30% compliance. Factors contributing to suboptimal adherence include affordability, polypharmacy challenges, and access. The latter may involve proximity to a pharmacy and complexities sur- rounding restricted formularies or prior authorization hurdles. Poor compliance may also be impacted by elements of polypharmacy, including pill burden, confusion, and intolerance or fear of side effects. General medication knowledge deficits and a patient’s underappreciation of intangible/invisible benefits from treatment may also reduce compliance. Clinicians should recognize that the factors leading to reduced adherence and/or compliance are even more impactful in older adults, who often face myriad challenges of disease burdens, financial insecurity, and cognitive impairment. Tools that may help to improve compliance and adherence are equally diverse, multipronged, and important to be employed by various members of the healthcare team. They include: ● Adequate initial and ongoing education regarding medications and conditions being treated. ● Selection of affordable medications and facilitation of access to patient support programs. ● Referral to sources or tools that improve compliance (e.g., medication calendars, reminders, apps). ● Informative reinforcement of the risks of nonadherence or noncompliance. ● Open-ended questions to explore barriers or patient concerns with medication regimens. The sequelae of suboptimal adherence/compliance are well established. In addition to the direct concern of a diagnosed condition not being adequately treated or possibly even worsened, a growing literature describes individual and societal impacts of suboptimal medication use. For example, a patient diagnosed with diabetes mellitus may be nonadherent with their medication regimen due to cost, complexity of disease management, and/or failure to feel tangible benefits from their treatment. With disease progression, additional microvascular and macrovascular complications may evolve. Renal dysfunction, hypertension, cardiovascular disease, stroke, and visual impairment can individually or collectively increase acute and chronic healthcare resource utilization, warrant additional medications, further complicate polypharmacy issues, and compound financial healthcare burdens. The Get the Medications Right Institute (GTMR, www.gtmr.org) was established to advocate for personalized, patient-centered, and coordinated approaches to medication use to achieve improved patient outcomes and reduce healthcare costs. Citing work by Watanabe and colleagues (2018), McFarland and colleagues Long-term care considerations All the elements of medication management in elderly patients described above have relevance regardless of where a patient is domiciled. However, patients housed in long-term care facilities are prone to additional risks and concerns related to a greater likelihood of cognitive impairment; limited ambulation; inability to render self-care; and the challenges of rendering care in a mixed-skill, sometimes under resourced, institutional setting. The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that focuses on identifying and improving medication safety concerns across various healthcare settings. In addition to advocating for using resources such as STOPP/ START and AGS Beers criteria, ISMP issued a list of high-alert medications in long-term care settings to raise added awareness of medications that pose a disproportionate safety risk to patients in these care environments (Institute for Safe Medication Practices, 2017). Six categories of medications were identified as high risk for pa - tients in this setting: ● Both oral and parenteral anticoagulants, including warfarin, DOACs, and heparin-related drugs : Spontaneous and fall-associated bleeding events are well-established risks associated with these medications. ● Chemotherapeutics, with specific concerns for oral methotrexate for nononcologic use : Lack of familiarity
2021), and other sources, GTMR associates the magnitude of suboptimal medication use in the United States to be $528 billion (about $1,600 per person) in wasted healthcare costs and 275,000 lives lost each year. Nonadherence issues have been attributed to approximately 15% of medication therapy problems, with the related challenges of inadequate, excessive, or unnecessary therapies and adverse reactions forming the balance of issues associated with suboptimal medication use. This organization advocates for team-based approaches, including adopting a comprehensive medication management (CMM) paradigm to improve outcomes, reduce costs, and avoid waste. While the focus of CMM and the goals of GTMR are not exclusive to older adults, the contributing factors associated with suboptimal medication use are closely aligned with the geriatric patient population. Prescribers and other healthcare team members may consider implementing the guiding principles proposed by Wooten (Box 2) to improve medication outcomes in older adults (Wooten, 2015a, 2015b). Box 2. Wooten’s Rules for Improving Pharmacotherapy in Older Adult Patients • Know the patient and use the patient’s most current medical record. • Follow the tenets of evidence-based medicine, but understand the limitations of the evidence. • Understand the potential pharmacokinetic and pharmacodynamic changes that can occur in older adult patients and use this specific patient information to make prudent prescribing decisions. • Recognize and investigate patient factors that may contribute to medication problems. • Avoid the prescribing cascade, if possible. • Prescribe and recommend only those medications/drug classes for which you have a thorough understanding of the pharmacology. • Identify, anticipate, and monitor potential drug interactions before they become a problem. • For each medication prescribed, establish a monitoring plan for both efficacy and toxicity. • Properly counsel patients/caregivers on all of the patient’s medications and ensure that the patient understands the pharmacotherapy plan. with oncologic therapies in subacute care settings and inconsistent dosing regimens (e.g., once weekly methotrexate, other therapies requiring a specific cyclical administration schedule) may predispose patients to overdose and serious side effects. ● Oral hypoglycemics : As previously described, older patients are sensitive to hypoglycemic episodes associated with sulfonylureas, especially in the context of inconsistent caloric intake. ● Insulin products : In addition to their inherent hypoglycemic risks, multiple insulin products and strengths may be erroneously interchanged. ● Parenteral nutrition products : While sometimes necessary to sustain or restore nutritional requirements, parenteral nutrition infusions contain numerous complex components, any of which may pose health risks if prescribed, compounded, or administered incorrectly. These products increase the risks of catheter-related bloodstream infections. ● Opioids, encompassing all routes of administration, with specific concern for concentrated oral morphine : In addition to the enhanced risks of the central nervous system and respiratory depression that opioids confer in elderly patients, variable dosage forms and configurations may further predispose patients to unintended medication exposures. • Assess and address compliance issues. Note. Adapted from Wooten, 2015a, 2015b.
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