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Medication Management in Geriatric Care
One of the side effect of aging can be the beginning of a complex medication regimen. For many, taking multiple medications can be confusing but it can also prevent adherence and create unsafe interactions. Sara Bradley, MD, and the Northwestern Medicine Geriatrics team are working to prevent medical complications that arise due to multiple medications and streamline the process for patients by taking a comprehensive approach to geriatric care.
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Learn more about Sara Bradley, MD
Sara Bradley, MD
Sara M Bradley, MD is an Associate Professor of Medicine (General Internal Medicine and Geriatrics).Learn more about Sara Bradley, MD
Transcription:
Medication Management in Geriatric Care
Melanie Cole, MS (Host): One of the side effects of aging can be the beginning of a complex medication regimen. For many people, taking multiple medications can be so confusing but it can also prevent adherence and create unsafe interactions. Here to tell us about that today is Dr. Sara Bradley. She’s an associate professor in general internal medicine and geriatrics at Northwestern Medicine. Dr. Bradley, a pleasure to have you back with us. Why is medication management so important and how many hospitalizations a year can be attributed to mismanagement of medications. Tell us just a few statistics that you can.
Sara Bradley, MD (Guest): Sure. So polypharmacy, taking more than four medicines, is very common especially in our older adults who have more medical problems and take more mediations. It’s estimated that 40% of adults over the age of 65 take at least five medications. The problem is is when you take a lot of medications, you're less likely to take those ones that really matter. Your increase risk of adverse drug reactions. Polypharmacy also contributes to things like falls and functional decline, delirium and cognitive impairment. It contributes to hospitalizations and ER visits. Anywhere from 17 to 30% of all hospitalizations are due to adverse medication errors and adverse drug events. These things can even lead to death. So if medication related problems were a disease, it would be the fifth leading cause of death in the United States.
Host: Wow. So why has adherence become an issue when you’re talking about polypharmacy? We’re going to talk a little bit about unsafe drug interactions, but where does adherence fit into this picture?
Dr. Bradley: So the more medications you take, the more complex the regimen becomes. So more medications, the less likely the patient will take those really needed medicine. About 25% of patients will stop taking medications because of cost. Another 25 to 30% will stop taking medications because they don’t think it’s useful. They don’t think it’s useful, they don’t think that they need it. They might not even discuss this with their doctor. So often we physicians don’t even have the correct medication lists for our patients. If they are stopping medications because of cough, they might skip doses. They might take a reduced dose. Things like that.
Host: Such a common problem. So also these complex medications regimen, it creates those problems, as you just said, but it also can create those unsafe drug interactions. Can you share for us some examples and situations where this really can happen, and some of the problems that taking those multiple prescriptions create because as I worry, Dr. Bradley, that the geriatric population sees so many doctors. How do they know how is prescribing what.
Dr. Bradley: Right, so there's several layers here. First older adults tend to have more medical problems. They take more medicines. But they're also at increased risk of drug events because of age related changes in physiologic mechanisms, such as decline in their kidney function and liver function. Changes as we age, unfortunately, we have decreased lean muscle and increased fat. So that changes the volume distribution of drugs in the body. The same about of a certain drug when they were younger as not a higher serum concentration or has a longer half-life, so it sticks around longer contributing to those adverse drug events. The problem with older adults is that people frequently don’t recognize these things as adverse drug events, right. Medications cause falls. They cause constipation. They cause dementia and delirium, but we don’t see that as a medication error. We just think, “Oh, it’s because the patient’s old” instead of recognizing that hey that that was something that I did as a physician that contributed to it. So frequently these adverse drug events are not even recognized.
I think you also asked about what are some common examples? Well one thing that we frequently see is guidelines do change over time. Patients, for instance with diabetes, have been working so hard. Have very tight control of their sugar. We now know that [inaudible] control as you get older can actually more dangerous and increased risk off falls and death. So maybe when someone’s 85, they need actually less diabetes medicine then they did when they were 55. So really trying to reduce and scale back on some of these medications to try to prevent some of this adverse drug events. Similar to blood pressure medicines. Blood pressure tends to get higher as well get older, but sometimes people’s blood pressure starts to drop and they can actually reduce their blood pressure medicine because, if we’re giving them too much medicine, again their blood pressure could go low, they become lightheaded, they fall. So always readdressing the need for the medications. Many of the studies that we use to guide our treatment of disease, the studies did not include older adults. Certainly not older adults with multiple medical problems who are on multiple medicines. So often we don’t really even know how to apply the current guidelines to someone who is 85 with multiple medical problems and multiple medications.
Host: What a great point. As things change and as these guidelines change, it can be confusing to anybody. So tell us about your team’s approach to medication management for your patients. Tell us about your comprehensive approach to care and some strategies that you use with your patients to help them manage multiply medications.
Dr. Bradley: So first we have a social worker who sees all of our new patients, and she does a wonderful job of asking about things like cost of medications. Can patients afford their medicines? Are there resources we can give them to help them with that? Asking them about what kind of assistance they have at home. How do they take their medications correctly and safely? Do they use a pill box? If the patient has memory loss, who’s filling that pill box? Who’s reminding them to take their medicines? So asking them about that structure.
Then we physicians in our practice really try to do a medication reconciliation at every visit. I always stress to my trainees if the only thing you do with a frail older adult is check the medication and making sure what we think they're taking is what they think they're taking; what their pharmacist thinks they're taking. That’s so important. Always looking at that medication list and saying, “Are there any high risk medications here that I'm concerned about? Are there any medicines that I don’t think the patient really needs anymore or that we might be able to decrease or stop all together?” Always looking for ways to reduce that medication list.
For example, sometimes patients are taking over-the-counter medicines that they think are relatively benign, and actually have a lot of danger. For instance, Benadryl. So Benadryl is an anti-histamine that many people will think oh, it makes me sleepy. That’s safe to take at nighttime. Actually it has a lot of anticholinergic side effects that are dangerous especially with age causing constipation, urinary retention, confusion, and even falls. Another example is proton pump inhibitors. So medicines like Nexium or Prilosec that we take for acid reflux, right? We think that these medicines are benign, but when we take them for a long period of time they can cause decline in our bone mineral density and cause kidney dysfunction and can contribute to increased risk of infection such as C. diff, a diarrheal infection, or pneumonia and that sort of thing.
Host: So wrap it up for us Dr. Bradley. What would you like other providers to know about implementing effective medication management procedures for seniors, the importance of medication management because of everything we’ve discussed here today?
Dr. Bradley: Well, the number one thing I would say is do a medication reconciliation at every visit. Whenever you're starting a new medication, we always say in geriatrics to start low and go slow. If you were gonna give a certain dose in a younger patient, you give half that dose in an older adult patient and increase it slowly. Always assess the need for all medicines. Think about is there anything we can get rid of, can we stop, can we taper. Always consider drug side effects could be the cause of a geriatric syndrome. Always keep in mind who the patient is and their personal preferences as well.
Host: That’s great information. Thank you so much Dr. Bradley for joining us again. That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. For more information on the latest advances in medicine, check out nm.org to get connected with one of our providers. If you found this podcast as informative as I did, please share on your social media. Share with other providers that way we can all get involved and learn from the experts at Northwestern Medicine together. Don’t miss all the other fascinating podcasts in our library. Until next time, I'm Melanie Cole.
Medication Management in Geriatric Care
Melanie Cole, MS (Host): One of the side effects of aging can be the beginning of a complex medication regimen. For many people, taking multiple medications can be so confusing but it can also prevent adherence and create unsafe interactions. Here to tell us about that today is Dr. Sara Bradley. She’s an associate professor in general internal medicine and geriatrics at Northwestern Medicine. Dr. Bradley, a pleasure to have you back with us. Why is medication management so important and how many hospitalizations a year can be attributed to mismanagement of medications. Tell us just a few statistics that you can.
Sara Bradley, MD (Guest): Sure. So polypharmacy, taking more than four medicines, is very common especially in our older adults who have more medical problems and take more mediations. It’s estimated that 40% of adults over the age of 65 take at least five medications. The problem is is when you take a lot of medications, you're less likely to take those ones that really matter. Your increase risk of adverse drug reactions. Polypharmacy also contributes to things like falls and functional decline, delirium and cognitive impairment. It contributes to hospitalizations and ER visits. Anywhere from 17 to 30% of all hospitalizations are due to adverse medication errors and adverse drug events. These things can even lead to death. So if medication related problems were a disease, it would be the fifth leading cause of death in the United States.
Host: Wow. So why has adherence become an issue when you’re talking about polypharmacy? We’re going to talk a little bit about unsafe drug interactions, but where does adherence fit into this picture?
Dr. Bradley: So the more medications you take, the more complex the regimen becomes. So more medications, the less likely the patient will take those really needed medicine. About 25% of patients will stop taking medications because of cost. Another 25 to 30% will stop taking medications because they don’t think it’s useful. They don’t think it’s useful, they don’t think that they need it. They might not even discuss this with their doctor. So often we physicians don’t even have the correct medication lists for our patients. If they are stopping medications because of cough, they might skip doses. They might take a reduced dose. Things like that.
Host: Such a common problem. So also these complex medications regimen, it creates those problems, as you just said, but it also can create those unsafe drug interactions. Can you share for us some examples and situations where this really can happen, and some of the problems that taking those multiple prescriptions create because as I worry, Dr. Bradley, that the geriatric population sees so many doctors. How do they know how is prescribing what.
Dr. Bradley: Right, so there's several layers here. First older adults tend to have more medical problems. They take more medicines. But they're also at increased risk of drug events because of age related changes in physiologic mechanisms, such as decline in their kidney function and liver function. Changes as we age, unfortunately, we have decreased lean muscle and increased fat. So that changes the volume distribution of drugs in the body. The same about of a certain drug when they were younger as not a higher serum concentration or has a longer half-life, so it sticks around longer contributing to those adverse drug events. The problem with older adults is that people frequently don’t recognize these things as adverse drug events, right. Medications cause falls. They cause constipation. They cause dementia and delirium, but we don’t see that as a medication error. We just think, “Oh, it’s because the patient’s old” instead of recognizing that hey that that was something that I did as a physician that contributed to it. So frequently these adverse drug events are not even recognized.
I think you also asked about what are some common examples? Well one thing that we frequently see is guidelines do change over time. Patients, for instance with diabetes, have been working so hard. Have very tight control of their sugar. We now know that [inaudible] control as you get older can actually more dangerous and increased risk off falls and death. So maybe when someone’s 85, they need actually less diabetes medicine then they did when they were 55. So really trying to reduce and scale back on some of these medications to try to prevent some of this adverse drug events. Similar to blood pressure medicines. Blood pressure tends to get higher as well get older, but sometimes people’s blood pressure starts to drop and they can actually reduce their blood pressure medicine because, if we’re giving them too much medicine, again their blood pressure could go low, they become lightheaded, they fall. So always readdressing the need for the medications. Many of the studies that we use to guide our treatment of disease, the studies did not include older adults. Certainly not older adults with multiple medical problems who are on multiple medicines. So often we don’t really even know how to apply the current guidelines to someone who is 85 with multiple medical problems and multiple medications.
Host: What a great point. As things change and as these guidelines change, it can be confusing to anybody. So tell us about your team’s approach to medication management for your patients. Tell us about your comprehensive approach to care and some strategies that you use with your patients to help them manage multiply medications.
Dr. Bradley: So first we have a social worker who sees all of our new patients, and she does a wonderful job of asking about things like cost of medications. Can patients afford their medicines? Are there resources we can give them to help them with that? Asking them about what kind of assistance they have at home. How do they take their medications correctly and safely? Do they use a pill box? If the patient has memory loss, who’s filling that pill box? Who’s reminding them to take their medicines? So asking them about that structure.
Then we physicians in our practice really try to do a medication reconciliation at every visit. I always stress to my trainees if the only thing you do with a frail older adult is check the medication and making sure what we think they're taking is what they think they're taking; what their pharmacist thinks they're taking. That’s so important. Always looking at that medication list and saying, “Are there any high risk medications here that I'm concerned about? Are there any medicines that I don’t think the patient really needs anymore or that we might be able to decrease or stop all together?” Always looking for ways to reduce that medication list.
For example, sometimes patients are taking over-the-counter medicines that they think are relatively benign, and actually have a lot of danger. For instance, Benadryl. So Benadryl is an anti-histamine that many people will think oh, it makes me sleepy. That’s safe to take at nighttime. Actually it has a lot of anticholinergic side effects that are dangerous especially with age causing constipation, urinary retention, confusion, and even falls. Another example is proton pump inhibitors. So medicines like Nexium or Prilosec that we take for acid reflux, right? We think that these medicines are benign, but when we take them for a long period of time they can cause decline in our bone mineral density and cause kidney dysfunction and can contribute to increased risk of infection such as C. diff, a diarrheal infection, or pneumonia and that sort of thing.
Host: So wrap it up for us Dr. Bradley. What would you like other providers to know about implementing effective medication management procedures for seniors, the importance of medication management because of everything we’ve discussed here today?
Dr. Bradley: Well, the number one thing I would say is do a medication reconciliation at every visit. Whenever you're starting a new medication, we always say in geriatrics to start low and go slow. If you were gonna give a certain dose in a younger patient, you give half that dose in an older adult patient and increase it slowly. Always assess the need for all medicines. Think about is there anything we can get rid of, can we stop, can we taper. Always consider drug side effects could be the cause of a geriatric syndrome. Always keep in mind who the patient is and their personal preferences as well.
Host: That’s great information. Thank you so much Dr. Bradley for joining us again. That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. For more information on the latest advances in medicine, check out nm.org to get connected with one of our providers. If you found this podcast as informative as I did, please share on your social media. Share with other providers that way we can all get involved and learn from the experts at Northwestern Medicine together. Don’t miss all the other fascinating podcasts in our library. Until next time, I'm Melanie Cole.