How Often Should the Nurse Review the Drugs Taken by an Older Adult Patient?

Background

For many older adults, the power to remain independent in 1'southward home depends on the ability to manage a complicated medication regimen. Nonadherence to medication regimens is a major cause of nursing home placement of frail older adults.ⁱ In the United States, an estimated 3 million older adults are admitted to nursing homes due to drug-related problems at an estimated annual cost of more than $xiv billion.² Older adults are the largest users of prescription medication, nevertheless with advancing age they are more vulnerable to adverse reactions to the medications they are taking. Approximately 30 percent of hospital admissions of older adults are drug related, with more than than 11 percent attributed to medication nonadherence and x–17 percent related to agin drug reactions (ADRs).^3–5 Older adults discharged from the infirmary on more than than five drugs are more likely to visit the emergency section (ED) and be rehospitalized during the first 6 months subsequently discharge.⁶ Nursing interventions that aid older adults in managing their medications tin help prevent unnecessary, costly nursing home admissions, hospitalizations, and ED visits, too every bit improve their quality of life.

The purpose of this review was to identify bear witness-based interventions related to medication management and the customs-dwelling older adult. The focus of this review was interventions that fall within the scope of practise of the registered nurse. The guidelines do not address the specific intervention of medication prescribing. Yet, the interventions are applicable to professional nurse providers whether they are prescribing or not. This chapter discusses run a risk factors for problems in medication management followed by evidence-based interventions in areas of medication reconciliation, medication procurement, medication cognition, physical ability, cerebral capacity, intentional nonadherence, and ongoing monitoring.

Hazard Factors

There is a wide variety of factors that place the community-dwelling older adult at risk for bug in medication direction. The young-old (ages 66–74) have been found to be more adherent to medication regimens than middle-anile older adults, simply after historic period 75, older adults present decreased comprehension of medication instructions and adherence.^7–15 Living arrangements influence the older person'southward ability to manage medications, and older adults who live alone were found to be more prone to medication errors.^16–21 It is postulated that this is related to the fact that there is no one to monitor, assist, or remind the older person about taking their medications. Persons with chronic disease, particularly depression, have a college incidence of nonadherence to their medication regimen.^{vii , ten , 22–30} Many of the risk factors related to inadequate medication management are items that are more prevalent in older adults living in the community. Other factors that will be discussed in more than detail later in the chapter are concrete impairments such every bit poor vision, grip force, and cerebral reject.

Older adults are more prone to adverse events due to the clinical complexity of their care rather than historic period-based discrimination.³¹ A study of older adult outpatients who took five or more medications constitute that 35 pct experienced adverse drug events.³² In addition, individuals with complex regimens had difficulty naming and explaining the purposes of medications and appeared to be at high risk for nonadherence.³³ The greater the medication complexity, the less likely the older developed is to adhere to the medication regimen.³⁴ The larger the number of medications, the more than likely the older developed will exist nonadherent.^{3 , 9 , 13 , 19 , 28 , 35–46} It is non only the number of medications merely as well the number of doses per day and actions related to taking medications that contribute to complexity of a medication regimen.³⁴ In a study of medication compliance, the compliance charge per unit was 87 percent for daily dosing, 81 per centum for twice a twenty-four hours, 77 percent for 3 times a mean solar day, and 39 percent for four times a day.⁴⁷ In add-on, a change in prescribed drug regimen has been constitute to be a predictor of medication nonadherence in older adults.⁹ Finally, the number of prescribing providers adds to the complexity of managing ane's medications, and persons with more one prescribing provider were found to be prone to medication errors.^{16 , 19}

Research Evidence

Medication Reconciliation

Medication reconciliation is the showtime step in profitable older adults in the medication management process. Multiple studies take demonstrated discrepancies from 30 percent to 66 per centum in what medications were ordered by the prescribing provider and the actual medications the older developed was taking.^{16 , 48–52} Prescribing providers were often unaware of prescribed medications their patients were taking,^{xvi , 53–55} and the larger the number of prescribing providers, the greater the chance of medication discrepancies.^{three , 42 , 56 , 57} A written report of elderly patients 2 days subsequently hospital belch found 64 percent were taking at to the lowest degree one medication that was non ordered, 73 percent failed to apply at least one medication co-ordinate to instructions, and 32 per centum were not taking all drugs ordered at belch.⁵⁸ Another challenge in reconciliation of medications is determining exactly what medications older adults are taking in their home. Ane written report plant 49 percentage of customs-based older adults kept stores of one-time medications from the twelvemonth before, and 6 percent admitted they cocky-prescribed medications on at least ane occasion.⁵⁹ Over the counter (OTC) medication use besides needs to be assessed, because estimates of older adults' apply of OTC drugs range from 32 pct to 86 percent.^60–62 A contempo study of older adults with hypertension attending a blood force per unit area clinic found 86 per centum reported two or more cocky-medication practices using OTC drugs that could result in an adverse drug interaction.⁶³

Multiple studies have demonstrated that 10–74 percentage of medications prescribed for older adults were inappropriate.^{48 , 57 , 64–74} A report of "chocolate-brown bag" medication reviews, in which patients bring all of their medications with them (oftentimes in a chocolate-brown newspaper bag) to a medical or chemist's consultation, revealed that 12 percentage of the patients had medication problems that could potentially result in hospital admission.⁷⁵ A review of ED visits of patients 65 years and older establish 10.six percent of the visits were related to an adverse drug event, and 31 per centum had at least one potential adverse drug interaction in their medication regimen.

Pharmacy reviews have demonstrated a reduction in polypharmacy in older adults and decreased agin drug events in older patients.^76–82 Beer'due south gear up of criteria for potentially inappropriate medication employ in older adults is one example of criteria developed for pharmacy screening.^{83 , 84} There are a variety of drug interaction programs that rapidly identify adverse drug interactions.

Besides, patients who were given a medication card with a list of current medications were more compliant with their medication regimen.⁸⁵ Employ of a medication list that is shared with the patient's chief care dr. decreased patient rehospitalizations in i study.⁸⁶

Medication Procurement

Not filling or refilling prescriptions is a common cause for medication nonadherence in older adults.^87–91 In a study of elderly patients at 15 days posthospitalization, 27 pct had not filled their new prescriptions.⁹² Patients who participated in programs that provided chemist's shop delivery and refill reminders had fewer adverse drug events and higher compliance than those who did non.⁷⁸

If the price of medication is viewed as loftier, older adults are more likely to not adhere to their medication regimen and be hospitalized.^{iii , xi , 56} Lack of funds, especially at the end of the calendar month, is one reason older adults delay filling prescriptions.⁹³ In addition, chronically sick older adults are more likely to experience financial burdens associated with covering out-of-pocket costs for their prescription medications, cutting back on medications due to cost, and apply less medicines monthly.^{89 , 93–98} A study of use of medications later on an increase in the copayment found a reduction in use of up to 45 percent in nonsteroidal anti-inflammatory drugs and 23 percent in antidiabetic drugs.⁹⁹

Older adults who take insurance to cover medications have greater adherence.^{12 , 14 , xix , 100} In one study, both adherence to medications and clinical outcomes improved while the number of hospitalizations declined when cardiovascular drugs were provided to indigent patients who could not beget to buy them.¹⁰¹

Medication Noesis

Studies of older adults' knowledge of medications have constitute more than l percent knew the names and purpose of their medications; however, less than 25 percent knew the consequences of drug omission or toxic side effects.^{nine , 16 , 54 , 102} For example, 1 study of elderly patients with congestive centre failure institute that xxx days later a new medication was prescribed, only 64 percent of the patients could place when they were supposed to have their medicine.¹⁰³ Likewise, older adults were found to have bereft noesis of inhaler technique and agreement how medications can better their asthma.¹⁰⁴ Noncompliant patients on anticoagulant therapy were more likely to written report they did not know why their medication was prescribed.¹⁰⁵ In a report of OTC medication employ, few older adults knew precautions related to the OTC drugs they were taking.⁶¹ One report of older adult medication noesis establish that older adults understood prescribed medications amend than OTC drugs, peculiarly nutritional supplements.¹⁰⁶

Patient education is a key intervention to assist older adults with medication management. Patient knowledge of drugs is positively associated with adherence.^{16 , 21 , 91 , 105 , 107–112} Nonetheless, older adults require specific educational methods. Learning is more effective in older adults if information is explicit, organized in lists, and in logical club. Instructions that are uniform with the older adults' schema for taking medications are improve remembered,¹¹³ and well-organized prescription labels are more useful for older adults.¹¹⁴ Pictures are non helpful unless the picture show is clearly related to the content.^115–118 A combination of both oral and written formats was identified past older adults as most helpful.¹¹⁹ Medication schedules or charts in combination with teaching or counseling enhances patient medication adherence.^{85 , 86 , 120–124} Iv weeks after starting a new medication for a chronic illness, patients identified a substantial need for further information.¹²⁵ Studies have demonstrated that patient educational activity and counseling over several home visits or with followup phone calls produces increased medication adherence in recipients.^126–141

Physical Ability

Poor vision and depression manual dexterity are associated with poor medication cocky-direction.^{nine , 21 , 39 , 142–144} The inability to read medication labels has been associated with nonadherence to long-term medications in the elderly.^{43 , 145} I study institute 28 per centum of community-based older adults did non keep their medication bottles properly airtight and so that they could open them, and 47 percentage admitted that labels on their medications were unclear and they could not read them due to poor eyesight, inability to read English, or small writing on the characterization.⁵⁹ Studies have demonstrated that from 31 per centum to 64 percent of older adults living at home have difficulty opening medication containers, with childproof containers presenting the near difficulty.^{9 , 144 , 146} In studies of persons with chronic obstructive pulmonary affliction (COPD), 38 percent used their inhaled medications with poor technique,⁸⁹ and poor hand forcefulness was associated with nonadherence in inhaler use.¹⁴⁷ In some other study of COPD patients, more than than 50 percent had difficulties with their inhalers.¹¹²

Medication-container modification is 1 surface area of intervention for older adults who accept difficulty opening or reading containers. Use of nonchildproof containers is one choice for older adults. All the same, cicatrice packs or other variations of unit of measurement dose packaging have resulted in increased compliance.^148–150 In a recent report of older adults, 64 percent were unable to open up childproof containers, and 10 percent were unable to use cicatrice packs.^nine As well, different tablet formations that increase the ease of breaking tablets take been found to increase patients' abilities to comply with their medication regimen.¹⁵¹ Finally, talking medication containers and large-print labels are modifications that can be useful for persons with visual impairment.

Cognitive Capacity

Poor knowledge is associated with both over adherence and nether adherence of a prescribed medication regimen.^{9 , xiv , 18 , 28 , 37 , 38 , 142–144 , 152–155} A report of customs-dwelling women plant that 22 pct were unable to accurately perform a routine medication regimen; all the same, only 2 pct cocky-identified that they had difficulty with their medications.¹⁵⁶ Forgetting is a major reason medication doses are missed.^{9 , 78 , 88 , 89 , 157–162} The most prominent type of medication noncompliance is dose omission, merely overconsumption is a common mistake, especially in persons on a in one case-daily dose schedule.¹⁶³

In that location are a number of interventions to assist older adults with remembering to take their medications. One simple method is the use of memory cues that prompt patients to have their medications.¹⁴⁸ Development of memory cues must be tailored to the patient's lifestyle.^{90 , 164} Placing medication in a special place and employ of a daily effect such every bit meal time amend medication adherence.^{91 , 106 , 165 , 166} A written report that examined the virtually mutual means older adults remembered to take their medications constitute the following methods to exist benign: (1) placing containers in a particular location, (two) taking medications in association with meals/bedtime, (three) using a timed pill box, (iv) reminders from another person, and (5) using written directions or a bank check-off listing.¹⁵⁹

Compliance aids such as pill box organizers have been found to increase medication adherence.^{16 , 78} Medication schedules and calendars are helpful, specially in combination with didactics and use of a pill box.^{38 , 40 , 78 , 120 , 150 , 167 , 168} In addition, electronic monitoring that provides feedback to the user increases adherence.^{141 , 169–171} Older patients using a phonation-reminder-message medication dispenser were significantly more compliant than those using a pill box or self-administering medications.^{172 , 173} Patients using topical pilocarpine were significantly more compliant using an electronic medication alarm device.¹⁷⁴ Programs that employ daily telephone reminder calls also have demonstrated increased medication compliance.^{155 , 175} Several studies have demonstrated that dose simplification from two times a twenty-four hours to one fourth dimension a day produces higher compliance and improved patient outcomes.^{122 , 176–182}

Intentional Nonadherence

One study of chronically ill persons who were starting a new medication constitute that almost a 3rd did not take their medication as prescribed, and half of the time it was deliberate.¹²⁵ Older adults' perceptions of the seriousness of their illness and vulnerability to complications were significantly related to medication adherence.^{13 , 46 , 90 , 91 , 97 , 166 , 183} In fact, low cocky-efficacy and beliefs that others are responsible for one'southward health intendance are predictors of medication nonadherence.^{21 , 89 , 105 , 159 , 184–194}

A major reason that older adults skip doses or stop taking their medications is related to medication side effects.^{nine , eleven , xvi , 26 , 38 , 46 , 89 , 91 , 93 , 110 , 125 , 159 , 161 , 162 , 191 , 195–198} In a comparison of compliant and noncompliant patients in fluvastatin handling, the noncompliant patients were more than likely to experience side effects of the medication.¹⁹⁹ Six months afterwards belch for acute coronary syndrome, 8 percent of those taking aspirin,12 percent of those taking beta-blockers, xx percent of those taking ACE inhibitors, and 13 percent of those taking statins had discontinued taking their medications.²⁰⁰

Utilise of commitment-based interventions has been found to increase self-efficacy and medication compliance.²⁰¹ Educational activity that addresses patient interest with decisionmaking, such as focusing on appropriate versus inappropriate use of medication, can improve self-efficacy.²⁰² Patients with depression who participated in a program to raise self-management and forestall relapse had significantly greater long-term adherence to their medication regimen.²⁰³ Patients whose provider had an open, collaborative communication style also were more adherent to their medication regimen.²⁰⁴

Ongoing Monitoring

Older adults take narrow therapeutic windows and require close monitoring, particularly when on multiple medications.²⁰⁵ Ongoing monitoring of the older adult'south medication management is critical. A report of home care patients plant 16 percent had skipped a medication in the concluding 24 hours, 6 percent were taking the wrong dose, and 5 percent were experiencing adverse effects from their medication.⁸⁷ In i study, symptomatic hypotension was identified in 13 percent of community-based elderly.⁶⁷ In another written report, older adults treated for urinary tract infections and sleeping disorders experienced a significantly college take chances of ADRs.²⁰⁶ A review of ED visits of patients 65 years and older plant 10.6 percent of the visits were related to an agin drug consequence, and 31 percentage had at least one potential adverse drug interaction in their medication regimen.²⁰⁷ Pharmacist management of echo prescriptions institute 12.4 percent of patients had compliance problems, side furnishings, ADRs, or drug interactions.²⁰⁸ A total of 35 percentage of elderly convalescent patients reported at least one agin upshot within the previous year.²⁰⁹

Monitoring medication adherence is an ongoing process. The longer people are on a medication, the more than likely they are to accept difficulty post-obit the medication regimen.^{179 , 210} For example, in ane study, only 31 per centum of people with type 2 diabetes who were on oral hypoglycemics adhered to their medication regimen.²¹¹ In another study, persons on oral hypoglycemic medications were nonadherent an average of 64.vii days in one year.²¹² Since adherence to medication regimen for type ii diabetes is strongly associated with metabolic control, interventions related to monitoring and improving adherence are critical.²¹³

Patients taking Digoxin who are not adherent have an increased number and duration of hospitalizations and twice the mortality charge per unit than those who are adherent.²¹⁴ Also, in a written report of long-term compliance of antihypertensive drugs, patients on ACE-inhibitors, beta-blockers, calcium aqueduct blockers, and diuretics were more likely to be noncompliant,²¹⁵ equally were persons using bronchodilators and benzodiazepines.^threescore

Practice-Implications: Medication Management Practice Guidelines

Medication Reconciliation

1. Review with patient all prescribed and nonprescribed medications the patient is taking. Include over-the-counter (OTC) medications, herbs, and vitamins.²¹⁶

2. Screen for agin drug interactions. If adverse drug interactions are identified, report to the prescribing provider any medications of business organization.^{76–82 , 84 , 216}

3. Identify the primary or secondary medical diagnosis related to each prescribed medication. If the medical diagnosis is unknown, request the diagnosis from the prescribing provider.^{84 , 216}

4. For patients age 65 and older, apply Beer's criteria for inappropriate medication for the elderly. If any medications appear in Beer's criteria, report to the prescribing provider whatever medications of concern.⁸⁴

5. Provide to the prescribing provider(southward) a listing of all medications (prescribed and OTC) the patient is taking and a list of corresponding medical diagnoses.²¹⁶

6. Verify prescribed medications and related medical diagnoses with the prescribing provider(s).⁸⁴

7. Provide the patient or caregiver a current list of all medications the patient is taking with dose and frequency; have the patient share this listing with the prescribing provider or other wellness intendance providers equally needed.^{85 , 86 , 216}

Medication Procurement

1. Assess the patient'south or caregiver'southward ability to procure medications.^87–92

   1. Place how and where the patient obtains and refills prescriptions.^87–92

   2. Assess how the patient pays for medications.^{3 , eleven , 56}

   3. Assess if medications doses are e'er missed due to lack of funds.⁹³

2. If the patient or caregiver has difficulty obtaining or refilling prescriptions, assist the patient with creating a system to procure medications via

   1. Chemist's commitment.⁷⁸

   2. Refill reminders or automatic refill service.⁷⁸

   3. Scheduling family unit or friends to pick up medications.

3. If funds to buy medication are a trouble,^{89 , 93–98}

   1. Refer the patient to a social worker to obtain Medicare Part D coverage, other insurance coverage, or participation in drug company programs.^{12 , fourteen , xix , 99 , 100}

   2. Consult with the pharmacist regarding utilise of generic drugs.

   3. Consult the prescribing doctor well-nigh availability of drug samples.¹⁰¹

Medication Knowledge

1. Assess the patient'south or caregiver's knowledge of

   1. Dose and frequency of medications taken.^{9 , 16 , 33 , 54 , 102 , 103}

   2. Special instructions related to medications, such equally "accept with food."³³

      1. If the patient uses an inhaler, understanding of the correct inhaler technique.¹⁰⁴

   3. Medication mode of action.^{9 , sixteen , 54 , 102}

   4. Side furnishings to monitor and study.^{9 , 16 , 54 , 102}

2. With each change in medication regimen (including OTC drugs), review medication purpose, dosage, frequency, side effects to monitor and report, and other medication-specific instructions.⁶¹

3. Interventions related to medication knowledge include^{16 , 21 , 91 , 105 , 107–112}

   1. Provide written instructions related to medications in large letters and bullet or listing format.^115–119

   2. Tailor instructions to how the patient takes his or her medicine.¹¹³

   3. Group information starting with generalized information, followed by how to take the medicine, and so the outcomes such as side effects to spotter for and when to call the doctor.^114–118

   4. Use medication schedules or charts to reinforce instructions.^{85 , 86 , 120–124}

   5. If the patient did not know of import medication information at a previous encounter, review dose, fourth dimension, side effects to monitor and report, and special instructions at the next visit.^125–141

Physical Ability

1. Assess for decreased manual dexterity or vision impairment and its impact on the patient's power to place the correct medication, open medication containers, and prepare medications (eastward.g., breaking tablets) for administration.^{9 , 21 , 39 , 43 , 142–145}

   1. Detect the patient opening medication containers.^{9 , 59 , 144 , 146}

   2. If the patient uses an inhaler, observe the use of the inhaler.^{89 , 112 , 147}

   3. If the patient is required to break tablets, appraise his or her ability to practise so.¹⁵¹

   4. If the patient is unable to open or see the label and contents of each medication container, provide i of the following:

      1. Pill box or other like shooting fish in a barrel-open container.^{150 , 172 , 217} If the patient is unable to fill up the pill box, identify someone who can aid him or her.

      2. Medication calendar with pill box.^{155 , 167 , 168 , 218}

      3. Cicatrice packs.^{138 , 149} Consult the pharmacy virtually the availability of the drug in cicatrice packs or nonchildproof containers.

      4. If tablet breaking is required and the patient has difficulty doing information technology, consult with the chemist about tablets that are easier to break or tablets that are the correct dosage without requiring breaking.¹⁵¹

Cerebral Chapters

1. Assess the patient'southward or caregiver's cerebral capacity to organize and recall to administer medication.^{106 , 156}

   1. Appraise when doses are taken.

   2. Assess what cues the patient uses to remember to take medication.

   3. Appraise what dose is nearly difficult to call up.^{9 , 78 , 88 , 89 , 157–162}

   4. Assess how frequently a dose is missed or an extra dose is taken.^{9 , fourteen , xviii , 28 , 37 , 38 , 142–144 , 152–155}

2. Teach the patient or caregiver the use of retentivity cues based on i of the post-obit methods:^{148 , 159}

   1. Clock fourth dimension. Ask if the patient or caregiver is usually aware of the time of twenty-four hour period or keeps track of time through a lookout or clock.

   2. Meal time.^{90 , 91 , 106 , 164–166} Ask if the patient eats meals at a regular fourth dimension.

   3. Daily ritual, such as using the bathroom in the forenoon, shaving, or hair combing.^{90 , 91 , 106 , 164–166}

3. If the patient requires additional support,

   1. Provide memory-enhancing methods or devices such equally

      1. Medication calendar or chart.^{38 , 40 , 78 , 120 , 150 , 167 , 168}

      2. Electronic reminder or warning.^{141 , 169–171 , 174}

      3. Voice-message reminder.^{172 , 173}

      4. Telephone reminder.^{155 , 175}

      5. Pill box.^{16 , 78} (If the patient is unable to fill a pill box, place someone who is willing to assist him or her.¹⁵⁸)

      6. Electronic medication dispensing device.¹⁷³

      7. Combine methods and devices when possible.^{38 , 40 , 78 , 120 , 150 , 167 , 168}

   2. Discuss dose simplification with the prescribing provider.^{122 , 176–182}

Intentional Nonadherence

1. Appraise if medication doses are missed intentionally.¹²⁵

   1. Drugs at high hazard for intentional noncompliance include the following:

      1. ACE-inhibitors^{200 , 215}

      2. Beta-blockers^{200 , 215}

      3. Calcium aqueduct blockers^{200 , 215}

      4. Diuretics²¹⁵

      5. Bronchodilators⁶⁰

      6. Benzodiazepines⁶⁰

   2. If the patient intentionally misses doses, assess the reason(s).

      1. Conventionalities medication is not helping.^{13 , 46 , 90 , 91 , 97 , 166 , 183}

      2. Fear of agin side furnishings.^{13 , 46 , ninety , 91 , 97 , 166 , 183}

      3. Side effects.^{9 , 11 , 16 , 26 , 38 , 46 , 89 , 91 , 93 , 110 , 125 , 159 , 161 , 162 , 191 , 195–198}

   3. The following medications are most risky for patients to miss:

      1. Coumadin¹⁰⁵

      2. Digoxin²¹⁴

      3. Beta-blockers²⁰⁰

      4. Insulin

      5. Prandinm® (repaglinide)

      6. Antibiotics

      7. ACE-inhibitors²⁰⁰

2. If the patient misses medication doses for reasons related to health beliefs,

   1. Explore with the patient his or her health concerns for not taking medication.²⁰²

   2. Discuss the benefits of taking medication as prescribed.²⁰²

   3. Provide positive reinforcement for taking medication as prescribed.²⁰¹

3. For patients on high-risk medications, reinforce the danger of missing medication doses.¹⁰⁵

4. If the patient misses medication doses for reasons related to medication side effects,

   1. Explore with the patient a plan to manage the side furnishings.²⁰³

   2. Modify the regimen to reduce the side furnishings.

Ongoing Monitoring

1. For all patients on a prescribed medication regimen, monitor the patient with each come across for the following:

   1. Medication adherence

      1. Monitor both nether- and overadherence.^{87 , 179} Overconsumption occurs frequently in a once-daily dose schedule.

      2. For persons using inhalers, assess

         1. Inhaler elimination charge per unit.^{89 , 104 , 147}

         2. Reported forgetfulness.¹⁰⁴

         3. Use of brusk-acting inhaler.^{89 , 104}

   2. Medication side effects^{67 , 205}

      1. If medication side effects present, notify the prescribing provider, as advisable.

   3. Lab work, as appropriate, for prescribed medications²¹⁶

      1. Cockcroft-Gault Formula or other creatinine clearance measure at least annually. If creatinine clearance <50 ml/min, notify the prescribing provider.

   4. Medication effectiveness²⁰⁵

      1. If signs and symptoms of the trouble the medication is treating are present, notify the prescribing provider, as appropriate.

Research Implications

In that location is a large volume of enquiry related to medication direction and the elderly. Medication management is a complex process that must be interdisciplinary in its approach. Many of the evidence-based interventions discussed are not discipline specific. A team of providers is needed to provide safe and therapeutic medication management.

There is a big amount of research related to risk factors for medication nonadherence. However, there is less evidence related to advisable interventions to enhance adherence and medication self-management. In addition, the near effective programs have multiple interventions, and then identifying the specific evidence for each intervention component is difficult. For example, one report included a combination of interventions of medication review, modification of containers, medication instruction, and a drug reminder chart.¹³⁸ All are of import components of a medication program for older adults, yet it is hard to identify the evidence supporting each component. What is promising is the use of technology to assist in medication management.^{173 , 219} This includes clinical screening software for adverse drug interaction and potentially inappropriate prescribed medications, electronic adherence monitoring, and electronic medication reminders. Much of this new engineering science is currently being tested.

Decision

Medication management is a complex procedure that consists of multiple activities. Factors associated with problems in the performance of these activities include living alone, impaired vision, dumb cognitive office, ages 75 and older, having iii or more medications and/or scheduled doses in one day, and more than one prescribing provider. Medication reconciliation is a central first pace in medication management. Multiple studies have demonstrated large discrepancies in what medications are ordered by the prescribing provider and the actual medications the older adult is taking. Prove supports medication reconciliation interventions that include a screen for inappropriate medications and adverse drug interactions, in addition to verification of medications that are prescribed. Other areas of medication direction include assessment and interventions related to medication procurement, medication knowledge, physical ability, cognitive capacity, and intentional nonadherence. Ongoing monitoring of these areas is crucial.

Nurses play a pivotal role in the medication management process of older adults. Considering the expense of prescription drugs in the current health care system, a small investment in providing comprehensive cess and interventions to assist older adults in accurate and safety management of their medications will provide cost-effective care and increase the quality of life of older adults struggling to manage their often-circuitous medication regimens.

Search Strategy

To behave this review, a search was washed in August 2005 of PubMed®, the Cumulative Alphabetize to Nursing & Allied Health Literature, Cochrane Database of Systematic Reviews, HealthStar, ISI Spider web of Science, Social Service Abstracts, Database of Abstracts of Reviews of Effectiveness, and Internet searches for citations occurring from January 1990 to August 2005. Key search terms used alone and in combination included medication adherence, compliance, elderly; aged; outcomes; polypharmacy; medication management; chronic illness; chronic disease; and individual types of chronic illnesses. All searches were express to patients ages 65 and older and Spider web sites in the English language. The ISI Web of Science was used to rail citations to major works, and article references were reviewed for inclusion. Bibliographies of retrieved manufactures besides were searched for relevant articles not identified in the reference database searches.

Show Tabular array

Medication Management of the Community-Dwelling Older Developed (Includes studies pattern level 4 and above)

Acknowledgments

Acknowledgment

Development of the Medication Management of Community-Based Older Developed Guidelines was partially funded by the Aurora-Cerner-University of Wisconsin Milwaukee (ACW) Knowledge-Based Nursing Initiative. The authors would like to thank Lenore R. Wilkas, M.L.S., for her practiced assistance.

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