Just one more day with her best friend: her mother. That was the ardent wish of one western Oklahoma resident last August, when her mother was admitted to the hospital, unable to communicate, hallucinating and no longer able to care for herself. Thanks to the advice and counsel of a University of Oklahoma pharmacist versed in the special medication needs of older patients, that wish was not only granted, but also extended for a precious, undetermined amount of time.
When her mother was hospitalized, following a period of decline in which she suffered several falls and a marked deterioration in her mental faculties, the devastating diagnosis was Alzheimer’s. Her daughter, Kim Roof, and other family members feared the worst: institutionalization. But then a friend of Kim’s recommended she place a call to an OU pharmacy professor, Dr. Mark A. Stratton, who also serves as the Langsam Endowed Chair in Geriatric Pharmacy and director of the Institute for Geriatric Pharmacy.
Stratton readily agreed to review the case. He discovered that the patient was taking six medications from different doctors, prescribed over several years. He counseled Kim that, for older patients, the side effects of some of these medications were commonly worse than the condition(s) being treated. He guided her through some questions to ask the doctors treating her mother at the hospital to determine which medications should be kept, which discarded. He also recommended the patient discontinue the use of an older antihistamine.
The results were next to miraculous. Though the Alzheimer’s has taken her mother’s short-term memory, Kim says that since following Stratton’s advice, the older woman “has never felt better.” Significantly, she has neither fallen nor experienced hallucinations since her medications were changed.
Kim recommends that anyone who is a caregiver to an elderly person in a similar situation consult Stratton and the other experts at the OU Institute for Geriatric Pharmacy. “He’s very knowledgeable—and a very nice guy, very personable. It was a very positive experience,” she says.
Dr. Jane Fitch, John L. Plewes Professor and chair of the Department of Anesthesiology in the OU College of Medicine, is fortunate to have elderly parents who are still in relatively good health. Now in their late 80s, they continue to live, with the help of a part-time caretaker, in their own home. However, when her parents called her last fall to request help in sorting through the confusing offering of Medicare Part D options being advertised in their home state (North Carolina), she was stumped. She called the interim chair of the Department of Geriatrics, Dr. David Staats, for advice; he suggested she talk to Stratton.
Less than two weeks after receiving her request for help, Stratton sent back his recommendations, which were for her parents to stay with their current coverage.
“He was just awesome!” she says. “He went above and beyond the call of duty. I told him about their illnesses, what drugs they were taking, and so on. He decided that all of the medications they were taking were appropriate for their illnesses and their age, and more importantly, he looked at their existing coverage through Medicare and their private insurer and did the homework, looking at the Medicare drug plan options in North Carolina, including the so-called ‘doughnut’ hole, and made the recommendation that what they have is the best option. That was just invaluable information. It gave them piece of mind. That kind of resource is priceless for anyone who is caring for their parents. It’s a great resource, a valuable gem on this campus.”
She adds, “This whole incident highlighted for me the importance of geriatrics-related care. We need more people who have this as their area of expertise and are educated and trained in this area to help us deal with these complex issues.”
It has been called “America’s Other Drug Problem.” Stratton calls it a “public health catastrophe.”
By whatever name, Stratton has made it his life mission to reduce the over-use and inappropriate use of medications among the elderly, which leads to countless, needless deaths, hospitalizations and suffering.
Quick Facts on Aging
• While the older population—those over 65—comprise only 13 percent of the U.S. population, they take more than 30 percent of the prescription drugs sold.
• More than half of deaths each year resulting from problems associated with prescription drugs occur in the older population. That translates into 50,000 to 75,000 deaths, making drug-related mortality the fifth-leading cause of death among America’s elders.
• Nearly 40 percent of annual hospitalizations due to problems associated with prescription drugs occur in this population.
• One-fourth to one-third of all hospitalizations of people over 65 are thought to be a consequence of some type of problem with their medications.
• Prescription misuse among this population may cost the U.S. health care system close to a staggering $200 billion annually.
• Older people experience adverse effects from medications at three times the rate of younger people.
The Institute for Geriatric Pharmacy includes four Certified Geriatric Pharmacists: Stratton and Dr. Keith Swanson, based in Oklahoma City, and Dr. Kimberly Crosby and Dr. Nancy Brahm at the OU-Tulsa Schusterman Center. Stratton and his colleagues are striving through education, outreach and research to improve the outcomes from drug therapy in older people.
Stratton points out that medication-related deaths are estimated to be the fifth leading cause of death among the elderly. Half of these are considered by experts to be entirely preventable through better education of prescribers and seniors themselves.
Educating seniors and senior caregivers begins with the basics: learn the danger signs.
“My rule of thumb is, when seniors or their caregivers notice a change in the quality of an individual’s day-to-day life—and there’s no readily available reason for that change—look at the medications they are taking,” Stratton says. “I worry that the medications may be causing changes in their mental state, as well as changes in gait and balance, which can all lead to other significant issues, like falling, unexplained fractures and automobile accidents. We then look at more subtle signs, such as changes in their interpersonal relationships or an inability to care for themselves.”
Many people—doctors included—may incorrectly assume that these symptoms signal the onset of Alzheimer’s or other mental disorders. And it may take an investigation worthy of a crime scene investigator to discover otherwise.
Stratton recalls a recent incident involving an 82-year-old woman, who came to the clinic complaining of excessive tiredness that was preventing her from grocery shopping, driving or enjoying activities with her husband. He reviewed her medications and saw that she had been taking a potent anti-anxiety drug for 17 years. “As we age,” he explains, “our bodies change how we process medications. Just because someone has been on something for a long time doesn’t mean the medication isn’t at fault.” He recommended to the woman’s doctor that she be taken off of that medication.
On another occasion, he was asked by a family to look into why an 81-year-old northwest Oklahoma resident was sleeping so much. They also were alarmed at some observed mental changes, as well as other problems, including gait issues, a failure to successfully regulate his blood pressure and an ulcer, which sent him to the hospital. The family located Stratton through the Internet and asked for his help. Upon investigating, Stratton determined that the elderly man was seeing several different primary care doctors and specialists and that he was taking some 22 prescribed medicines, over-the-counter and herbal products. After working with the family and a new doctor who understood the special needs of the elderly, they were able to stop many of these medications, which led to an improved quality of life.
Stratton’s search for answers often leads to common sources that may seem innocuous. Common culprits include over-the-counter cold and allergy medications, nighttime pain relievers and sleep aids. “Many of these over-the-counter products contain antihistamines that can cause drowsiness, confusion, delirium, and gait and balance problems,” he says. “As we get older, changes occur in the processes of absorption, distribution, metabolism and elimination of medications. We get more sensitive. What we could take at 60, we might not tolerate at 80. Our kidneys and livers become less effective filters; our brains become more sensitive.”
Medication Tips for Seniors
Dr. Mark Stratton suggests that seniors:
• Tell their doctor and pharmacist not only about the prescription medications they are taking, but also any over-the-counter, herbal or alternative remedies. These, too, contain active drugs, which can cause side effects.
• Be especially wary of medications used for pain, anxiety, insomnia or depression, as older people are especially sensitive to these types of medications, increasing the risk of falls and other accidents, as well as lowering mental clarity.
• On multiple medications prescribed by different physicians, or when using more than one pharmacy, request that medications be screened for potential drug-drug interactions.
• Immediately report possible drug side effects to their doctors or pharmacists. In most instances, within each class of drugs, there exist medications with minimal risk of side effects in older people.
• Always ask the name of a new prescribed medication, what it is used for, how it should be taken and for how long, its possible side effects, its cost and if a generic equivalent is available.
• Use a single pharmacy and get to know the pharmacist.
• Take all medications (prescription, OTC and herbal) or a current list to every doctor visit. A current list of medications should be kept on the person at all times.
• Keep all medications in one place. Perform a yearly inventory of medications and properly dispose of outdated or unused medications.
In an effort to educate the geriatric population, their families and caregivers, he and other members of the institute offer a number of public outreach services throughout the year, including some that are held in concert with agencies on aging. At Brown Bag Medication Reviews—held at various venues across the state, such as retirement villas, churches and senior citizens centers—they discuss common medication mistakes and review lists of medications audience members are taking to check for possible dangerous interactions and other issues.
He and his staff also offer several opportunities for educational and other training for current members of the medical and pharmacy communities, as well as students enrolled not only in the College of Pharmacy, but also in the colleges of medicine and dentistry. Through grand rounds, seminars, classes, continuing education programs and other activities, their goal “is to assist current and future physicians, physician assistants, nurse practitioners, dentists and others how to more rationally use medications in this population in order to decrease the risk of unnecessary hospital visits or even deaths,” he says.
“We teach those students who are on their way to becoming prescribers to consider carefully what particular drug or drugs, and at what dosage, are appropriate for each patient. We teach them to integrate a number of factors in order to reach the best possible outcome at the least risk to that patient. We teach them to avoid inappropriate or unnecessary prescribing which can lead to significant functional and cognitive declines that can ultimately lead to institutionalization.”
Stratton blames today’s fragmented health care system, in which patients are sent to multiple doctors and specialists with no central oversight, for part of this growing problem. Another contributing factor is the proliferation of new medications for just about every ailment known to man, which are marketed directly to the consumer. While pushing for a wide range of health care reforms on the national level, he is a firm believer that consumers should take upon themselves some responsibility for self-education. (See “Medication Tips for Seniors” above.) He also points to the Beers List of potentially inappropriate medications for the elderly, which can be found online, as an excellent starting point for research.
Of course, if further help is needed, the experts at the OU Institute for Geriatric Pharmacy are available. In Oklahoma City, Dr. Mark Stratton can be reached at (405) 271-6878, Ext. 47240 or Ext. 47102. In Tulsa, Dr. Kimberly Crosby is at (918) 660-3588. More information can be found at http://pharmacy.ouhsc.edu/geriatric.
Jerri Culpepper writes freelance articles for Sooner Magazine