Assessing and Monitoring Medication Therapy in Seniors

The world population is older that it has ever been before,1 with the oldest old (persons aged ≥85 years) comprising the most rapidly growing segment of society.² Seniors (persons aged ≥65 years) of today are more physically fit—by nearly all objective parameters measured—than their same-aged counterparts of decades past.¹ However, seniors are more likely than younger adults to have chronic conditions and require multiple medications simultaneously.³ NPs, whether working in primary care, in a geriatrics specialty practice, or with the developmentally disabled or psychiatrically ill, have a special mission of providing care for seniors. This mission is special because elderly patients are so vulnerable in so many ways.

Vulnerability of Seniors

As humans age, particularly as they reach their sixth and seventh decades of life and beyond, they experience deteriorative changes that increase their vulnerability to all types of challenges.⁴ This increased vulnerability diminishes their ability to survive insults that they could have otherwise overcome when they were younger.⁴ For example, because of age-related physiologic changes, older persons do not metabolize medications in the same manner as their younger counterparts, and they are more susceptible to adverse drug events.⁵ This vulnerability is the basis for considering a newly manifested sign or symptom (S/S) in an older adult as potentially being caused by a medication until proven otherwise (Table 1).⁶ Assessment and monitoring of medication therapy, as an ongoing practice, is para mount in members of this age group.

The post-World War II Baby Boom in the United States began in 1946 and lasted until the early 1960s (sources vary in terms of the definition of the “end” of the Baby Boom).⁷ The first Boomers are now reaching age 65. Each day this year, from January 1, 2011 through December 31, 2011, more than 7000 individuals will turn 65 (they will turn 85 starting in 2031).⁸ Whereas the likelihood of surviving to age 65 for US males in 1900 was about 37%, and that for females was 41%, in 2005 this likelihood increased to about 79% for males and 87% for females.^5,9 Because of the increased numbers and longer life spans of Baby Boomers, the overall number of seniors in the United States is expected to skyrocket.

With each passing year, more and more evidence supports the concept that, of all the preventable health-related problems facing today’s seniors, the most important categories are those associated with pharmacotherapy.^10,11 The cost of hospital-, nursing home-, and community-associated medication-related problems (MRPs) approaches $85 billion a year.³ MRPs decrease quality of life(QoL) by affecting an individual’s cognitive and physical ability to function normally. While MRPs cost the US healthcare system billions of dollars and thousands of lives, and affect people of all ages, they occur more often and more severely in older individuals.³

To complicate matters, medication prescribing for geriatric patients is often inappropriate. But even if the prescribing is appropriate, many seniors have difficulty adhering to their regimens.⁴ (For a discussion on medication-related problems in seniors and avoiding suboptimal prescribing, see Reference 11.) Of all the challenges facing the healthcare system today, aging is clearly in the forefront, requiring effective ways to provide high-quality, cost-effective care to seniors while focusing on QoL and functional ability.⁸

Assessing and monitoring medication therapy is an integral part of this approach. Starner et al¹² recommend using a four-step method:

Step One: Determine whether MRPs are causing any S/S that patients may be exhibiting or reporting. NPs need to pay particular attention to any current medications potentially causing a geriatric problem or syndrome (Table 2).^10,12,13

Step Two: Match patients' health condition/problem list with their medication list. If a medication is identified as not matching with the problem list, then consider that the medication may be unnecessary. NPs also need to consider the converse—that patients may have a chronic condition that is not being (adequately) treated and that might benefit from use of an evidence-based medication regimen.

Step Three: Review patients' vital signs and the results of laboratory tests used to monitor the efficacy and toxicity of each medication in their regimen (Table 3).^6.12.14-18

Step Four: Assess the appropriateness of the remaining medications. Inappropriate medication selection is among the possible reasons for failure of medication regimens.

Although a variety of approaches may be used,¹⁹ Starner et al¹² described the Medication Appropriateness Index (MAI) as one tool with demonstrated reliability and validity. The MAI (see Reference 20) consists of 10 questions about each medication that a patient is using (eg, Is the dosage correct? Is there unnecessary duplication with other medications?).^12,20,21 Additional factors to consider when reviewing the appropriateness of a particular medication regimen include potential drug interactions with food (eg, ingestion of grapefruit juice can affect the metabolism of sertraline, statins, and carbamazepine) and/or laboratory test results (eg, exogenous estrogen can affect thyroid function test results) and potential problems meeting proper storage requirements for medication (eg, refrigeration).¹² Use of a drug-interaction checker may be helpful in this process (see Resources).

According to Steinman et al,²² use of inappropriate medications and underuse of medications are common in seniors taking five or more medications. Regardless of the number of medications in a patient's regimen, NPs need to be mindful of appropriate and potentially inappropriate medication use in every case.²²

Educational programs in geriatric medicine need to be improved.²³ With regard to prescribing medications for seniors in particular, nursing school curricula, continuing education programs, and clinical practicum sites need to focus on teaching about appropriate pharmacotherapeutic options, regular monitoring for adverse drug reactions, counseling techniques, low health literacy, and tips for caregivers—all with the ultimate goal of reducing MRPs in this vulnerable population. In addition, NPs are responsible for educating themselves and keeping abreast of pharmacotherapeutic concerns affecting seniors. For a discussion on the report from the Institute of Medicine calling for immediately necessary initiatives to train all healthcare practitioners in the basics of geriatric care, see Reference 24.²⁴

Aging in the United States, as well as other developed countries, is certain to be dynamic in the coming years. In this environment, NPs have an unprecedented opportunity to serve seniors. This opportunity encompasses the responsibility for prescribing safe and effective medications, including ongoing assessment and monitoring of the medication regimen.

Dr. Zagaria is a Senior Care Consultant Pharmacist and President of MZ Associates, Inc., in Norwich, NY (www.mzassociatesinc.com).

Resources

Medication Appropriateness Index: Ten questions to ask about each individual medication. See Reference 20.

Drug Interaction Checker: Explains the interaction between the chosen drug(s) and food and the level of significance (major, moderate, or minor), and can provide a recommended course of action to manage the interaction in some cases. http://www.drugs.com/drug_interactions.html.