The Medication Use Process and the Older Patient

The medication use process comprises the steps that take place between the time a health condition is recognized until after a medication is taken. This process is ideally an integrated system of actions performed by several healthcare providers working together with the patient to achieve successful outcomes.

It is useful to identify the steps, and recognize:

• How complex the overall process really is, especially in older adults
• Why success is not always achieved
• How to increase the odds of success by increasing the involvement of the patient and/or caregiver

Indeed, the more knowledgeable and even assertive the patient can be in the treatment, the better the chances for success. This highlights the importance of patient education at each step of the process. The various healthcare providers working as a team along with the patient and appropriate caregivers are more effective than they are on their own.

Keep in mind that the overall goal of this process is appropriate, effective and safe medication use. Errors leading to medication-related problems can occur with every step.

Here are the steps in the medication use process:

• Step 1: Taking the medication history
  Many older adults are under the care of multiple providers, and have multiple medical charts. Therefore, a complete history of prescription and nonprescription (including herbal) drug use must be obtained and documented for future use.
   
• Step 2: Recognizing symptoms leading to diagnosis
  This step is sometimes the recognition of a new symptom as the side effect of a change in medication. It can be triggered by a perceptive patient or family member/caregiver. The more knowledgeable a patient or caregiver is of the patient's disease or condition, the more likely he or she will recognize changes and seek advice.
   
• Step 3: Prescribing medications
  Many factors are ideally taken into consideration before prescribing medications for an older patient:
  • Medication and dosage appropriateness
  • Age, weight and gender
  • Kidney and liver function
  • Other conditions and other medications currently taken
  • Cost and convenience of therapy

  A review with the patient (and family or caregiver, if applicable and considerate of confidentiality) should follow, focusing on why and how to take the prescribed medication. The older adult deserves respect; therefore, disclose confidential information, including information about medication, only after receiving the approval of the older person to do so.

  Finally, an assessment of the patient's/caregiver's understanding and ability to follow directions completes the prescribing step. An informed patient is a critical teammate.

• Step 4: Dispensing medications
  Multiple factors are involved, including:
  • The frequent need for review of the availability of insurer-approved drugs
  • Review of the patient's profile for other medications/herbals which may interact with a new medication
  • Age and weight considerations
  • Optimal formulation for the patient, including generic/brand-name determinations

  A pharmacist trained in geriatrics is optimal, since he or she has received additional education and has been certified in geriatric pharmacotherapy (medication therapy).

  Consultation with the older person and/or caregiver is arranged to share information, reinforce proper use and answer questions. It should be done in a private area, with sensitive regard for the older patient's vision and hearing needs. The pharmacist should confirm the prescriber's assessment of the patient's or caregiver's ability to comply with directions. At a minimum, informed patients or caregivers should know the reasons for taking the medication; what/when to expect results; how to watch for signs of serious side effects; and what those side effects may be.

• Step 5: Administering medications
  This may be the most complex part of the process, especially in the older adult who may have several medications or multiple doses to take daily, complicated by vision, hearing and memory impairment. Various medication reminder systems and technologies can be helpful in promoting accurate and timely administration.

  There should ideally be other steps in the process to assess how well this step is being performed, and provide ongoing education or assistance if needed. Often, however, caregivers and healthcare providers assume that patients are using medication as directed by the prescriber, and hence decisions to continue, increase, decrease or change medications are based on faulty information. The patient and caregiver are the key team players.

• Step 6: Monitoring for effectiveness and side effects
  This step is performed on subsequent healthcare visits, as well as through patient self-management and monitoring. If the patient is aware of what to expect, the provider can be alerted earlier, and therapy can be adjusted and side effects minimized.

The many steps involved in the medication use process illustrate its complexity and how all healthcare providers - physician, nurse practitioner, pharmacist, nurse - as well as the patient and caregiver contribute to its success.