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Managing Multiple Medications
Steps to Minimize the Risk
By Kim Murdock, MBA
Not long ago, I was talking to a friend about her
mother, who recently was released from the hos- At a Glance
pital where she was treated for severe vertigo and an The average senior takes two to seven daily medica- tions, and about 4 percent of adults age 57 to 85 inner-ear infection. In addition to continuing her two (approximately 2.2 million) are potentially at risk for typical prescriptions for blood pressure, the doctors a major cross-drug interaction. Fifty percent of such prescribed an antibiotic, a medication for nausea and cases involve the use of nonprescription medica- dizziness, and a nasal decongestant. My friend’s mom tions. Although many interactions are not serious or life-threatening, serious consequences can occur, especially if multiple physicians are prescribing the medications. In Managing Multiple Medications, After coming home from the hospital, my friend’s author Kim Murdock provides steps that seniors and mother lost a significant amount of weight from the their caregivers can take to minimize the potential vertigo and corresponding nausea. She became thin to the point of frailty and seemed “out of it”—incapable of giving coherent responses to conversation or questions. Her balance was non-existent—she could barely walk A Bitter Pill
unassisted—and she slept day and night. Although According to a study in the December 24/31 issue of The Journal of the American Medical Association (JAMA), about 4 percent of adults aged 57 to 85 (ap- My friend couldn’t understand why her mother was so proximately 2.2 million) might be at risk for having a incoherent over the telephone. So she went through major cross-drug interaction, and 50 percent of these her mom’s drugs, talked to a doctor, asked a lot of cases involve the use of nonprescription medications. questions—and took her mom off one of the drugs In the study, researchers at the University of Chicago (a Valium-type drug used to combat the nausea that surveyed 3,005 seniors, age 57 to 85, to estimate the resulted from the vertigo). Within a day, her mom was prevalence and patterns of medication use and poten- able to walk independently and have a normal conver- tial major cross-drug interactions (Qato et al. 2008). Other estimates indicate that one in four hospital Just last week, I had a conversation with a different admissions of a senior is a direct result of medication friend who told me about a senior acquaintance who problems, including prescription-drug interactions tried to commit suicide. Thankfully, the attempt failed. (Today’s Seniors). One report estimates that seniors Doctors put the woman on a two-week suicide watch (those 65 and older) make more than 175,000 emer- and took her off all medications. They discovered that gency-room visits per year in response to negative drug while on the medications, the woman was depressed reactions; commonly prescribed drugs caused one- enough to want to commit suicide. However, once she third of these visits (SeniorJournal.com). According to was off the medications, the woman no longer suffered Dr. Mehmet Oz of The Dr. Oz Show, people who take six from such crippling depression. Frighteningly, her de- or more medications, including supplements and over- spair seemed to be caused by a medication interaction. the-counter drugs, have a 94 percent chance of suffer-ing a drug interaction. Was it just coincidence that I had these two conversa-tions within a short period? How common are these According to the U.S. Federal Drug Administration types of stories? How often do seniors suffer from nega- (FDA), the average senior takes two to seven daily medications (Kohls). A JAMA study found that more CSA Journal 45 • December 2009 17
than 50 percent of survey respondents use five or more • What are the possible side effects, and what prescription medications, over-the-counter medica- tions, or dietary supplements. Twenty-nine percent of • How long before the medicine should start to respondents use at least five prescription medications concurrently; the prevalence of this finding increased • Can I take this medicine safely with my other with age and was highest among adults age 75 to 85. prescriptions, over-the-counter medicines, and Sixty-eight percent of respondents who take prescrip- dietary supplements? If so, can I take them at the tion medications also use over-the-counter medica- same time? If not, how should I time doses? tions, dietary supplements, or both (Qato). 3. Take a friend. If possible, seniors should have an
These statistics are sobering. However, a study pub- advocate who can accompany them to doctors’ lished in JAMA in March 2003 found that nearly 28 appointments. An advocate, such as a close friend percent of negative drug interactions in seniors were or family member, can help seniors remember the preventable (SeniorJournal.com). As a CSA, what can questions they want to ask as well as the answers you do to help seniors prevent negative interactions? that providers give. Many seniors are uncomfort- Begin by suggesting the following nine steps: able questioning doctors. A close family member or friend might feel more comfortable asking ques- 1. Mind your meds. Seniors should become knowl-
tions of a physician with whom they do not have a edgeable about their medications. Many seniors take medicine solely on the advice of doctors and do not understand exactly what the medicine is 4. Get it on tape. Seniors should ask to record conver-
supposed to do and why they need to take it. Se- sations with the doctor so that they can easily refer niors should not blindly trust their medical provid- to answers later. Sometimes answers make com- ers; all patients should understand why the doc- plete sense at the doctor’s office but are difficult to tor has prescribed medication. Similarly, seniors recall after time has passed. Seniors can ask their should read the package inserts and labels for all physicians whether they can record the conversa- medicine. If they have questions, they should ask 5. Make a (full) list. Seniors should bring a complete
2. Talk to the doc. Seniors should talk to their doctors
list of medications (both prescription and over-the- and health advisors. The FDA suggests that when a counter) and dietary supplements to all doctors’ ap- doctor prescribes a new medicine, seniors should pointments, especially when seeing a new specialist. All too often, prescribing doctors are unaware of the • What is the purpose of this medicine—what is it full scope of medications that their patients might be taking. Many seniors visit different specialists— • How and when should I take this medicine, including cardiologists, endocrinologists, arthritis • Should I take this medicine with food, on an empty stomach, with other medicines, or by Be an Advocate
Anne Huddle, a Denver teacher, became concerned when • What is the timing between each dose? her mother, who lives in Ohio, couldn’t hold a conversation and became lethargic. Anne flew to Ohio and accompa- • What should I do, specifically, if the prescription nied her mom to a doctor’s appointment. Anne’s mom says, “Take as needed”? How will I know when I need the medicine (for example, at what level of trusted the doctor and didn’t want to ask questions; she saw doing so as questioning the doctor’s authority. Anne • What foods, drinks, other medicines, supple- was comfortable asking questions and ultimately discov- ments, or activities should I avoid while taking ered that a drug prescribed for her mom had caused her mom’s listlessness. Her mom got off the medication and • Do I need additional tests while taking this medi- cine? Will the doctor require a follow-up visit? 18 CSA Journal 45 • December 2009
specialists, and primary care doctors—for a variety having this list, doctors can ensure they are not of ailments. Seldom does one doctor oversee the prescribing a medication that will adversely react senior’s overall care and coordinate all medicine. Prescription drug interactions are just one con- 6. Stick with one pharmacy. Seniors should get all
cern. Among prescription medication users, 46 medications filled at one pharmacy. According percent use over-the-counter medications at the to one report, as many as 33 percent of seniors fill same time, and 52 percent concurrently use dietary their prescriptions at more than one pharmacy, so supplements. Some over-the-counter drugs can pharmacists—who are highly knowledgeable about react negatively with prescription medicines. For potential drug interactions—are unaware of the example, Warfarin, a popular blood thinner, inter- seniors’ complete list of prescriptions (Gilbert). acts negatively with many NSAIDs (a class of anti-inflammatory drugs) and can sometimes cause se- According to Chris Hansen, a Denver pharmacist, vere bleeding. Decongestants for allergies or colds one of the most important things seniors can do is can raise blood pressure in some people. Similarly, find a pharmacy they trust—and stick with it. The the supplement St. John’s Wort can interfere with systems at pharmacies are set up to flag possible the effectiveness of some drugs (Care.com). drug interactions. Similarly, the systems can flag allergies, so the pharmacist can alert patients if Therefore, on the list of medicines that seniors take a drug will interact with an allergy. According to to all their doctors and pharmacists, seniors should Hansen, at least one patient shows up at her phar- include all prescription medications; over-the- macy every couple of weeks with a prescription counter-drugs, such as pain relievers, antacids, for a drug that the patient is allergic to. When that cough medicines, and laxatives; supplements, happens, Hansen can call the provider or talk to including vitamins and herbal remedies; and topi- the patient. Many seniors, searching for the best cal medicines, such as ointments and creams. By price, use multiple pharmacies. Unfortunately, in CSA Journal 45 • December 2009 19
doing so they bypass the safety nets that are built Medicinenet.com. Seniors - Tips for Safe Medicine Use. http://www .medicinenet.com/script/main/art.asp?articlekey=19470 (accessed into pharmacy systems. Seniors should use one pharmacy and make sure to give the pharmacy their full information. Oz, Mehmet. The Doctor Oz Show. Directed by Brian Campbell. New York City, NY: Harpo Productions, September 21, 2009. 7. Ask your pharmacist. Like the doctor, the phar-
macist is a valuable resource who can help seniors Qato, Dima M., G. Caleb Alexander, Rena M. Conti, Michael Johnson, Phil Schumm, and Stacy Tessler Lindau. December 24/31, 2008. Use of Pre- understand their medications and answer any scription and Over-the-counter Medications and Dietary Supplements questions they might have after speaking with their Among Older Adults in the United States. The Journal of the American doctors. Sometimes, the pharmacist is busy and Medical Association 2008; 300(24):2867-2878. might not be able to have a long conversation. Ask when the pharmacist will have more time to call or SeniorJournal.com. Drug Interaction Risk Increases as Medica- tion Use by Senior Citizens Grows. http://seniorjournal.com/NEWS/Health/2008/20081229-DrugInteractionRisk.htm. December 29, 2008. 8. Keep an eye on the side effects. Seniors should
SeniorJournal.com. Top Ten Drug Interactions Most Dangerous to monitor side effects and alert their doctor immedi- Seniors in Long-Term Care. http://www.seniorjournal.com/NEWS/ ately if they experience any unexpected symptoms Eldercare/4-12-14TenDrugs.htm. December 14, 2004. or changes in how they feel. Alerting the physician isn’t a waste of time and is safer than dealing with Today’s Seniors. Prescription Drugs Interactions. TodaysSeniors.com. http://www.todaysseniors.com/pages/Prescription_Drugs_Seniors.html U.S. Food and Drug Administration. Medicines and You: A Guide for 9. Look outside the bottle. Seniors should discuss
Older Adults. Fda.gov. http://www.fda.gov/Drugs/ResourcesForYou/ with their doctors additional ways to combat their ucm163959.htm (accessed September 23, 2009).
health issues. With certain lifestyle changes, seniors might be able to stop using some medications, A frequent retreat participant, Kim Murdock is thus decreasing the likelihood of negative drug founder of Alive & Well, a coaching and interactions. For example, a good stretching or consulting company located in Denver, Colo. yoga regimen can help relieve pain, as can physical She is a freelance writer, coach, and public speaker therapy. Diet and exercise can often combat high specializing in work-life balance, goal achieve- cholesterol and blood pressure. Losing weight can ment and the reduction of stress. She holds an often head off type 2 diabetes or lower the amount MBA from the University of Denver and is an adjunct professor at the University of Denver’s Daniels College of Business. She can be reached at kim@be-alive-and- A Healthy Start
Seniors and their caregivers must take steps to avoid negative drug consequences. Although the tips out-lined here might not solve all possible drug-interaction problems, they will go a long way to helping seniors stay safer when taking medications of all kinds. References
Care.com. Managing Meds: How to Organize Your Senior’s Meds and
Avoid Dangerous Interactions. August 4, 2009. http://blog.care.com/
and-avoid-dangerous-interactions.html (accessed September 23, 2009).
Gilbert, Harvey MD. Polypharmacy & Seniors: Avoiding Drug Interactions. Gilbertguide.com. http://www.gilbertguide.com/articles/polypharmacy-seniors-avoiding-drug-interactions/ (accessed September 23, 2009).
Kohls, Roz. Misusing Medicine Can Be Dangerous. Senior Citizens Resource Guide. http://www.herald-journal.com/guide/seniors/ misusingmed.html (accessed September 23, 2009).
20 CSA Journal 45 • December 2009
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