Eldercare at Home: Using Medicines Safely
Caregiving How Tos
Understanding the Problem
People age 65 and over buy more than 30 percent of all prescription medicines and 40 percent of all nonprescription (over-the-counter) medicines sold in this country. Older people are also more likely than younger people to have chronic illnesses such as arthritis, diabetes, high blood pressure, and heart disease that require taking medicines on a regular basis. Because older people often have several different health problems, it is common for them to take several different medicines.
When compared to younger people, older individuals tend to be more sensitive to the effects of many drugs. For example, a drug such as Valium(TM)(diazepam) may stay in an 80-year-old body four times as long as it does in a 40-year-old body. The liver and the kidneys break down and remove most drugs from the body. As people age, these organs may not work as well as they once did and some drugs may leave the body more slowly, sometimes causing side effects. Therefore, when drugs are prescribed by a doctor or other health care provider, it is a good idea to ask if it is the proper dose for an older person.
Many people see several different doctors who each may prescribe one or more medicines. In such cases, it is very important that at least one doctor keeps track of all the medicines a person is taking to minimize drug interactions and other risks associated with taking many medicines. If the (primary care) doctor is unaware of the medicine already prescribed by other doctors and health care providers, this can cause problems.
Tell the doctor and pharmacist about medicines that the person you are caring for is taking, including nonprescription medicines. These include the following:
- All prescription drugs from any doctor or nurse practitioner including eye drops, creams, patches and inhalers.
- Nonprescription medicines, including vitamins, minerals, sleeping pills, laxatives, cold medicines, and antacids.
- Supplements, folk remedies, nontraditional products, or "alternative medicines," such as plant compounds, herbs, special teas, or nutritional supplements.
- "Social" drugs such as alcohol, tobacco, or caffeine.
It will be helpful to the doctor, in making diagnoses, to know all the medicines that the patient is taking. The doctor needs this information because nonprescription medicines can interact with each other as well as with prescribed medicines in ways that could be harmful to the patient. Nonprescription medicines can also cause side effects that the doctor may have to treat.
Pharmacists are able to give you information about side effects of medicines and supplements, and even how they can interact with each other. Ask the pharmacist for this information and ask any other questions you have about the medicines. Doing so may prevent a serious problem.
Your goals are to:
- Follow the doctor and pharmacist's instructions. If you don't understand their instructions, ask for clarification
- Know all medicines and supplements that are being taken and their side effects
- Know if the medicines and supplements being taken by the patient are safe to use together
- Ask for generic medicines in order to keep costs lower
- Watch for side effects from the medicines and report them in a timely manner to the doctor
A drug reaction can be an emergency. The following is a list of serious symptoms that could be caused by a drug reaction. These drug reactions often begin shortly after starting a new medicine or when the dosage (amount and frequency) of a drug is changed.
Call the doctor or nurse immediately or go to the emergency room if any of the following symptoms occur
- Hallucinations (hearing or seeing things that are not there)
- Palpitations or rapid heart beat
- Trouble waking up, especially when others try to wake the person
- Severe nausea or vomiting or prolonged loss of appetite
- Dizziness , falling, trouble with balance
- Unusual bruising or bleeding from minor cuts or blood in the stool
- Severe confusion
- Severe fatigue
- Impaired or blurred vision, or seeing gold "halos" around objects
- Hives, itching, skin rash, or swelling of the face
- Severe shortness of breath
- Black, tarry stools
It is especially important that if a person has difficulty breathing or if there is swelling in the throat, call 911 or take the person to an emergency room immediately.
Call the doctor or nurse during office hours to discuss the following problems
While some side effects from medicines happen immediately, others happen slowly over a period of days or weeks, or even months. What may seem to be a new health problem or a worsening of an existing condition may be a reaction to a medicine.
- Shortness of breath (If sudden or severe, call the doctor immediately.)
- Fatigue (If sudden or severe, call the doctor immediately.)
- Confusion or being "out of it" (If sudden or severe, call the doctor immediately.)
- Incontinence or problems urinating (If sudden or severe, call the doctor immediately.)
- Depression, feeling "down," or taking no interest in activities previously found enjoyable
- Persistent cough
- Feeling jittery or fearful
- Sensitivity to sunlight
- Increased lower leg swelling
Know the answers to the following questions before calling the doctor
- What is the symptom? (Try to be accurate and specific.)
- When did the symptom start?
- Is it a new symptom or an ongoing problem that is now worse?
- How severe is the symptom? Does it interfere with usual activities (such as preparing meals or dressing)?
- What medicines are being taken? (Include prescription and non-prescription.)
- Is the older person following instructions for prescription medicines? If not, what is being taken and how much?
- Has a day or two been skipped in taking prescription medicine?
- Does the older person have any allergies?
Here is an example of what you might say when calling for help
"Hello. This is Ellen Smith. My mother is Ann Smith and she is Dr. Miller's patient. My mother has been throwing up for the past 12 hours. Two days ago she started taking indomethacin for her arthritis. Dr. Miller prescribed it. Do you think it could be causing the vomiting?"
- Keep a current record of all medications taken.
Make a list of all the medicines that the person you are caring for takes. Include prescription and nonprescription medicines.
Write the name of each medicine, the doctor who prescribed it, what it is for, the amount taken, and the times of day it is taken.
The person you are caring for should keep a copy of the list in the medicine cabinet and in his or her wallet or pocketbook. You should keep a copy, too. This record should be reviewed with the doctor at every visit and whenever a doctor prescribes a new medicine by phone.
Ask about drug allergy and medicine bracelets and necklaces.
Drug allergy bracelets can be bought in many pharmacies. These are small metal bracelets that can be worn over the wrist or hung on a necklace. For example, a bracelet might say "Allergic to penicillin." or “I take warfarin.” Custom medical identification bracelets or necklaces are also available by mail for a fee. Some pharmacies have the application forms.
Customized bracelets can tell medical personnel, such as emergency medical personal such as ambulance workers, about a person's medical condition, allergies, medicines, and special needs, such as blood type and if the person has advance directives (or a living will). In some instances this information will be provided to health care workers when they call a telephone number imprinted on the bracelet.
Ask the doctor or nurse to review all medicines and explain the reason for each medicine at least once a year.
As new medical problems occur, new medicines may be prescribed and it is important for the doctor to know what medicines the person you are caring for is already taking. Also, new information about side effects may become available about these drugs. Therefore, it is important that medicines be reviewed regularly.
Use only one pharmacy, if possible.
This way, the pharmacy will have all of your prescription medicines and drug allergy information on one computer. This will be helpful when the pharmacist checks for drug interactions as new prescriptions are filled.
Tell the pharmacist the medical problems that the older person has. Medicines taken for one problem may make another problem worse, and the pharmacist may notice this if it has escaped the doctor's attention.
Labels can be hard to read and difficult to understand.
Ask the pharmacist to explain the information on the label including expiration date, number of refills (if any), and directions for use. If the information is not clear, ask for an explanation.
- For example, if a label says "Take three times a day," what does that mean? Does that mean every eight hours?
- Does the patient need to be awakened promptly to take the medicine?
- Should the medicine be taken with meals or an hour before meals?
- What should you do if a dose is skipped?
- Can it be taken with other medicines?
- If there are no children in the home, refuse child safety caps on bottles
Child safety caps have helped prevent child poisonings, but they can be difficult for an older person to open. If it is too much of a struggle to open the bottle, an older person may not take the medicine. If children sometimes visit, keep medicines locked up or on a shelf they cannot reach or work on some other solution that both helps an older person get his or her medicines easily but also keeps the medicine away from children.
- Store medicines in a cool, dry place
Although many people keep their medicines in the bathroom, its high moisture content makes it a poor place to keep them. Many tablets and capsules lose their strength if exposed to moisture or strong heat or light. The bedroom is usually a better location. Store medicines in the refrigerator only if told to do so by the pharmacist or if they are labeled "Refrigerate." If you do not know how to store the medicine, ask a pharmacist.
- Keep medicines in their original containers
Mixing different pills in one bottle can be confusing and even dangerous. Since many medicines look alike, this can confuse the patient, caregivers, or people who may be called on to help in an emergency.
- Do not keep medicines at an older person's bedside
An older person can wake up in the middle of the night and take an additional dose of medicine without realizing it.
- Have the older person sit up or stand when taking pills, and use a half cup of water to wash them down.
Use water-not milk or other drinks-to help wash down a medicine. Some medicines are less effective when taken with milk. Water will help prevent the medicine from sticking in the throat and esophagus and causing irritation. If the person you are caring for has difficulty swallowing, ask your pharmacist if the medicine is available in liquid form, or ask if it is all right to crush the tablet and mix it with applesauce or other soft food. Some tablets or capsules should not be crushed or chewed.
- Use a pillbox.
You can buy a pillbox with many sections at your pharmacy. Some pillboxes have compartment sections for seven consecutive days and for times of day the medicine must be taken: early morning, noon, evening, and bedtime.
There are also pillboxes with alarms to notify the user when the next dose should be taken. (These are useful for medicines that require precise timing, such as medicines for Parkinson's disease.)
For medicines that cannot be placed in a pillbox-such as liquids, cream, and patches-a reminder note placed on the refrigerator may be helpful. Keeping medicines on the kitchen table with a note saying when to use them may also be helpful.
- Use reminders.
A checklist or marking on a calendar may be helpful to show when medicine should be taken and when it was last taken. Alarm clocks can be helpful or you may have to remind the person you are caring for when to take medicines.
- Ask about other ways to take medicines.
Most people have trouble remembering to take a medicine three or four times a day. If the person you care for has trouble taking the prescribed medicine, or has trouble remembering to take the medicine, tell the doctor or pharmacist. He or she may know of a similar medicine that is easier to take, or one that needs to be taken only once a day.
Some medicines are available in the form of patches that are placed on the skin and need to be changed only every few days; however, they are usually more expensive than the same medicine in pill form.
- Throw away old medicines.
Check the expiration days on medicine bottles, and throw medicines away if the date has passed. It is usually a good rule of thumb to discard medicines after a year.
It is natural to want to hold onto unused medicines ("just in case"), but stockpiles of medicines can be confusing and dangerous. Some pharmacists highlight the expiration date with a yellow marker; you can do the same thing at home.
Highlighting the expiration date on nitroglycerin tablets is especially important for they may keep their strength for only six months once opened.
Some communities have laws about how drugs can be disposed of. For example, in these communities it is illegal to flush medicines down the toilet. Ask your pharmacist about how to properly dispose of expired or unnecessary medications.
Problems You Might Have Carrying Out Your Plan
"I would like to discuss my aunt's medicines with her doctor, but he's so busy I don't want to bother him."
The medicines your aunt takes are an important part of her care. Her doctor needs to review them with you. If you have trouble bringing it up at the appointment, tell the office staff in advance that you would like the doctor to review all of her medicines at the next visit, and bring them to the appointment. (Please note that doctors can only share this information with the person named in the Older person’s HIPPA forms. If you are not the person named in the forms, then the designee who is will need to be present at the appointment and share this information with you.)
"I'm too busy to make sure my mother is taking all of her medicines."
There are many things that can be done to simplify the medicine-taking routine and to make it easier for her to remember. Pillboxes can contain all the medicines your mother needs for seven days, counted out and organized by day, time, and dose. Medicines that can be taken once a day instead of three times a day might also be helpful. Ask your doctor or pharmacist for suggestions.
"I can tell that the medicine is not helping my father, so I'm not going to give him the medicine anymore."
You shouldn't stop giving a prescription medicine unless your doctor says it is OK. It may be helping in ways that you are not aware of. It may also be the type of medicine that should be stopped gradually, taking smaller and smaller doses until your father is off it completely. Some drugs, if suddenly stopped, may cause problems.
"The medicine the doctor prescribed is too expensive."
The high cost of medicines is a major concern for many older people. Most older adults are eligible for Medicare Part D, and some are eligible for extra assistance for medications through social security. Be sure to understand the older person's benefits available through Medicare Part D or other insurance plans. Each Medicare Part D plan has their own list of medicines that are covered (their formulary). Formularies can change each year in January, but choosing a formulary medication typically means it will be cheaper or easier to fill at the pharmacy. Some pharmacies have inexpensive medication lists (e.g. $4 lists) of generic medications that are the same price regardless of insurance coverage. Choosing one of these medications may also save the older adult money.
If the older person does not have insurance coverage and the price of medicines is a problem, tell your doctor or pharmacist. The doctor may be able to prescribe a less expensive medicine, or substitute a generic medicine that does the same thing as the brand name. Generics are generally just as good as the brand names but usually much less expensive.
Also, many drug companies have programs that supply their medicines for a small fee or no charge to patients with limited incomes whose insurance does not cover prescriptions and for those without insurance who cannot afford the medicines. With certain programs, your doctor will have to provide the company with information about your medical condition and why you can't pay. Ask the doctor or pharmacist for more information about these programs. Also, social workers can tell you about programs or agencies that can help you pay for medicines.
Think of Other Problems You Might Have Carrying Out Your Plan
What other problems could get in the way of doing the things suggested in this section? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out the plan?
Managing medicines and making sure that they are used safely is an important part of caregiving. With careful attention to the older person's medicines, you can prevent many problems. Getting an older person on a schedule for taking medicines can improve his or her life dramatically. Changing or stopping medicines can sometimes improve quality of life including becoming more active, thinking better, and improving sexual functioning.
To manage medicines effectively, you have to be organized, persistent, and ask questions. When you see changes in an older person, always keep in mind that the medicines he or she is taking may play a part in this change. Report your concerns to the doctor or nurse.
What to Do If Your Plan Isn't Working
Improperly managed medicines can be dangerous. If, in spite of your best efforts to use the ideas in this section, medicines are not being managed properly, you should get help. You may need the help of a home health nurse, or to bring someone into the home to help manage the medicines. Perhaps this is a time to consider moving the person you are caring for to a setting with more structure where someone is paid to be responsible for managing medicines. These range from assisted living settings to nursing homes-depending on the person's other needs.