Medication

As we get older, physiological changes can affect our metabolism, making it more likely that we will experience adverse reactions and side effects from medications. With age, we are more likely to have multiple medical conditions and be taking multiple medications, which puts us at higher risk of falls, delirium, hospital admissions, declining nutritional status, decreased physical and social functioning and death.

The ability to manage complex medication routines is influenced by a person’s level of social support and connectedness, with lower levels of support being associated with higher medication use.¹ If we understand a patient’s circumstances we can help them to manage their medications successfully.

Up to 30 per cent of hospital admissions for patients over the age of 65 are medication related and half of these are potentially preventable.²

This topic gives an overview of issues around medication use in older people. It recommends actions that we and our organisations can take to ensure older patients have an effective medication regime that they can manage.

In addition to following your health service specific policy and procedures, consider the recommended actions and discuss them with colleagues and managers.

Medication and ageing

“Medicines…have the potential to provide great gains as well as significant harms to older people” ¹

Physiological changes can cause adverse reactions

Medicines can be problematic for older people because as we age physiological changes can affect the way our body absorbs, distributes, metabolises and eliminates drugs. These physiological changes include increased body fat, decreased body water, decreased muscle mass, and changes in renal and liver function and in the Central Nervous System. These changes can cause adverse drug reactions (ADRs) in older people.

Frail older people are more likely to have pronounced changes in response to medicines. Generally, medications in frail older people aim to control symptoms and help maintain function.

For older people there can also be a higher risk of unintended consequences of medical treatment (iatrogenesis) related to medication.

Polypharmacy increases risk of adverse events and errors

As people age they are more likely to be taking several medications, including prescribed medications, over the counter or complementary medicines.

Taking multiple medications – known as ‘polypharmacy’ – increases the risk of medications being implicated in hospital admissions, particularly when an older person presents with falls, confusion or incontinence³. Polypharmacy can cause problems due to prescribing errors, problems with taking the medicines, and interactions of medicines.

When people take multiple medications, they are at greater risk of:

• falls and associated harms, such as fractures
• dehydration
• functional decline
• cognitive impairment
• delirium
• declining nutritional status
• adverse drug reactions
• hospitalisation
• mortality⁴.

Also, the more medications a person takes, the greater the risk of medication errors. These errors may be due to difficulty in getting an accurate medication history and review, in prescribing and in following complex medication regimes.

An average of five to seven medication changes are made during the hospitalisation of an older person⁵, which also increases the risk of prescribing errors and adverse drug events.

Hospital admissions can be related to medications

It is estimated that up to 30 per cent of all hospital admissions of people aged 65 years and over are medication-related, and approximately half of these could be prevented⁶.

Medication-related admissions in older people can be caused by:

• ADRs
• failure to receive or take a prescribed medication
• errors with taking medications.

Identifying medication risks and issues

Identifying people at risk

A patient is considered at risk of medication issues if they:

• are aged over 65 years
• take five or more medicines
• have conditions that are commonly associated with preventable medication-related hospital admissions – such as asthma/COPD, depression, cerebrovascular event, hip fractures, renal failure, acute confusion, bipolar disorder and hyperkalaemia¹.
• are identified as at risk of falls or have decreased mobility – some medications can alter balance and coordination
• have a cognitive or sensory impairment – the patient may not be able to follow medication instructions
• are identified as at risk of under-nutrition – nutrition and hydration play a major role in the absorption of medications
• are identified as at risk of incontinence – some medications may cause continence problems
• are identified as at risk of delirium – some medications can cause delirium
• are identified as at risk of depression – apathy may impact on the patient’s ability to take medications accurately
• manage their own medications and live alone or are socially isolated. They may be taking medications inaccurately, or they may have difficulty in accessing medication or seeking support regarding their medication. Conversely, social connectedness helps with medication adherence.²
• have been recently discharged from hospital - this is a high risk time for medication errors due to the number of medication changes that are typically made during a hospital stay
• have poor literacy or are from a non-English speaking background - this may impact on their understanding of how and when to take medications and what they are for.

Assessment can inform medication management

If a person is identified as being at risk of or as experiencing medication issues, we need to refer them to the pharmacist and treating doctor for a comprehensive assessment. This will inform our intervention plan. In addition, start by completing a Best Possible Medication History.

Best Possible Medication History (BPMH)

This is a complete medication history that should be taken for each patient identified as being at an increased risk of issues with medication management.

Obtain information for the BPMH by interviewing the patient and a family member or carer.

Collect the following information for the BPMH:

• current dosing schedules
• duration of treatment
• current indications
• allergies and ADRs (including a description of the reaction)
• current levels of adherence (the extent to which a patient follows the agreed instructions or recommendations for taking a medication as given by the health care provider).

Confirm the information through other sources, such as the patient’s medicine containers and medication list, their family (particularly if the person is quite unwell, has a cognitive impairment or receives assistance from someone to take their medications), GP, community pharmacy and other health services.

Medication reconciliation

To avoid errors in transcription, check that all of the medications the patients should be taking are what they are actually taking.

Repeat this process on admission, discharge and transfer of care between healthcare settings, for example, from the Emergency Department to the General Medical Ward.

To reconcile medications prescribed:

• verify against medicines ordered on the medication chart
• compare to admission, transfer and discharge orders
• resolve any discrepancies with the prescriber.

Reviewing the medications list

When complete, the medications list should be reviewed to focus on medications that are associated with the development of geriatric syndromes.

Targeting medications with the highest risk of causing injury could prevent more adverse drug events and emergency department visits.^1,2,3 These medications include Warfarin, Insulin, Digoxin, narcotics, opiates and sedatives. If an older person is taking any of these medications, discuss them with the treating doctor and refer to the ward pharmacist for further assessment. Along with the team’s clinical judgment, use the prescribing appropriateness criteria and the STOPP/START tool to minimise inappropriate prescribing during the review process.

Optimising medication use

Medication safety is improved and errors decrease significantly when strategies are put in place to increase the accuracy of medication history taking and medication reconciliation⁸.

There are several things we can do to support an effective and easy to manage medication regime for older people while they are in hospital.

Document medication information

Keep detailed records of medication to monitor for changes to the older person's baseline Best Possible Medication History (BPMH).

The records should include:

• BPMH
• medication reconciliation
• key information about each medicine (drug name, dose, form, frequency, duration)
• patient compliance/adherence issues
• support for managing medications, for example carer and family help the patient manage medicines; the patient collects medicines in a medicopak/webster pack from community pharmacy
• risk factors
• medicines recently ceased
• allergies and adverse drug reactions
• plans to continue, cease or change medicines during the patient’s episode of care, which can be used to inform the discharge summary and prescriptions at time of discharge.

Medication information tools

The following tools for documenting and sharing medication information can be used to reduce prescribing, dispensing and administration errors.

• Medication Management Plan (MMP) – use this standardised form to ensure complete and accurate documentation of medication information on admission and throughout the episode of care⁹.
• National Inpatient Medication Chart (NIMC) - is an evidence-based, best practice suite of nationally standard medication charts. The NIMC enables information to be communicated consistently between health professionals¹⁰. Use of the NIMC is a mandatory requirement for health service organisations seeking accreditation against NSQHS Standard 4.

Deprescribing

Deprescribing is reducing the dosage or discontinuing a medication with the aim of reducing the risks associated with polypharmacy and improving quality of life¹¹.

Talk to the patient, the doctor and pharmacist about the possible benefits of deprescribing and consider it after a thorough medication review when¹²:

• there is a risk of polypharmacy
• the patient is experiencing adverse drug reactions
• the treatment has been ineffective
• the patient has experienced a fall
• the patient's treatment goals have changed.

Approach deprescribing with caution, as there are both risks and benefits. Focus on improving quality of life, reducing risks and alleviating symptoms. Ensure that this is a shared decision with the patient¹⁰.

When considering deprescribing, the nursing, medical and pharmacy teams will:

• weigh up the benefits with the potential adverse consequences
• target patients with highest Adverse Drug Event risk
• target non-beneficial medications
• target drugs known to do harm or are inappropriate
• set a discontinuation regime and ongoing evaluation (ideally with the same clinician)
• set shared goals with the patients and provide education, as it can be daunting for patients and families to discontinue medications they have been taking for many years.

Balance the risks and benefits of medications

Medication use in older people involves balancing disease management with avoiding adverse events.

Discuss the risks and benefits of each treatment with the patient.

Consider how treatments may affect the patient’s care goals, such as maintaining physical function and independence.

Consider how medications may impact on the person’s quality of life.

Medication and discharge planning

As discharge can be an overwhelming time for patients and families, there is high risk for medication errors and misunderstandings. We can help patients make a smooth transition from the hospital to their home or care facility by providing comprehensive and clear information.

Prepare a discharge summary

Discharge summaries should include:

• a comprehensive discharge medication list
• detailed medication information (generic medication name, dosage form, dose, directions, route of administration, regular and PRN medication)
• indication and duration for new medication
• explanation of any changes that may have been made to their usual medications (differences to pre-admission medications)
• details of ongoing medication management plan and medication management needs (issues with taking the medications, recommendations for home medication reviews).

Educate patients and carers

• Provide the patient, and family and carers with an accurate list of medications
• Educate the patient and family and carers prior to discharge, including
  • proper storage and use of medications – demonstrate where possible
  • what to do if a dose is missed
  • potential side effects
  • when to call the GP or pharmacist about any concerns
  • refill information.
• Provide a written copy of all information that is given verbally.
• Consider what strategies will assist the patient to take their medication properly.
• Ensure the patient is able to follow medication instructions.
• Sometimes, pharmacists in hospitals can arrange a medication trial. This is a good way to see if the patient can take their medications independently before they are discharged home.
• Some Victorian hospitals have a pharmacy outreach service that can visit patients at home after discharge to review their medication management, provide education and facilitate continuity of care. These services do not require a GP referral. Link the patient to this service if needed. This is especially important if the patient lives alone and is socially isolated.

Make medication use simple

• Medication regimens should be as simple as possible – ideally with once or twice daily dosages.
• Medication instructions and dosages should be clearly written.
• Consider if the patient would benefit from the use of dose administration aids (DAAs), such as monitored dosage boxes. Remember that DAAs are not suitable for all patients, for example, patients with cognition impairments, vision impairments or limited dexterity. Assess the need and suitability first¹³.

Simplify medication supply

• Ensure the patient has enough medications to last to their next GP visit.
• Encourage the patient and their family and carer to:
  • always carry an up-to-date list of medications
  • use only one pharmacy and visit only one GP.
• Synchronise medication quantities so the patient can make repeat orders at the same time.

Inform the GP

• Ensure discharge information is accurate and reaches the GP in a timely manner.
• Provide the following information to the GP:
  • medication changes and the reasons why
  • need for follow up or review
  • need for a GP-initiated Home Medicines Review (HMR). Commonwealth Government-funded HMRs must be initiated by the patient’s GP and carried out by an accredited pharmacist.

Inform the pharmacy

Ensure discharge medication information is provided to the patient’s community pharmacy, especially if a pharmacy-packed DAA will be used after discharge.

Inform the care services

If the patient is being discharged to a residential aged care facility or a community nursing service, ensure that a medication chart will be available to facilitate continuity of medication administration (usually this requires provision of an interim medication chart from the hospital).

Practice person-centred care

Medicine safety is best achieved in partnership with older people and the risk of error is greatly reduced with patient involvement. Older people place great importance on maintaining independence in self-management of medicines and have a strong sense of responsibility for this¹⁴.