US Pharm. 2011;36(4)(Compliance & Adherence suppl):3-5.
It is no surprise that, given the advances in drug development, improvements in vaccination, and innovations in health care, people are living longer. In 1980, the average life expectancy for women and men living in the United States was 77 years and 70 years, respectively.1 These numbers have increased: U.S. women are now expected to live to 80 years of age, and men to 75 years of age.1
By definition, a geriatric population includes patients aged 65 years and older.2 In 2011, the first of the baby-boom generation turns 65, increasing the geriatric population by 30% each year from now until 2050.2 This is important for pharmacists because geriatric patients account for the majority of prescription drug use.3 In fact, 20% of patients aged 65 years and older take at least 10 medications daily.3 As the number of medications increases, the potential for adverse drug events (ADEs) increases also.4 ADEs in elderly patients include weight loss, falls, declining cognitive function, and loss of independence; in the worst-case scenario, ADEs are the cause of approximately 10% of hospital admissions in this population.5 Although there may be numerous causes to consider in the development of an ADE, 85% of preventable ADEs occur at the time of prescribing, thereby presenting an opportunity for pharmacist intervention.6
There are three things the pharmacist can do to help improve a geriatric patient’s adherence to therapy. First, the patient’s medication list must be reviewed for appropriateness. Second, medication therapy management (MTM) may be employed. Finally, the pharmacist can collaborate with the patient to choose an effective adherence strategy.
Assessing Appropriateness
The practice of evidence-based medicine requires that providers adhere to treatment guidelines when caring for their patients. For example, it is well established that a patient with heart failure will benefit from treatment with a beta-blocker, ACE inhibitor, diuretic, and, in some cases, digoxin.7 If the patient also has been diagnosed with diabetes, prescriptions for a sulfonylurea, metformin, aspirin, and a statin may be added.8 Hence, if treatment guidelines are followed, it is not uncommon for a geriatric patient with multiple coexisting conditions to have a medication list containing 10 or more drugs.9
On the other hand, it is not unusual for a provider to avoid prescribing certain medications to a geriatric patient for fear of a negative outcome.9 For instance, studies have shown that warfarin is often underprescribed in elderly patients despite its proven efficacy for stroke prevention in this population.10 One study found that only 45% of patients aged more than 80 years who were hospitalized for atrial fibrillation were discharged with warfarin.10 Although these patients had two or more risk factors for embolic stroke, their physicians hesitated to prescribe warfarin because of concerns about falling and hemorrhage.10
In reviewing an elderly patient’s medication list, the pharmacist should not ask, “Is this patient on too many/few medications?” Instead, the question should be, “Is this patient taking the appropriate medication?”9 A tool used to determine a medication’s appropriateness for elderly patients is the Beers List.11 Because randomized, controlled trials on medication use in the elderly are rare and data are limited, Dr. Mark Beers and a panel of geriatric-care experts developed a consensus document in 1991 to offer guidance where explicit criteria were lacking.12 The Beers List, which was updated in 2003, has been adopted by the Centers for Medicare & Medicaid Services for nursing home regulation.11 The Beers List includes 48 medications that generally should be avoided in patients aged more than 65 years because they either are ineffective or pose an unnecessarily high risk when safer alternatives are available.11 The list also names 20 disease states in which certain medications should be avoided.11 TABLE 1 offers an abbreviated version of the Beers List, including only high-severity medications.11
One might assume that using the Beers List when making treatment decisions will reduce ADEs. Unfortunately, there is no prospective research showing that this is the case.13 However, a systematic review of health care outcomes associated with the Beers List found that inappropriate medication use was associated with increased hospitalization in the community setting.13 Therefore, until a causal relationship between the list and improved outcomes is proven, it must be assumed that the Beers List is helpful, but not perfect. There are medications on the list that may be necessary for some patients (e.g., short-term benzodiazepines for insomnia), while the list omits some medications that probably should be included (e.g., atypical antipsychotics, which carry a black box warning for dementia patients). The bottom line is that common sense must be used when applying the Beers List to patient care.
Managing Medications
In the management of elderly patients, it is easy to get caught up in the details of optimizing the medication list and forget about assessing adherence.9 However, as Dr. C. Everett Koop stated, “Drugs don’t work in patients who don’t take them.”14 Adherence to a medication regimen is defined as “the extent to which patients take medications as prescribed by their healthcare providers.”14 It has been reported that up to 50% of older patients have problems adhering to at least one of their medications.9
Surprisingly, advanced age alone is not a predictor of nonadherence.15 Many factors contribute to nonadherence, including cognitive impairment, medication side effects, the regimen’s complexity, and the patient’s skepticism about the benefits of treatment. All of these factors should be considered in the management of geriatric patients.14,15
Patients are hesitant to admit to providers that they are nonadherent, whereas providers may not be able to recognize nonadherence without being told.9,14 This is where the pharmacist can play an important, albeit underutilized, role in patient care. Although there is no gold standard for medication review, a brown-bag review of a patient’s medications offers insight into his or her medication-taking behavior.9 (In a brown-bag review, a patient brings all of his or her prescription and nonprescription medications to the pharmacist for evaluation.9) During the review, the pharmacist can ask the patient about side effects, missed doses, and therapy effectiveness, and then intervene as necessary to improve the patient’s adherence.9
Taking the brown-bag review one step further, MTM is a formalized method in which a review of medications is performed by a pharmacist or other trained health care professional.16 By definition, MTM includes the provision of education about prescribed medications, improvement of medication adherence, and detection of adverse drug reactions or improper medication use.16 In 2013, legislation will go into effect mandating that all Medicare Part D participants to receive MTM; prescription drug plans also will be required to reimburse the provider of the MTM service.17
Advocating Adherence
It makes sense for pharmacists to perform MTM for elderly patients, since the addition of a pharmacist to the health care team has been shown to improve outcomes. In one study, a pharmacy care program, which included standardized medication education and follow-up by clinical pharmacists, led to improved adherence and clinically meaningful reductions in blood pressure in geriatric patients with coronary risk factors.18 Similarly, another study found that consultant pharmacists’ use of MTM in an assisted-living population improved medication-related problems, as well as patient satisfaction.19 Also, interventions by clinical pharmacists have been shown to reduce inappropriate prescribing and ADEs in geriatric veterans.20
It is assumed that improved adherence will lead to improved outcomes; however, there is not an accepted value that reflects adequate adherence.14 For example, some clinical trials require an adherence rate of 80%, while clinical practice suggests that an adherence rate of 47% may be adequate.14 Regardless, poor adherence leads to worsened disease and death.14
To maximize adherence, the pharmacist should first determine which barriers are preventing patients from taking their medications properly.9 Limited dexterity presents a physical barrier to adherence.9 It has been found that 36% of elderly patients are unable to open child-resistant pharmacy bottles.21 An easy-to-open 4 x 7 compartment pillbox was reported to improve compliance in a majority of the elderly patients studied.22 Other compliance aids to consider for ease of medication administration include oral dosing syringes, insulin syringe magnifiers, and spacers for inhalers.9
A psychiatric barrier to adherence is the patient’s attitude toward his or her medication.23 In a small study, patients with a positive attitude who felt that their medications were beneficial were more compliant than those who felt that their medications were of no merit.23 In such cases, the pharmacist should educate the patient about medications, disease states, and associated goals of therapy.9
It is easy for patients with a complex medication schedule—in which multiple doses are taken throughout the day—to forget to take some of their doses.14 Therefore, the simplest dosing schedule should be prescribed for elderly patients.22 The use of long-acting medications, if clinically appropriate, is an option for decreasing the complexity of the regimen and the pill burden.9 Medication organizers and containers with reminder alarms are useful tools for reminding patients to take their medicine, although one study concluded that elderly patients preferred the simplicity of a pillbox over an electronic reminder.22,24
Finally, the cost of medications must be considered in relation to adherence, for even patients with adequate prescription drug coverage are faced with a financial burden when they must take multiple medications.9 Pharmacists are not responsible for controlling drug costs; however, they can offer patients generic substitution, help them apply for prescription-assistance programs, and help them choose a Medicare Part D prescription plan.9 Data do not support the efficacy of one adherence approach over another.14 Therefore, a combination of patient education, family and caregiver support, and use of an acceptable adherence aid tailored to the patient’s needs will be most effective.
Conclusion
The management of geriatric patients takes time. Clinical experience shows that it works best to start the medication review process with medication reconciliation. Lists of the patient’s diagnoses and his or her medications should be made. If there is a mismatch (e.g., a medication is ordered for a condition the patient does not have), it is prudent to alert the treatment team. If a medication is missing (e.g., in opioid medication use, when the patient lacks orders for a bowel regimen), the ordering physician must be contacted. If a patient is taking a medication that is on the Beers List (e.g., oxybutynin), it behooves the pharmacist to investigate the reason for the medication before automatically recommending discontinuation.
Performing MTM services is impossible if insufficient time is allotted. Therefore, it is best to schedule an appointment for the patient to come in when he or she will not be picking up a prescription. Time permitting, the pharmacist might offer to fill a patient’s pillbox at monthly intervals. Assistance from pharmacy students and pharmacy residents makes this overwhelming task much more manageable.
Because of their accessibility, pharmacists are in the perfect position to encourage adherence in an elderly population. With administrative support, the cooperation of the interdisciplinary treatment team, and the agreement of pharmacy staff, working with geriatric patients to improve compliance is possible and can be highly rewarding.
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