From debates on the Medicare prescription plan to reports on adverse drug reactions, medication management in the elderly has become a hot topic. As this facet of healthcare goes under the microscope, it's important to review the myriad challenges that face providers across post-acute care settings.

HOME CARE: Healthcare practitioners agree poor medication adherence is a prevalent problem among the elderly who live at home.

Since there are no regulations about medication use in the home, most community-dwelling older adults manage their own medications, and many aren't doing it well. In fact, some anecdotal estimates suggest that almost half of these older adults fail to take their prescribed medications daily, but the true extent of noncompliance remains unknown.

There are many reasons the elderly might not adhere to their medications, including cost and not understanding the medication's purpose or how to take it.

To help non-medical caregivers - such as family members - identify and address medication-use obstacles, several organizations have collaboratively developed the Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE).

The tool looks at three important domains: knowledge (what people know about their medications), administration (how people take their medications) and procurement (how people get their medications).

By answering a series of questions, caregivers can tabulate a deficiency score that identifies areas where older people need more help taking their medications. Caregivers can then work with healthcare providers or pharmacists to address these areas to improve compliance.

For example, if someone simply forgets to take his medication, a caregiver could suggest bubble packages and pillboxes. Pre-filled syringes could help people who have difficulty drawing insulin.

Pilot studies in settings throughout the greater Baltimore City area have shown the MedMaIDE to be reliable and effective. In the future, the researchers want to standardize interventions and teach MedMaIDE to caregivers after hospital discharge.

POST-DISCHARGE: Many people may need extra interventions after coming home from the hospital, where doctors often change medications. Patients may become confused, which can lead to duplicate medications or medication omission.

To avoid these problems, the entire healthcare team should take the following steps.

1) During the hospital stay, ask the patient's family or caregiver to bring in all prescription and over-the-counter medications.

2) During discharge planning, create a separate, easily readable medication schedule, versus listing it in the small space on a discharge form. Explain each medication's purpose, dose and time to the patient and caregiver.

3) If this is not feasible or there is no caregiver available, send out a home-health nurse to evaluate medication management and set up a system to improve the patient's ability to self-medicate. Systems can be as simple as putting all medication where the patient will see it, or as complex as getting the local pharmacy to fill a bubble package.

When implementing recommendations or interventions, reassess and follow up to see if patients achieve successful compliance.

ASSISTED LIVING: Monitoring medication compliance in assisted living is as much of a challenge as it is in the home setting. Providers have to balance the medical side of medication monitoring with the autonomous component of offering independence in a home-like setting.

In its April 2003 report, the Assisted Living Workgroup recommended providers address several medication-management issues, including problem identification, implementing policies and procedures to reduce medication-related errors, and educating staff and family.

The elderly often perceive they have no difficulty with medication management and will refuse to have someone administer their medicines. Hence, staff (namely nurses and aides) must consistently evaluate residents' abilities to self-medicate. Encourage your staff to review medication administration prior to admission, annually and whenever a transition in health occurs (i.e., recent hospitalization). Establish consistent policies and procedures, such as how to manage medications while residents are on vacation and how to accept a prescription refill.

It is also important to provide frequent education on medication management to your staff. Schedule in-service seminars to educate staff and residents on monitoring certain medications, screening for memory issues or managing behavioral problems.

It is further advantageous if the facility develops a relationship with one pharmacy to specially package medications, review medication regimens, provide medication records and help avoid medication-related issues.

Skilled Nursing Facilities: Medication management is different from assisted living because trained providers administer all medications to residents. Still, medication errors can and do happen. Advise your staff to minimize this with the 3 Rs: right person, right medication and right time.

Many residents are on multiple medications for several diseases, heightening the potential for these drugs to interact.

To monitor this, regulations mandate a consultant pharmacist perform drug-regimen reviews each month. While these reviews help minimize adverse medication reactions, consultant pharmacists may not be aware of significant changes in medications or a patient's adverse behavior or function until the next time they are at the facility.

Encourage staff to consult with the pharmacist to evaluate medications sooner if they suspect the medications are a potential cause of a problem.

Regardless of the care setting, medication management takes a team approach that fosters effective communication between patients, caregivers and all healthcare providers.

Nicole Brandt is assistant professor of geriatric pharmacotherapy at University of Maryland Baltimore School of Pharmacy. She is also the director of educational and clinical programs for the Lamy Center.

The MedMaIDE Project
Organizations that were involved in creating and developing the MedMaIDE include:

Baltimore City Commission on Aging and Retirement Education; Baltimore City Health Department; Catholic Charities; Housing Authority of Baltimore City; Maryland Board of Nursing; Maryland Department on Aging; University of Maryland Schools of Medicine, Nursing and Pharmacy; Geriatrics and Gerontology Education Research Foundation; Andrus Foundation.

Did You Ask?
For successful medication management, be sure to ask the following questions.

Community and Assisted Living Facility:

Is this person adhering to their medication? Evaluate via pill count, medication refill patterns, etc.

What is this medication for and how should I monitor for efficacy and toxicity?

How long will this medication be taken?

How do I administer this medication?

Is there any potential for drug-drug, drug-disease and/or drug-food interactions?

Skilled Nursing Facility:

What is this medication for and how should I monitor for efficacy and toxicity?

How long will this medication be taken?

How do I properly administer this medication?

Is there any potential for drug-drug, drug-disease and/or drug-food interactions?

Is this person experiencing any medication related problems?

- Nicole Brandt