Being a nurse for over 29 years now, I have seen my share of problems with medication. As a care manager though, it was unbelievable. The overwhelming majority of individuals whose homes I would visit had severe issues with medications. The problems all fell into three categories:
1. The client was not taking medication properly.
2. The prescribers were not aware of other providers who were prescribing medication.
3. Providers were adding medications to “fix” a side effect of a different medication, which caused more issues and even more medication, starting the cascade of polypharmacy and over-medicated individuals.
As a care manager, it was my job to begin fixing the issue. To see where the client’s true baseline was before the onslaught of drugs took over. Inappropriate polypharmacy — the use of excessive or unnecessary medications — increases the risk of adverse drug effects, including falls and cognitive impairment, harmful drug interactions, and drug-disease interactions, in which a medication prescribed to treat one condition worsens another or causes a new one. (NIH, 2021)
The best place to begin is an in-home assessment. This will determine if medications are being taken properly. It is not good enough to just ask the client for an updated list of medications, they most likely have a list somewhere… outdated… the physician gave them at the last visit… which is usually not what the client is actually taking. I always asked, “Can you show me where your medications are and show me how you take them?” This is where you will find out the true state of this person’s medications. I have seen it all! Garbage bags of medication, duplicate medications from multiple pharmacies, full pill bottles filled months prior, and empty pill bottles that were a month’s worth of pills showing it was filled a very long time ago and then my client will tell me: “oh yeah, I have to get to the pharmacy to fill that.” Even after looking at the organization of the medication, bottles, prescribers, and pharmacies, there is still more you can do to get a better idea of the client’s medication situation. Also, ask the client to show you what pills they take in the morning and their routine. As they walk you through, watch to see if they know what medications they take and when. If there are pill organizers, that is great!
Make sure to ask who fills the pill organizer & look inside each day. Match the pills in the bottle to the pills inside the container. Are they filled correctly? Make notes of all the issues you see. Ask the client what they take each pill for. Is it correct? Sometimes the client begins taking medication wrong due to dementia or forgetfulness which causes more confusion and eventually a spiral of taking medication wrong leading to the decline of the individual. However, the decline can be reversed if caught early enough. Once the problem is known, the care manager can make appropriate recommendations to resolve the issue such as organizing medications, recommending medication administration machines, pill packs or other resolutions to solve the problem.
The second problem care managers often encounter is prescribers not in communication therefore medications are duplicated or have a compounding effect from polypharmacy. If you ever heard the term medication reconciliation, this is what the care manager can do to ensure the medications are correct, which will include collaboration with providers. By assessing the pill bottles as noted above, the care manager can determine what medications were prescribed by which physician. If there are discrepancies, most often, it is best to make an appointment and go with the client to both providers and discuss the full medication list including any side effects that are observed by the care manager or reported by the client or client’s family. If it is a more urgent situation, the care manager can either call the provider and try to get it straightened out sooner than later.
The third issue is when too many medications are prescribed to a client. One medication causes a side effect, so medication is added to combat that side effect, which causes more issues and more meds, and so on. There are websites available to enter in medications and get a report on the side effects of multiple medications used in conjunction. Most care managers are not able to prescribe or change medications, but it is a starting point for understanding how to help an individual. Physicians are not in the home and often don’t get the reports of what is going on in the home in the small timeframe they can spend with clients. After side effects are known and if the client is exhibiting such effects, the care manager should attend a visit with the provider and discuss the side effects and let them conclude the benefits vs risks of medications. As an example, I have seen many times, a client is falling often and the family is considering nursing home care or home care to combat falling, dementia, etc. After running a report on medications from a site (I often used Drugs.com) I would discover a side effect of dizziness. If the client is falling every day and several interactions cause dizziness, I would take that to the provider and let them know what was going on in the home and go from there.
Medications are important to bring quality of life to individuals. The care manager can bring clarity to clients, providers, and families to improve outcomes and make sure the medications are doing good and not harm and certainly not to bring a faster decline.
Resources
National Institute on Aging [NIH], (2021). The Dangers of Polypharmacy and the Case for Deprescribing in Older Adults. Retrieved from https://www.nia.nih.gov/news/dangers-polypharmacy-and-case-deprescribing-older-adults#:~:text=Inappropriate%20polypharmacy%20%E2%80%94%20the%20use%20of,or%20causes%20a%20new%20one.
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