Health Literacy Is Key to Preventing Prescription Cascade

By Kandace L. West

It’s a Saturday morning and two third-year pharmacy students and I are sitting in Norma’s living room. Norma is an 82-year-old retired elementary school teacher, and is accompanied by her two daughters, Cindy and Patty. Like many adult children caring for their aging parents, Cindy’s concern for her mother’s health and medication use is absolutely valid; she has hired me to review her mother’s medications because of concerns following Norma’s hospitalization last year.

According to the Centers for Disease Control and Prevention, medication-related problems such as adverse drug events account for more than 700,000 preventable emergency room visits per year in the United States. Because of the number of medications they take, adults ages 65 and older are twice as likely as their younger counterparts to experience this sort of hospitalization.

As Norma recalls what she most enjoyed about her career, I begin to review the 18 medication containers she has neatly arranged on her coffee table. I am a geriatric pharmacist, and run a company that consults with patients and their families on optimal medication use. Each in-home appointment begins and ends with patient education.

There is an abundance of epidemiologic studies demonstrating how low health literacy contributes to poor health outcomes. I’d like to play a part in preventing that. To that end I encourage every patient I see to question their healthcare providers when they don’t understand something that involves their health and healthcare. In this visit, the patient and her daughters voice concerns about how best to take certain medications, and recent changes in the patient’s health and behavior, including increasing nighttime confusion. All of this helps me figure out how much the patient and her family understand about her health and the goals of therapy.

Then I go to work filling in these gaps in knowledge. I explain to the patient and her family the role of each medication (this includes all prescriptions, over-the-counters, herbals and supplements), proper dosages, ideal method for administration, necessary monitoring and follow-up and, most importantly, whether or not the patient needs all the medications she’s taking.

I like everyone in the room—students, the patient, her daughters—to be clear on why Norma has been prescribed all her medications, but paramount among them is her prescription for lorazepam (a benzodiazepine used for anxiety). Lorazepam is a potent anxiolytic and, given her age and medical history, the likely cause of Norma’s confusion. The case grows stronger when her family tells me she has recently become unsteady on her feet. Benzodiazepines like lorazepam raise the risk of falls in all age groups because of they are sedatives, but their treatment effects are more pronounced in older adults because of elders’ physiological changes. Such changes decrease metabolism and can cause medication to build up to toxic levels. I discuss this with the family and recommend viable, non-pharmacologic alternatives for treating Norma’s anxiety, as well as safer, almost equally efficacious pharmacologic therapies to discuss with her primary care physician.

We also talk about referring Norma for a cognitive evaluation, to make sure there are no other underlying causes for her increasing confusion. Weeks later, after she had followed up with her primary care physician, who safely titrated her off lorazepam, her confusion and gait had significantly improved.

Medications have the potential to do great good, but they also have the potential to do harm. In this instance, one medication was detrimental in two ways, and communicating that with both the patient and provider helped this patient avoid a medication-related fall, necessitating a prolonged hospitalization. In older adults, such an event usually causes a domino effect leading to declining health.

The field of pharmacy practice continues to evolve, and as a geriatric pharmacist I strive to be the steward of safe and appropriate medication use, ensuring that my patients (e.g., aging adults) do not fall victim to polypharmacy, inappropriate medication use and other medication-related problems. I continue to train students on the job, in order to afford them the opportunity to experience the numerous clinical interventions geriatric pharmacists can make to help improve the health and lives of others. (For a list of potentially inappropriate medications in the elderly, consult the American Geriatrics Society Beers Criteria.)

Kandace L. West, Pharm.D., is a certified geriatric pharmacist, who graduated from the USC School of Pharmacy, where she continues instructing the next generation of clinical pharmacists. She founded and operates Pharmacist Integrative Healthcare, which focuses on optimizing medication therapy, including prioritizing safe and appropriate medication use in all age groups, but especially the elderly. She can be reached at

This article was brought to you by ASA’s Healthcare and Aging Network.

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