This month is National Recovery Month, a national observance held every September by the Substance Abuse and Mental Health Services Administration (SAMHSA) to promote and support new evidence-based treatment and recovery practices, the emergence of a strong and proud recovery community, and the dedication of service providers and community members across the nation who make recovery in all its forms possible. Recovery month is in its 32nd year and celebrates the gains made by those in recovery from addictions. And to observe this month, our September blogs will feature information on substances of abuse that affect our seniors whether it be a substance use disorder, dangers of mixing medications or contributing to cognitive issues or falls.
"Substance use disorders among our seniors have nearly doubled since 2006, affecting almost 6 million older adults," said Attorney RJ Connelly III. "The reality is that seniors with a substance use problem face many more risks than younger people due to cognitive impairments, medication interactions, nutritional concerns, poor social supports, and the risk of falls. Misusing or abusing substances is also linked to increased mortality rates and higher costs of healthcare."
Americans continue to have a stereotypical view of substance abuse and addiction. It happens to the “other family” -- not ours. Many believe it is a problem of the “lower class”, those lacking education, the young, the homeless, and even minorities. These are stereotypes and stereotypes die hard because, in most cases, they are the refuge of those who are neck-deep in denial. In truth, addiction and abuse can be found in every family, every culture, every economic class, and, as we will discuss in our September blogs, at any age. In this week's blog, we will look at the importance of monitoring a senior's medications and medication management.
Our Experience With Medication Mismanagement
When Connelly Law Offices, Ltd. becomes a guardian for an individual, one of our many responsibilities is to maintain contact with the ward and their care providers to ensure that they remain both physically and mentally healthy. Such a task is something the staff at Connelly Law takes very seriously – not only from a legal standpoint but from a moral one as well.
A guardian can take many roles. At times, we receive calls from family members who have not heard from their loved ones and ask us to do a safety check. Other times we may be contacted by a hospital or nursing facility asking the office to provide some information that they may need to develop an appropriate plan of treatment. But increasingly, we are finding more and more problems associated with medication errors among seniors who have chosen to age in place who lack the appropriate oversight of their medications.
One of our clients suffered a medical emergency in the community which required hospital admission. The client had no immediate family and our office was asked to gather some personal items for him as well as his medication box and bottles in order for the treating staff to get a better picture of the client’s medication needs.
Upon entering the client’s apartment, our staff noticed that several bottles had tablets and capsules of differing colors and shapes. We opened one bottle labeled “Warfarin” (a powerful blood thinner) and found five different medications inside, none of which was the prescribed drug listed on the bottle. The medications found were (we used an online medication identification website to identify the drugs):
Bupropion (Aplenzin, Budeprion SR, Budeprion XL, Buproban, Forfivo XL, Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban) - a psychotropic used to treat depression.
Gabapentin (FusePaq Fanatrex, Gabarone, Gralise, Neurontin) - an anti-convulsant and treats nerve pain.
Fluoxetine (Prozac, Prozac Weekly, Rapiflux, Sarafem, Selfemra) - treats depression and panic disorder.
Lisinopril (Prinivil, Zestril) - treats high blood pressure and heart failure.
Risperidone (Risperdal M-Tab, RisperiDONE M-Tab) - treats schizophrenia and bipolar disorder.
Three of the five are considered psychotropics, one medication used for neuropathy having abuse potential, and another used for cardiovascular stability. All of these medications were capable of producing serious side effects if taken inappropriately. This was not the first time we have encountered this but by far it was the most serious case we have seen. This begged the question -- just how prevalent is this problem and how does this affect our seniors?
A Sizable and Dangerous Problem
In speaking with multiple medical providers, it turns out that medication errors in the home cause harm to at least 1.5 million seniors annually at a cost of over $4 billion to the health care system. The numbers are so high because of the sheer number of drugs - and seniors - involved.
More than 76 percent of adults over the age of 60 use at least two prescription drugs and 37 percent take five or more, according to the National Center for Health Statistics. As seniors live independently for longer periods of time, their medical needs grow and the medications they are prescribed are more complex, resulting in more mistakes.
Other issues that account for the surge of medication errors include inappropriate storage, problems opening bottles, using different pharmacies, and seniors being unreliable reporters about the medications they are on when seeing multiple doctors for specialized healthcare needs.
Besides the obvious problems such as overdosing and possible toxic reactions, there is also a chance that the symptoms caused by medication misuse could result in a misdiagnosis. Mixing certain medications can cause memory loss, confusion, and changes in mood and personality, presentations mimicking the symptoms of Alzheimer’s disease.
Seniors are especially at risk of developing dementia-like symptoms because their bodies are not able to process medications as well as a younger person does. A slower metabolism, less lean body mass, less water in the body, and decreased kidney and liver functions make it harder to clean out toxins. As a result, drugs can accumulate in the body, and over time, this becomes toxic and the side effects become magnified.
One other note about the client’s apartment our staff visited, besides the jumbled prescription medications, the floor was littered with empty vodka and rum bottles. As if misuse of prescription drugs was not bad enough, adding alcohol to the mix elevated the possibility of a fatal outcome. But it's not just prescription medications that are problematic.
OTC Supplements Can Also Be Dangerous
We have provided a paper at the end of this blog that will allow you to gather the medications and make a list. And the list must be accurate. All prescription medications, over-the-counter medications, and supplements must be listed. This is important since some supplements, which many consider harmless because they are purchased without a prescription, can interact with prescription medications - sometimes with serious results. Let’s look at some of the most common supplements and prescription drug interactions:
Black Cohosh - often suggested for "hot flashes" and vaginitis can enhance liver toxicity when combined with Lipitor or Tylenol.
Co-Q10 - promoted to prevent heart damage, can interact with warfarin, decreasing the blood-thinning effects of this medication.
Cranberry Supplements - often taken when a urinary tract infection is present (by the way, medically, providers are now telling us that cranberries are no more effective for UTIs than plain old water), can increase the blood-thinning effects of warfarin resulting in bruising or clotting issues.
Echinacea - used by many when a cold is present, slows the breakdown of caffeine in the liver leading to nervousness and jitters.
Evening Primrose Oil - used by some to promote cellular health, can increase the risk of seizures for those taking anti-seizure medications.
Valerian - suggested for insomnia, has a list of over 500 drugs that can interact with it, including muscle relaxers, pain medications, and sleep medications.
St John’s Wort - called nature’s natural anti-depressant, should not be combined with SSRIs, tricyclic antidepressants, dextromethorphan, warfarin, birth control pills, and some HIV medications.
Saw Palmetto - marketed as a supplement for prostate issues, can slow clotting and increase bleeding risks for those taking medications like warfarin.
Melatonin - a hormone the regulates the sleep cycle, can also cause excessive sleepiness in those who take benzodiazepines and muscle relaxers. Even more concerning, melatonin can increase blood sugar and interfere with diabetes medications.
Kava - said to address nervousness, can combine with some medications and increase liver toxicity, It can also affect those using buprenorphine, leading to respiratory distress and even coma.
Ginseng - around for centuries, can decrease the effectiveness of drugs like warfarin and subject the user to possible clots.
These are just a few of the supplements that can interact with prescribed medication. Do your research before going the "natural" route.
Read the Labels
No medication or supplement should be taken without first reading the label and understanding any possible interactions. Know what's in over-the-counter medications. For instance, some over-the-counter cold medications can contain acetaminophen. Without realizing it, the person could also take more Tylenol later, thereby doubling the dose. Tylenol can be extremely toxic to the liver.
Clean up the Closet
Often, seniors have multiple doctors who may prescribe the same medication. And because some generics may be the same medication but look different, they may think they are different medications. Know what medications are prescribed and clean up a messy medicine cabinet.
Use the Pharmacist
Once you have a med list in place, consult with the pharmacist who will be able to see any duplications of prescriptions or over-the-counter meds. We knew of one case where a senior had trouble sleeping and was taking Tylenol PM. Her cardiologist suggested that she take Benadryl without knowing she was also taking the Tylenol PM. The result was the senior complained of being tired and sluggish resulting in another doctor’s appointment and additional bloodwork. Because a senior’s body is not as efficient as a younger person's in processing medicine, the excess medication stays in the system longer. A pharmacist will pick up on this.
A Fist Full of Pills
Because seniors take so many medications, swallowing them can prove to be a difficult task for some resulting in medication non-compliance. There are ways around this. Some medications come in liquid form and others can be crushed and mixed with food like applesauce or puddings.
Do Not Make Changes on Your Own
Perhaps the Tylenol PM is making your father groggy, or the diuretic mom takes in the evening keeps her up half the night running to the bathroom. Changing the times they are taken on your own is not a good idea as they may have been prescribed to be used at that time for a very good reason. Make sure your healthcare providers are part of that discussion.
Pill Boxes work
Prepackaged medications can eliminate the need for multiple pill bottles and decrease the chances of mistakes. Using a pillbox is a necessity for some seniors. Trying to open bottles, reading each label, counting pills can be time-consuming, confusing, and lead to non-compliance. Today, there are pillboxes for everyone - different colors, different sizes, and even talking pillboxes. Many pharmacies now offer pre-packaged medications that not only make taking medications easier for the senior but also help loved ones track the medications to ensure they are being taken on time or not being abused.
Seek Outside Assistance
Home healthcare agencies now provide specially trained caregivers who can fill pillboxes and monitor medication compliance. Using a private nurse can cost upwards of $100 a day while home healthcare providers can offer similar services for about $20 an hour. But, check and make sure what level of training those handling medications must go through and what supervision process is in place. Theft of controlled substances is a growing issue among caregivers.
"Managing medication for a senior is a complicated and challenging issue," said Attorney Connelly. "But by making sure your loved ones are taking medications appropriately, you’re helping them stay healthy while supporting their wish to remain at home for as long as possible."