Just as we all benefit when we all are better informed about health, everyone involved in the health care of older adults can benefit from learning to think more like a geriatrician.
This means keeping certain guiding principles in mind. It also means watching for certain common pitfalls, when it comes to the medical care of aging adults.
In 2016, the most important principles of geriatric care were distilled down to a “4 Ms” model for age-friendly care:
- Mentation: preventing, identifying, treating and managing mental health and cognitive conditions
- Mobility: helping older adults avoid falls and remain mobile, for maximum independence
- Medication: optimizing medication use to avoid harm and improve health
- What Matters: ensuring that medical care addresses what matters most to an older person and is aligned with their specific health goals and care preferences
Problems in aging health are especially common when it comes to medications. So geriatricians always pay attention to what drugs have been prescribed, and why. Then we often improve an older person’s health by suggesting changes to their medications.
In this article, I’ll share five geriatrics medication safety truths that I often find myself explaining to families. They are what I always keep in mind as I do my work, as they are the foundation for better prescribing in aging adults, as well as for checking an older adult’s medications for safety and appropriateness.
I tell people these medication safety truths because I know that most older adults will not have their medications regularly reviewed by a geriatrician or geriatric pharmacist.
But with the right knowledge, you’ll be better prepared to ask your doctors the right questions. This can help them address common oversights, and can improve the safety of your medications.
Here’s what you should know, along with tips on what you can do:
1. Fewer medications is often safer
That’s because the more medications an older adults takes, the greater the chance of side-effects, interactions, and emergencies due to adverse events.
(A side-effect would be something like dry mouth from a depression drug. An adverse event is something like internal bleeding due to taking a blood-thinner.)
Fewer medications also means lower drug costs and pill burden, which means an older person is more likely to keep taking their medications in the long run. Now, after careful review we sometimes find that it’s not possible to reduce the number of medications. But it’s still a good goal to keep in mind.
What you can do: Periodically tell the doctors that you’d prefer to be on fewer medications if possible. Ask the doctors – or a pharmacist — to help you identify any medications that could perhaps be eliminated. In some cases, it may be possible to treat a problem with non-drug therapies instead. (See below.)
2. Non-drug treatments are often safer and can be equally effective
These include psychotherapy, exercise and social activities for depression, physical therapy for pain, watchful waiting for minor problems, or behavior management for dementia agitation. Although these may take more effort to implement initially, they often are better for older adults and families in the long run.
But many doctors are used to recommending prescription medication as a default. So don’t assume they will tell you about non-drug treatment options automatically; like all busy people they tend to fall back on their habits.
What you can do: Whenever a doctor proposes a prescription medication treatment for a given problem, be sure to ask about non-drug treatment options too. The doctor should be happy to review these once you’ve expressed your interest.
3. Medications often get “forgotten”
When I review an older person’s medications, I often find medications that seem to have been “forgotten.” It might be a drug that was initially prescribed in the hospital but isn’t still needed. Or it might be a starter dose of a medication that perhaps should’ve been increased (or stopped, if a problem such as depression has improved).
This happens in part because many medical visits are relatively short, which can make it hard for clinicians to carefully review all medications to make sure they are all needed, and at the right dosage. So don’t assume that a renewed prescription means a doctor has carefully thought through the need for the medication. It’s much better to plan on actively reviewing the need for every medication, on at least a yearly basis.
What you can do: If a medication was recently added during a hospitalization, make sure the primary care doctor checks up on it at a later follow-up visit. You can also request a comprehensive medication review, which usually means that all medications are re-evaluated for appropriateness and safety.
4. Doctors often prescribe medications that are on the Beer’s list
This is a list of medications that older adults should avoid or use with caution. Despite ongoing efforts to make sure that all doctors are trained to modify healthcare as needed for older adults, it still remains common for these medications to be prescribed, without documentation that the benefits and risks have been discussed with the older patient.
In general, older adults and their families should not assume that their doctors have carefully thought through the risks of using these drugs in an older person. It’s much safer to plan on nudging the doctor to identify and reconsider these drugs. Pharmacists are also a good resource, for spotting these drugs.
What you can do: Check and see if any of your parent’s medications are on the Beer’s list. (It’s often easiest to open the Beer’s list on a computer and use the search function to see if any of your parent’s medications are on the list.) If you discover that your parent is taking medications that are on the Beer’s list, you can use my video below as a guide.
5. When considering a particular medication, the goal is to properly weigh the pros and cons
It’s not ideal for an older person to be taking a medication on the Beer’s list. But sometimes it makes sense, when the likely pros outweigh the likely downsides.
The key is to be choosing medications intentionally and judiciously.
In geriatrics, we often call this “balancing the benefits and burdens.”
Burdens include consistent downsides (like cost or hassle) which definitely affect an older person, as well as the risks (like side-effects or interactions) which will only affect a minority of aging adults.
Risks can often be reduced with a lower dosage of a medication. For instance, studies suggest that for most people, a medium dose of cholesterol medication is almost as beneficial as a high dose, but it causes problems less often. Also, bear in mind that doctors may not understand how much cost, hassle, or burden a medication causes, unless you tell them.
What you can do: When considering starting or continuing a medication, plan on asking the doctor to clarify the likely benefit, along with the risk. The likely benefit is often smaller than people realize, as is explained in this excellent article about medication.
Remember, healthcare works best when it’s a partnership between patients, family caregivers, and doctors.
By understanding best practices in prescribing for older adults, and by learning about common pitfalls in medication safety, you’ll be better able to ensure you’re getting the medications you need, and avoiding medications you don’t need.
You can also learn more about eliminating unneeded medications here: Deprescribing: How to Be on Less Medication for Healthier Aging.
