Safe Medication Practices: Nursing Assessment of Medications in Older Adults

Carol A. Miller, RN-C, MSN

Disclosures

Geriatr Nurs. 2003;24(5) 

Introduction

Since 1999 when the Institute of Medicine reported that approximately 7000 deaths occurred annually as a direct result of medication errors, health care professionals have been identifying and implementing interventions to improve medication safety. For example, much attention has focused on establishing systems for reporting medication errors and adverse medication effects. The primary goal of these reporting systems is to collect and analyze data so health care professionals can identify common causes of medication errors and adverse effects and implement plans to prevent medication-related problems. For instance, studies show that as much as 18% of serious, preventable adverse drug events occur because health care practitioners do not know enough about thepatient before prescribing, dispensing, and administering medications.[1] Thus, an important nursing responsibility is to assess older adults, their medications, and their medication-taking behaviors. Nurses caring for older adults, particularly those who are old-old or medically frail, face major barriers to obtaining this base of information. This drug consult column—the first of a series addressing nursing responsibilities for medication safety in elders—reviews some of these barriers and provides guidelines for a nursing assessment of medications.

A typical older adult in the United States takes 4 to 5 prescription and 2 over-the-counter drugs at a time and fills 12 to 17 prescriptions per year.[2] This level of medication use is primarily associated with the increased prevalence of chronic illness among older adults and is usually appropriate and therapeutic; however, it is also associated with a significant increase in drug interactions, adverse medication effects, and nonadherence to the prescribed regimen. Thus, it becomes increasingly more important to monitor and assess therapeutic and adverse effects and medication-taking behaviors. However, as the complexity of the medication regimen increases, it becomes increasingly more difficult to obtain adequate and accurate information about medications. Some of the factors that increase the difficulty of obtaining adequate and accurate information about medication regimens of older adults are:

 

  • Older adults obtaining care from multiple health care providers

  • Health care practitioners' lack of information about medications obtained from a variety of sources (prescription medications offered by friends and relatives or nonprescription products, such as herbs, nutritional supplements, and over-the-counter products)

  • Health care practitioners' lack of information about a patient's nonadherence with a treatment regimen

  • An older adult's fear of disclosing information about folk remedies or about medications obtained from sources other than the prescribing health care practitioner

  • An older adult's fear about disclosing information about self-directed changes in the medication regimen

  • An older adult's hoarding of medications and insisting on taking medications that may no longer be appropriate

  • Nonadherence to the prescribed medication routine (eg, because of high cost of medications or insufficient knowledge about the importance of taking the medication)

  • An assumption by the patient or health care practitioner that, once most medications are started, they should be continued indefinitely

  • An assumption by the patient or health care practitioner that, once an appropriate medication dosage is established, it will not need to be changed

  • An assumption by the patient or health care practitioner that a lack of adverse effects early in the course of treatment indicates that adverse effects will never occur

  • Changes in the person's weight (especially weight loss), which may affect pharmacokinetics

  • Changes in the patient's daily habits (eg, smoking, activity level, or nutrient and fluid intake) that may affect the action of medications

  • Changes in the older adult's mental or emotional status, which may affect medication consumption patterns

  • Changes in the older adult's health status, which may affect medication actions, increasing the potential for adverse effects

Goals of an accurate and comprehensive nursing assessment of medications in older adults are: to identify the actual medication-taking behaviors, identifying any factors that interfere with the prescribed regimen, determine the effectiveness of the medication regimen, ascertain risks for adverse effects or altered therapeutic actions, detect the presence of adverse medication effects, and identify opportunities for health education about medication regimens. Guidelines for interview questions that nurses can use for assessing medications in older adults are summarized in the sidebar.

In addition to interviewing older adults or their caregivers about medications and medication-taking behaviors, nurses obtain essential assessment information by observing and reviewing the person's array of medications. When nurses conduct the medication assessment in the home setting, they can ask to see all the medications that the older person uses. In settings other than the home, the nurse can ask the older adult ahead of time to bring in all of his or her medications. Direct observation of medication containers provides useful information, such as the actual prescription instructions and the dates of prescription refills. Nurses must use this information cautiously, however, because the contents of the medication containers may not be the original medications. Inconsistencies between the prescription label and the contents of the container may be used as a basis for further questioning. For example, if the label indicates that the original prescription was for 30 pills and the prescription has not been refilled for 1 year, the nurse might inquire about the reason for this. The older person may explain that the prescription is so expensive that he or she takes it only occasionally. Often the nurse will find that the original container is not being used because it has a childproof cap that the person cannot manipulate. The pills may then be stored in an incorrectly labeled container, which increases the risk of medication errors.

Another reason for direct examination of medication containers is to discover information about sources of care and duplication of medications. Persons who are seeing more than 1 health care practitioner may not acknowledge multiple sources of prescriptions, but this information can be discovered by reading prescription labels. Nurses also may discover that the same or similar medications are being prescribed by more than 1 health care practitioner or under more than 1 brand name. Because of the use of generic medications and the increasing number of brand names and similar medications, persons can inadvertently be taking duplicate medications. The person taking the duplicate medication usually is unaware of this because the medications are dispensed with different names on the labels.

Dates on labels also reveal important information that can lead to additional questions. For example, if the patient has 3 types of antihypertensive medications, each prescribed at a different time, the nurse can inquire whether the second or third medication was supposed to replace or supplement the original medication. Finally, checking the prescription container can provide valuable clues to adherence. By looking at the date on the label, the amount of the last refill, and the contents of the prescription container, nurses can make a rough estimate of the consumption pattern.

In summary, nurses have important responsibilities for assessing not only the medication regimen prescribed for an elder but also the medication-taking behaviors of older adults and factors that influence adherence to the prescribed medication regimen. By obtaining an accurate and adequate database about all medications and pharmaceutical products taken by an older adult, nurses can plan interventions for preventing and identifying adverse medication effects and for ensuring therapeutic effectiveness of medications. The next column will discuss nursing interventions for improving medication safety for older adults.

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