mental status fluctuates. Her husband is in charge of administering medications. Her problems and medications are listed as follows: