Managing 5 or more medications for an elderly family member? Here’s what caregivers should know
When seniors take multiple medicines, side effects and drug interactions can be harder to spot. Here’s what caregivers should watch for and how to manage medications safely.
(Photo: iStock/justocker)
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If you’re caring for a senior, you’ll be required to plan a myriad of medications daily – from pills to topical creams, patches, eye drops, inhalers, injectables and even vitamins, herbal supplements and traditional medicines. And you’re not alone.
About one in seven seniors (or 14.5 per cent) above age 66 in Singapore takes more than five different prescription medicines each day, according to a 2019 SingHealth study involving nearly 1,500 older adults. More specifically, these folks were taking 6.3 medications a day on average.
“Polypharmacy is generally defined as the concurrent use of five or more medications by a single patient,” said Associate Professor Lita Chew, SingHealth’s group chief pharmacist – and it also includes topical, injectable and non-prescription medicines as well as supplements.
You’d be right to protest that it can’t be helped when the senior you’re caring for has one or several chronic conditions, such as high blood pressure, high cholesterol, diabetes and/or heart disease.
“People with these long-term conditions often have more than one medical condition at the same time, requiring additional medications to manage both their conditions and any related complications,” said Dr Cheryl Tan, the principal clinical pharmacist with NHG Pharmacy. “Medications for pain, mental health conditions and other long-term medical conditions may also contribute.”
In hospitals, for example, “it is common for patients with multiple chronic diseases to be taking between five and 10 long-term medications. Some patients with complex health conditions may be taking considerably more”, said Thurga Devi, a senior clinical pharmacist from Ng Teng Fong General Hospital.
Polypharmacy is also almost a given in nursing homes. At Allium Care Suites, all of their residents are on five or more medications daily, said Zangcai Huang, the head of nursing and the clinical governance officer of Allium Healthcare.
WHY IS POLYPHARMACY A POTENTIAL CONCERN?
“Polypharmacy often reflects the need to manage several long-term medical conditions, with medications being added on over time as people develop new health issues, and receive care from different healthcare providers,” said Dr Tay.
That becomes a potential issue because “as we age, the body handles medications differently”, explained Dr Tay. “Kidney and liver function may decline, which can affect how quickly medications are cleared from the body. Older adults may also have changes in body composition and increased sensitivity to certain medications.”
As a result of all those changes, “older adults are more susceptible to the side effects of the medications”, said Thurga.
“Cognitive changes can further complicate the management of complex regimens,” highlighted Assoc Prof Chew. “Older patients are also more likely to be under the care of multiple specialists, which increases the risk of duplications or interactions going undetected.”
Huang highlighted that the patient’s frailty is another factor to consider. “Research has shown that medication-related risks tend to be greater among the ‘old-old’, people with frailty and those with multiple health conditions. This is why medication management in older adults has to take the person’s overall condition into account, rather than simply looking at whether each prescription is appropriate.”
HOW MANY MEDICATIONS IS TOO MANY?
“There isn’t a magic number where a medication list suddenly becomes ‘too much’,” said Dr Tay. “Five medications are commonly used as a definition of polypharmacy but five appropriate medications may be safer than two inappropriate ones. The concern arises when the list keeps growing without anyone periodically asking,” she said.
The more important questions are, said Huang, does each medication still have a clear purpose? Does it remain appropriate for the person’s current health, and provide more benefit than risk?
That’s not to say that older patients will just have to deal with an ever-growing list of medications. To counter that, chronic conditions can be screened, detected and treated earlier. Together with a healthy lifestyle, the disease’s progression and complications could be managed without the need for additional medications over time, said Dr Tay.
WHAT ARE THE SIGNS THAT WE SHOULD RELOOK A SENIOR’S MEDICATIONS?
“Some red flags include recurrent falls, excessive drowsiness, new confusion or worsening memory, constipation, low blood sugar levels or frequent hospital admissions,” said Thurga. “Families sometimes attribute these symptoms to ‘old age’ when medications may be contributing factors.”
Huang added that a change in blood pressure and/or heart rate may also be an indication. “One challenge is that (new) medication side effects can sometimes be mistaken for a new illness,” he said. The caregiver may assume cognitive decline to be the cause but the underlying problem could partly be medication related.
“This is why we should pay attention to when a symptom started and whether it coincided with a new medicine, a change in dosage, or the addition of another medication,” said Huang. However, it would be prudent to have the situation assessed by the doctor or pharmacist – and not stop the medication, he emphasised.
HOW OFTEN SHOULD WE REASSESS A SENIOR’S MEDICATIONS?
“A full medication review should take place at least once a year for patients on multiple long-term medications, and more frequently after a hospitalisation or significant change in condition,” said Assoc Prof Chew. “Discharge from hospital is a particularly critical moment as new medications are sometimes added during a stay without older ones being reviewed or removed.”
Dr Tay said that “there is no single review interval that suits everyone”. In diabetic patients, “we found that patients who received two reviews achieved better diabetes control compared with those who received just one review over six months”, she said, citing a study by NHG Pharmacy.
“While these findings are preliminary, they suggest that medication reviews need not be a once-off exercise,” said Dr Tay. “For patients with complex medication regimens, two or more medication reviews a year may be a reasonable approach, particularly where there are ongoing issues with diabetes control or medication changes.”
Medicines that should not be mixed
Blood thinners and nonsteroidal anti-inflammatory drugs (NSAIDs)
A familiar combination to avoid is warfarin and aspirin as the latter, which is an NSAID, can significantly increase bleeding risk when taken with a blood thinner like warfarin, said Assoc Prof Chew.
Antibiotics and antifungals
“Certain antibiotics and antifungals can interfere with the metabolism of other drugs, raising patients’ blood levels to harmful concentrations,” said Assoc Prof Chew.
Sleeping pills, antidepressants and strong painkillers
“Problems often arise when several medications have overlapping side effects,” said Thurga. One example is medications that induce drowsiness and fall risk, including sleeping tablets, antidepressants and strong painkillers. “When combined, they can cause excessive drowsiness, impaired balance, confusion, and falls,” she said.
Medicines with anticholinergic effects
These include medicines for sleep, bladder control, nausea, allergies and Parkinson’s disease. “They can cause side effects such as dry mouth, constipation, urinary retention, blurred vision and confusion,” said Dr Tay. “When several of these medications are used together, their effects can add up and increase the risk of falls and other complications.”
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CAN CAREGIVERS SIMPLY STOP GIVING A MEDICINE?
Ceasing to give a medication aka deprescribing, should be discussed with the doctor or pharmacist. “Deprescribing should be considered when a patient’s health circumstances change, following a new diagnosis, or when a medication originally intended for short-term use has been continued indefinitely without review,” said Assoc Prof Chew.
Dr Tay emphasised that “deprescribing should be individualised”. “Some medications cannot be stopped suddenly and may require a gradual dose reduction, so patients should not stop medications on their own.”
WHAT CAN CAREGIVERS DO THEN?
You don’t have to ask questions only at a review. “Patients and caregivers should feel empowered to ask questions,” said Thurga. “It is appropriate to clarify whenever a new symptom appears after starting a medication, or the patient struggles with adherence.”
To help you along whenever a new medication is prescribed, Huang has this list of questions for you to ask:
- What is this medicine for?
- How long does my family member need to take it?
- What side effects should we look out for?
- Could it interact with their existing medicines and/or supplements?
- Is there anything they should avoid while taking it?
- What should we do if a dose is missed?
Family members and caregivers are important partners in medication safety, said Assoc Prof Chew. “Maintaining an up-to-date list of all medications, including supplements and traditional remedies, and bringing it to every appointment is one of the most impactful things a caregiver can do.”
She added that the list should include the name of each medication, dose, frequency and prescribing doctor. Pill organisers and phone reminders can help manage complex regimens, though the right solution will differ from person to person.
WHAT ARE THE TOOLS THAT CAN MAKE TRACKING MORE CONVENIENT?
Huang suggested using medication reminder and tracking apps to help with schedules and reminders. “However, technology should support medication management rather than replace clinical oversight. An app can remind someone to take a tablet; it cannot determine whether that tablet is still appropriate for them.”
One app example, said Thurga, is Medisafe. “It is a medication-adherence app (not Singapore-specific though) available for medication reminders and alarms, which are especially useful for caregivers managing complex medication regimens.”
Meanwhile, try these practical everyday tips, if you’re caring for a senior:
- Use a pill organiser or medication box, if it is appropriate for the person’s medicines.
- Set reminders on a phone, smartwatch or other devices. Avoid relying solely on memory, particularly when several medicines are involved.
- Keep medicines in their original packaging, unless the pharmacist or healthcare professional advises otherwise.
- Practise First Expiry First Out (FEFO): use medications with the earliest expiry date first.
- Do not stop or alter medications without first checking with the doctor or pharmacist.
- Do not double a dose after a missed dose, unless specifically instructed to do so.
“The most useful ‘tool’ is still a regular medication review involving the patient, caregiver, doctor, pharmacist and nursing team,” said Huang. “Good communication between everyone involved in the person’s care is essential.”
Source: CNA/bk
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