Many older adults have multiple chronic conditions that require complex medication regimens. Consequently, 50% of family caregivers report direct involvement with medication administration in the home, but with minimal support.1 Given that many caregivers are older adults themselves,1 managing these complex regimens can be difficult and stressful.
To promote medication safety and to ensure that older adults are receiving age-appropriate care, The John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States, developed the Age-Friendly Health Systems initiative. An Age-Friendly Health System implements the evidence-based 4Ms framework, which encompasses four core elements of care to be assessed and acted on: What Matters, Medication, Mentation, and Mobility. The health care team can use the framework across the health system to ensure that the plan of care aligns with What Matters to the older adult and family caregiver.2 This article, the third in a series on the 4Ms, presents strategies for assessing and acting on hospitalized older adults' medications in partnership with family caregivers, tips to help caregivers manage medications at home, and resources for clinicians and caregivers.
Older adults often have multiple medical conditions requiring multiple specialists and prescriptions. A recent national population-based study found that 36% of older adults take five or more prescription medications daily to manage chronic illnesses.3 Additionally, 38% use over-the-counter (OTC) medications and 64% use dietary supplements.3
The risk of harm from adverse drug events becomes greater with the number of medications used.4 This risk is compounded when the medications prescribed are potentially inappropriate medications (PIMs)—those known to cause harm, leading to increased hospitalizations and health care costs.5 Polypharmacy has also been associated with poor health outcomes, including hospital readmissions, lower medication adherence, and increased mortality.6, 7 (It should be noted, however, that the quality of medication prescribing cannot be determined by the medication count alone; older adults with multiple medications can still have high-quality and appropriate prescribing.)
Overprescribing in older adults is driven by direct-to-consumer advertising and older adults' beliefs and expectations about medication-based solutions.8, 9 Clinician factors contributing to polypharmacy include lack of specialized training in geriatrics and pressure to prescribe in order to earn high patient satisfaction ratings.10, 11 The prescribing cascade, defined as the use of one medication to treat a condition inadvertently caused by another, is another significant contributor to overprescribing in older adults.12 These factors create barriers to safe prescribing practices and reducing polypharmacy.
Clinicians are aware of the complexity polypharmacy adds to the care of older adults, but its burden is not always recognized and is important to consider. Family caregivers report that medication administration is stressful because of the fear of making mistakes and the time-consuming nature of the task.13 Older adults and caregivers must also navigate issues related to obtaining medications (such as cost, insurance, and coordinating with pharmacies) and using medications (such as remembering, organizing, scheduling, and administering them).14 An increased number of medications amplifies these issues and adds significant caregiver burden.
Medication safety and efficacy are affected by the aging process. Normal aging is associated with physiological changes, such as decreased liver size and blood flow and decreased renal function, that affect medication absorption, distribution, metabolism, and clearance.15 Other physiological changes, such as changes to cardiovascular system structure and function and to the central nervous system, may impact medication tolerability and increase the risk of adverse effects.15 Normal age-related changes in mentation and mobility require consideration of the lowest recommended dose to reduce adverse effects and improve tolerability.16
Medication adverse effects, potential long-term adverse effects, and effectiveness are strongly affected by adherence—which is influenced not only by medication access and ability to use the medication as prescribed, but also by the older adult's perceived benefit of a medication, health beliefs, and attitude toward a medication.17 As more older adults depend on their caregivers' support for medication management, it is essential to recognize the intricate balance caregivers must maintain between respecting an older adult's hesitation to take a medication as prescribed and ensuring they follow clinicians' recommendations. Additionally, for many older adults, loss of independence in medication management can result in anxiety, negative thoughts, and low self-esteem, potentially causing conflict with their caregivers.18
Assessing medications in the inpatient setting requires a team approach that includes a nurse, prescribing clinician, and pharmacist in partnership with the older adult and the family caregiver. Collaboratively, the health care team assesses medications through the lens of the 4Ms framework, aiming to ensure that the medications are prescribed at age-appropriate doses and do not unnecessarily put the older adult at increased risk for harm.
The first step in assessing medications is to conduct medication reconciliation, which should be completed upon admission and at each care transition during the hospital stay.19 This necessitates obtaining an accurate list of the medications the older adult currently takes.4 Family caregivers are instrumental in keeping an updated list of medications and are frequently its sole source.20 The nurse can guide the family caregiver in organizing the medication list—which should include start date, generic and brand name, indication, dose, and prescriber—and remind the caregiver to bring the list to the hospital and to all clinician appointments. The nurse should also ask about OTC medications the older adult is taking, as well as OTC supplements, as nearly one-quarter of older adults fail to inform their prescribing clinician about the use of these products.21
The next step is to review the list for medications that are considered high risk for older adults.22 These can be identified by using tools such as the American Geriatrics Society (AGS) Beers Criteria23 or the STOPP/START criteria.24 It is essential that nurses and prescribing clinicians familiarize themselves with these tools in order to recognize potentially harmful medications and inappropriate doses that are routinely prescribed for older adults.
Identifying the high-risk medications an older adult is taking requires clear communication between clinicians, older adults, and caregivers, and this collaboration supports shared decision-making. The nurse can educate the caregiver about high-risk drug categories for older adults, including but not limited to benzodiazepines, nonsteroidal antiinflammatory drugs, antihistamines, tricyclic antidepressants, anticoagulants, anticholinergics, opioids, antipsychotics, and all prescription and OTC sleep sedatives or sleep medications.25 It is important to explain to caregivers that even though these medications are considered high risk, they are still sometimes necessary and appropriate to prescribe. If the older adult is prescribed one or more high-risk medications, the caregiver must monitor for any adverse effects or new symptoms and report them to the clinician as soon as possible.
Nurses play a vital role in assessing family caregivers for problems with at-home medication administration. Is the older adult having issues swallowing certain medications? Could a switch be made to an alternate form, such as a chewable tablet, a patch, or an oral liquid?26 Is the older adult receiving injections? Is the caregiver experiencing any difficulty preparing the dose?
Nurses and family caregivers can work together in attending to the effects of medications. For example, if the older adult is taking oral hypoglycemic medications or insulin, the caregiver has the added responsibility of tracking blood sugar levels and watching for signs and symptoms of hypoglycemia. The nurse should ensure that the caregiver has the necessary supplies and knowledge to successfully complete these tasks. Similarly, if the older adult is taking antihypertensive agents, the nurse can assess whether the caregiver has access to a blood pressure monitor at home and confirm that the caregiver knows the blood pressure target range.
ACT ON MEDICATIONS
In the 4Ms framework, acting on medications includes promoting safe medication use by deprescribing and/or reducing doses of high-risk medications. This process needs to be person centered and align with What Matters to the older adult and family caregiver.22
A key step is to understand the older adult's goals of care and health care priorities.22 The nurse can ask the older adult what matters to them regarding their health and whether any of their medications interfere with what is important to them, such as babysitting a grandchild or taking a morning walk with a friend. The nurse would then identify any high-risk medications such as opioids or benzodiazepines, which can lead to confusion or an increased risk of falls,27 impeding the older adult's ability to engage in What Matters. The caregiver can also tell the nurse how medications are affecting the older adult and share any concerns with the health care team.
When nurses identify high-risk medications that are interfering with the older adult's goals of care, they can act on this by suggesting that the prescribing clinician discuss deprescribing with the older adult and caregiver. Using the 4Ms framework as a guide, the health care team can consider deprescribing or reducing the doses of those medications that might interfere with What Matters, Mentation, and/or Mobility.
Deprescribing is a systematic process of identifying and then decreasing or withdrawing an unnecessary medication.28 A medication is considered unnecessary when its potential harm outweighs its benefits to the older adult's health and well-being.28 Deprescribing is influenced by clinicians' professional judgment and older adults' specific needs. A deprescribing framework, developed by Scott and colleagues, is summarized in Table 1.28
Table 1. -
A Deprescribing Framework28
|Step 1: Current medications
||Conduct medication reconciliation to identify medication list and corresponding indications.
|Step 2: Elevated risk
||Identify medications contributing to patients' risk.
|Step 3: Assessment
||Assess each medication for its current and future benefit relative to current or future risk.
|Step 4: Sorting
||Target and prioritize medication for discontinuation.
|Step 5: Elimination
||Create and implement a plan to eliminate target medications.
Deprescribing is best supported by interprofessional collaboration. For example, including a pharmacist in interprofessional rounds improves medication safety for older adults, reducing adverse drug events and associated costs due to fewer hospitalizations.29 Nurses can support older adults and family caregivers by partnering with them during the deprescribing process. The older adult and family caregiver may have concerns that they are no longer receiving the care they deserve. Discussing the rationale for reducing PIMs and emphasizing that this may improve overall quality of life and reduce the risk of medication-related harm is one strategy to put them at ease.16, 30
The role of older adults and caregivers in safe medication use and deprescribing is noted in Scott and colleagues' deprescribing framework.28 Clear deprescribing options for the older adult, such as complete discontinuation; dose reduction; or avoiding specific withdrawal symptoms, rebound symptoms, or disease worsening, should be defined and set before discontinuing medications, and caregivers must be educated on what to expect and monitor for.28 Nurses can ensure that caregivers are empowered to take an active role in medication use and decision-making.
Managing complex medication regimens can be overwhelming for caregivers.31 When preparing for the transition to home, one beneficial strategy is for the nurse to sit down with the caregiver and help to develop a medication schedule that aligns with the older adult's daily routine, using mealtimes and bedtimes as cues. This strategy is twofold: it ensures that the caregiver has a schedule for home that is workable and a schedule the caregiver understands how to execute, both of which can improve medication adherence.
Clinicians are responsible for supporting older adults and their caregivers with medication education and access, monitoring, and deprescribing throughout the continuum of care. Hospitalization and discharge planning are key times to ensure optimal medication use.
RESOURCES FOR CLINICIANS AND CAREGIVERS
Table 2 lists clinician tools for assessing and acting on medications. For a general overview of the 4Ms framework, see Try This: Age-Friendly Health Systems: The 4Ms.32
Table 2. -
Health Care Professional Tools for Assessing and Acting on Medication
AGS = American Geriatrics Society; START = Screening Tool to Alert to Right Treatment; STOPP = Screening Tool of Older People's Prescriptions.
The AGS Health in Aging Foundation offers numerous resources and educational materials on medication management for family caregivers.33 The Food and Drug Administration and the Family Caregiver Alliance also offer comprehensive guidance.34, 35 Additionally, nurses can refer caregivers to the tear sheet, Information for Family Caregivers, which offers tips for medication safety and management after hospitalization.
Resources for Nurses
- What to Know About Medication
Note: Family caregivers can access these videos, as well as additional information and resources, on AARP's Home Alone Alliance web page: www.aarp.org/nolongeralone.
2. Fulmer T, et al. The age-friendly health system imperative. J Am Geriatr Soc
3. Qato DM, et al. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med
4. Steinman MA. Polypharmacy: time to get beyond numbers. JAMA Intern Med
5. Clark CM, et al. Potentially inappropriate medications are associated with increased healthcare utilization and costs. J Am Geriatr Soc
6. Alves-Conceição V, et al. Medication regimen complexity measured by MRCI: a systematic review to identify health outcomes. Ann Pharmacother
7. Reeve E, et al. Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med
8. Clyne B, et al. Beliefs about prescribed medication among older patients with polypharmacy: a mixed methods study in primary care. Br J Gen Pract
9. Kantor ED, et al. Trends in prescription drug use among adults in the United States from 1999-2012. JAMA
10. Urfer M, et al. Intervention to improve appropriate prescribing and reduce polypharmacy in elderly patients admitted to an internal medicine unit. PLoS One
11. Chen Z, Buonanno A. Geriatric polypharmacy: two physicians' personal perspectives. Clin Geriatr Med
12. Ponte ML, et al. Prescribing cascade: a proposed new way to evaluate it. Medicina (B Aires)
13. Reinhard SC, et al. Home alone: family caregivers providing complex chronic care
. Washington, DC: AARP Public Policy Institute and the United Health Fund; 2012 Oct. https://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/home-alone-family-caregivers-providing-complex-chronic-care-rev-AARP-ppi-health.pdf
14. Nicosia FM, et al. What is a medication-related problem? A qualitative study of older adults and primary care clinicians. J Gen Intern Med
15. Donohoe KL, et al. Geriatrics: the aging process in humans and its effects on physiology. In: DiPiro JT, et al., editors. Pharmacotherapy: a pathophysiologic approach
. 11th ed. New York: McGraw Hill; 2021.
16. Brandt NJ, et al. Practice and policy/research implications of deprescribing on medication use and safety in older adults. Policy Aging Rep
17. Lehane E, McCarthy G. Intentional and unintentional medication non-adherence: a comprehensive framework for clinical research and practice? A discussion paper. Int J Nurs Stud
18. Lindauer A, et al. Medication management for people with dementia. Am J Nurs
2017;117(5 Suppl 1):S17–S21.
19. Joint Commission. National Patient Safety Goals effective January 2022 for the hospital program
. Oakbrook Terrace, IL; 2021. National patient safety goals for hospitals; https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf
20. LaValley S, et al. Caregivers' roles in medication management for older family members [abstract from GSA annual scientific meeting]. Innov Aging
21. Jou J, Johnson PJ. Nondisclosure of complementary and alternative medicine use to primary care physicians: findings from the 2012 National Health Interview Survey. JAMA Intern Med
22. Brandt NJ. Optimizing medication use through deprescribing: tactics for this approach. J Gerontol Nurs
23. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc
24. National Health Service Cumbria Clinical Commissioning Group. STOPP START Toolkit: supporting medication review (version 2)
. Durham, UK: North of England Commissioning Support (NECS) Medicines Optimisation Team on behalf of Cumbria CCG; 2016 Jun.
25. Motter FR, et al. Potentially inappropriate medication in the elderly: a systematic review of validated explicit criteria. Eur J Clin Pharmacol
26. Liu F, et al. Patient-centred pharmaceutical design to improve acceptability of medicines: similarities and differences in paediatric and geriatric populations. Drugs
27. Institute for Healthcare Improvement. Age-friendly health systems: guide to using the 4Ms in the care of older adults
. Boston; 2020 Jul. http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf
28. Scott IA, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med
29. Pellegrin KL, et al. Reductions in medication-related hospitalizations in older adults with medication management by hospital and community pharmacists: a quasi-experimental study. J Am Geriatr Soc
30. Gabauer J. Mitigating the dangers of polypharmacy in community-dwelling older adults. Am J Nurs
31. Harvath TA, et al. Managing complex medication regimens. Am J Nurs
32. Fulmer T, Berman A. Age-friendly health systems: the 4Ms
. New York, NY: The Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing; 2019. Try this: best practices in nursing care to older adults (general assessment series); https://hign.org/sites/default/files/2020-06/Try_This_General_Assessment_35.pdf
33. Health in Aging. Medications and older adults
. American Geriatrics Society Health in Aging Foundation. n.d. https://www.healthinaging.org/medications-older-adults
34. U.S. Food and Drug Administration. Medicines and you: a guide for older adults
. Silver Spring, MD; 2015 Oct 7. https://www.fda.gov/drugs/resources-you-drugs/medicines-and-you-guide-older-adults
35. Cameron KA. Medications: a double-edged sword
. San Francisco: Family Caregiver Alliance; n.d.; https://www.caregiver.org/resource/caregiver's-guide-medications-and-aging/#