If you’re helping an older person with health and healthcare, chances are that person is taking at least a few prescription medications, if not several.
Do you ever wonder if he or she is on the right medications? Do you worry about side-effects and interactions?
These are sensible concerns to have. Although medications do often help maintain health and wellbeing, studies have repeatedly shown that lots of older adults end up suffering from problems related to medication.
So I want to share a list of common ways that medications affect the health and wellbeing of aging adults. I’ll then explain what you can do, to minimize problems.
Six Common Medication-Related Problems in Aging Adults
Here are the most common problems that I see:
- Side-effects affecting thinking and balance. Although all medications can cause side-effects, quite a few commonly used drugs are known to make thinking and balance worse in aging adults. These include:
- Drugs in a class known as “anticholinergics,” which includes drugs for overactive bladder, itching/allergy, vertigo, nausea, and certain drugs for nerve pain or depression. Diphenhydramine, or Benadryl, is a commonly used anticholinergic that’s often included in over-the-counter sleep aids and PM-version painkillers. (Wondering how to spot these medications? I have a link to a great list of anticholinergics in this post.)
- Sedatives and tranquilizers, which are often prescribed for sleep or for anxiety. Examples include zolpidem and lorazepam (brand names Ambien and Ativan, respectively).
- These drugs can increase fall risk, or can provoke confusion. Geriatricians commonly recommending stopping or reducing the dosage of these drugs. For more information about four types of medication that affect memory, see here.
- Symptoms persisting despite drug treatment. Many older people are started on a drug for a certain symptom, such as pain, heartburn, incontinence, or depression. But because primary care visits tend to be busy, it’s easy for doctors — and even patients — to postpone following up on the symptom indefinitely. (Many symptoms would benefit from non-drug treatment too, but that’s another issue.)
- In many cases, a “starter dose” is prescribed, but is not adjusted.
- Older adults may end up with the risks and burden of taking a drug — including the cost of the drug — while not getting much benefit from the drug.
- Geriatricians usually try to make sure that all drugs for symptoms are serving a useful purpose in improving wellbeing or quality of life.
- Drug interactions. Some drugs tend to interact with others. A frequent source of problems is warfarin, a commonly-used blood thinner, which can interact with antibiotics as well as with other drugs. (Despite its risks, it’s often appropriate to prescribe warfarin to an older adult.)
- Warfarin is one of the most common causes of medication-related hospitalizations in older adults.
- To reduce the risk of serious problems, one may need to apply extra care in monitoring warfarin effect (via the prothrombin blood test) and extra care in checking for interactions when a new drug is prescribed. For more on using warfarin safely, see this article.
- Side-effects due to a strong effect of drugs on the older person. Examples of this include:
- Blood pressure medications at a dose that brings blood pressure much lower than the goal blood pressure. This can result in lightheadedness, or even falls, when an older person stands. (See this post and this post for my recommendations on safer managing of blood pressure in the elderly.)
- Blood sugar that is pushed quite low by diabetes drugs. Low blood sugar episodes can cause falls and have been linked to faster cognitive decline. Drugs that lower blood sugar are involved in many medication-related hospitalizations.
- Burden of scheduling and taking medications. Many older adults end up with several pills to take at several different times per day. At a minimum this is often a hassle; at worst it becomes a serious drain on quality of life.
- Some older adults are unable to take all their medications properly. Depending on which medications are missed, this can cause serious effects on an older person’s health.
- Cost of medications. Even with prescription drug coverage provided by Medicare Part D, the monthly costs of medications can be high. This is a burden for older adults, who often have limited financial resources.
- It can also cause people to skip taking certain medications, or not fill prescriptions for more expensive medications (such as inhalers).
There are of course many other medication-related problems that can occur, especially when hospitalizations or multiple doctors are involved. But the ones above are especially common when it comes to the primary care of aging adults.
What You Can Do
In an ideal world, every older adult would have access to a reliable process for reviewing medications, ensuring that the benefits outweigh the risks and burdens, and monitoring for side-effects and problems.
However, as many of you know, our healthcare system is not yet ideal for aging adults. So if you are caring for an older person and want to be proactive about checking on medications, here are some specific things you can do:
- Review the Beers List of Potentially Inappropriate Medications for Older Adults, and see if your older relative is taking medications on the list. This document includes a comprehensive list of “anticholinergic” drugs, and also lists other medications that are especially risky for the elderly.
- Don’t panic if you discover that an older person is taking a medication on the Beers list. Do plan on discussing with the doctor. You’ll want to understand why the benefits are likely to outweigh the burdens, and you can also ask if a lower dose is possible.
- You can also review “Ten Medications Older Adults Should Avoid or Use with Caution,” authored by the American Geriatrics Society. This document highlights ten especially commonly used medications that can often be stopped or reduced.
- If you need help spotting risky medications, consider asking a pharmacist for assistance.
- Make a comprehensive list of all medications being taken. Include prescription drugs, over-the-counter drugs, and herbal supplements. Then, for every drug being taken, make sure you and your older relative understand:
- The purpose of taking the drug. Ask yourselves if the drug seems to be serving its purpose. If you aren’t sure, plan to ask the doctor. If it’s a drug to manage a symptom such as pain, consider how the symptom seems to be doing. If the doctor hasn’t reassessed the symptom lately, or if the symptom is still bothersome, you’ll want to discuss with the doctor.
- If there are alternatives to taking the drug. Especially when it comes to treating symptoms, there are often non-drug alternatives that can and should be considered. For instance, certain types of counseling can be effective for depression and anxiety. Physical therapy can help treat some forms of pain. Pelvic floor exercises and timed toileting can reduce incontinence.
- If a lower dosage is possible. In general, the risk of side-effects and problems goes up with higher doses of medication. Consider asking if a lower dose is possible for any of the medications.
- If you’re concerned about drug-drug interactions, have the medication list checked for possibly dangerous interactions.
- Don’t forget to include any over-the-counter drugs or supplements when you check for interactions.
- You can use an online drug interaction checker such as this one, or ask a pharmacist for help.
- If you identify a potentially problematic interaction, let the doctor know as soon as possible. But don’t stop the medication on your own, as that can be dangerous too.
- If cost is an issue, ask the doctor about options for reducing the medications, or at least switching to less expensive alternatives.
- For instance, stopping a medication that is not working well for a symptom can help reduce drug costs.
- If medication is required for a given problem, such as very high blood pressure, ask if there is a cheaper medication available.
- Pharmacists may be able to offer suggestions regarding less costly alternatives, or other ways to modify the medication plan.
- If taking medications on schedule is an issue, ask the doctor for help simplifying and streamlining the daily medication plan.
- For drugs taken several times a day, there may be a once-a-day option.
- Or ask whether a drug can be stopped, and a non-drug treatment tried instead.
- Pharmacists can often recommend ways to safely adjust when and how medications are taken.
- Keep the doctors well-informed about your relative’s medications and medication use. In particular, help the doctors avoid these two common pitfalls:
- Confusion as to what has been prescribed by other doctors. Most seniors see multiple doctors, and hospital stays can create additional changes to the medication list. Don’t assume that doctors have an up-to-date list. (They almost never do!) Instead, bring an up-to-date list every time you see the doctor, or better yet, bring the bottles along too. Don’t forget to include supplements and over-the-counter drugs.
- Confusion as to what the older person is actually taking. If your relative hasn’t filled a prescription due to cost, or isn’t taking a medication for any reason, be sure to let the doctor know this. This is especially important if the older person has had concerns about side-effects.
By implementing some — or ideally all — of the steps above, you can help make sure that an older person gets the most benefit from medications, while minimizing the risks and burdens.
For more on medication safety, see “How to Review Medications for Safety & Appropriateness,” or see our Medication Safety topic page.