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                                           Chapter 13
                               Use of Medications by Elders
              Brenda M. Coppard, Kelli Coover, and Michele Faulkner
Key Terms
self-medication, over-the-counter, polypharmacy, adverse drug reactions, side effects, drug
                                     Chapter Objectives
1. Identify factors that predispose elders to adverse drug events, and discuss strategies to detect
medication problems.
2. Define polypharmacy and identify recommended interventions to diminish drug-related
problems of polypharmacy in elders.
3. Identify classes of medications commonly associated with adverse drug reactions in elders.
4. Identify and describe skills needed for safe self-medication.
5. Apply the OT Practice Framework: Domain and Process, second edition, to analyze self-
medication for individuals with various conditions.
6. Explain the ways that adaptive devices compensate for skills needed for safe self-medication.
7. Describe elder and caregiver education needs regarding self-medication.
Ashley is a certified occupational therapy assistant (COTA) working in a skilled nursing facility
3 days a week. Her time for seeing the residents is dependent upon the needs of the facility. One
of the residents she follows is Anna, a 79-year-old woman with a history of a recent stroke, high
blood pressure, depression, and insomnia. Ashley has noticed changes in Anna’s alertness and
behavior, based on the time of day that she is seen for intervention. When Ashley follows Anna
in the morning, she seems very tired, unfocused, and often complains of dizziness. Ashley has
found such morning therapy sessions to be less productive toward meeting Anna’s intervention
goals. When she sees Anna in the afternoon, she seems to be almost a completely different
person, exhibiting much more energy and enthusiasm to do intervention tasks. Ashley began to
question the inconsistency of Anna’s behaviors. Could Anna be experiencing poor sleep,
resulting in the morning fatigue? But why the dizziness? Is Anna more depressed? If that is the
case, why does she seem to be in a much better mood in the afternoon? Ashley also questions
whether the behavioral differences could be related to the medications that Anna is taking.

Ashley decides to consult with the treatment team about Anna’s inconsistent behavior and her

       The other health care practitioners on the treatment team are a physical therapist, a nurse,
a speech therapist, and a pharmacist. There is much discussion about Anna because other
members of the treatment team have noticed her inconsistent behavior, too. Some members
suggest asking for lab work to review lab level values. The pharmacist, Roger, looks at Anna’s
medications and points out a possible correlation between the timing and the dosages of the
medications with the behaviors that Anna is exhibiting. He questions whether Anna is
experiencing some common side effects from the medications that she is taking and informs the
team that he plans to consult about Anna’s medication with her physician. The following week
when Ashley follows Anna for the morning intervention sessions, she is much better focused.
Ashley learns that as a result of the team meeting, Anna’s medications were readjusted.

   COTAs often work with elders on a daily basis in a variety of treatment settings. Because
COTAs spend a considerable amount of time with the elder population, they are a valuable asset
in addressing medication routines. COTAs also may convey vital information regarding
medications and side effects to the health care team. When specific medication information is
required, advice should be sought from a pharmacist or other medication expert. Common
medications and medication-related problems encountered by elders are discussed in the chapter.
Skills for self-medication and intervention programs for elders and caregivers are also discussed.

Factors Affecting Medication Risk in Elders
Elders consume the majority of prescription and over-the-counter (OTC) medications in the
United States. Because of the aging population and individuals are living longer, often with
chronic diseases that require medication therapy, it is no surprise that over 40% of elders in the
community take at least five prescription medications.1 When OTCs are included, the number of
medications consumed per day often exceeds 10 or more. It is important to note that natural
products (such as health foods, supplements, and vitamins) may also be consumed by this
population. Yet because they are erroneously not considered medications by some, they may not
be reported when an elder is questioned about medication use.

Several components contribute to the incidence of polypharmacy (use of multiple medications in
a single individual). Sometimes the use of many medications is the right thing for patients to
control their diseases and ensure a better quality of life. However, there are risks associated with
polypharmacy. Drug interactions happen with increased frequency the more drugs that a person

consumes. These interactions may include the increase or decrease in effectiveness of one drug
caused by another or a more pronounced manifestation of an adverse event due to the elder
taking two drugs that have a similar side-effect profile. In addition, sometimes new medications
are introduced for the specific reason of offsetting a troublesome effect caused by another.
Providing new medications may be appropriate, but this scenario often occurs because the
problem is not recognized as drug-induced. Risk factors that contribute to polypharmacy include
the use of multiple physicians with different specialties who may prescribe similar medications,
the use of multiple pharmacies, inappropriate medication reconciliation upon discharge from the
hospital, and the fact that elders often have multiple conditions requiring medication therapy.

Physiology and the Aging Process
Many factors are involved in the increased incidence of medication-related adverse events in
elders. With aging, kidney and liver functions decline. Many medications are excreted by the
kidney and metabolized, or degraded, by the liver. Therefore, changes in organ function may
frequently lead to drug accumulation in the body. This accumulation may result in toxic levels of
drugs. To avoid drug accumulation, it is imperative that consideration be given to modifying
doses for older individuals.

       Although not all of the reasons are well understood, older persons tend to be more
sensitive to the effects of certain medications. Body composition (lean tissue to fat ratio) changes
as we age. Changes in body composition may result in alterations in how the body distributes a
medication, making more or less of the drug available to have an effect. This is true for both the
desired effects and for unwanted side effects. The adage “start low, go slow” should generally be
used when initiating a new medication therapy in an older person.

Elder Medication Use and Implications for the COTA
When medical records are available, COTAs should always check the medication section to
determine which medications are being used. This information helps COTAs be aware of
possible side effects and drug interactions that might be observed with clinical intervention.
COTAs should contact the elders’ physicians and pharmacies with any medication-related
concerns or questions. (Common drug-related abbreviations and definitions are listed in Table
13-1. Medications commonly used by elders are listed in Table 13-2. Note that this is not an all-
inclusive listing of medications used by elders or those that may contribute to side effects. Only
generic names are listed, and they should be cross referenced with trade names when necessary.)
  Cardiovascular diseases (high blood pressure, congestive heart failure, irregular heart rhythm,
chest pain, heart attack, and stroke) are common in the older population. Medications used to

treat these diseases may alter a patient’s blood pressure and/or heart rate, resulting in dizziness
and the potential for falls. One class of medication, the diuretics, may cause excessive urination.
As such it is recommended that nighttime dosing be avoided because of the risk of falls and
interruption in rest. COTAs may notice that the client needs frequent breaks during therapy to use
the restroom, and that the timing of the medication dose may need to be altered to avoid this.
Persons taking one or more of the medication types mentioned previously should be closely
monitored during therapy for the emergence of side effects, and consideration should be given to
routine monitoring of blood pressure by the COTA. In addition, many of these same clients will
be using medications to treat high cholesterol. Some of these drugs may cause diffuse muscle
pain when they are started, with a dose increase, or with the addition of another medication,
which may increase blood levels of the former. The COTA can help identify this type of drug-
induced musculoskeletal pain and see to it that it is addressed by the appropriate individual
because, in some cases, the consequences of this side effect can be severe and even life

        Drugs that affect the blood’s ability to clot are also frequently used in persons with
cardiovascular diseases. The COTA must be aware that the client is using one of these agents as
the risk of a serious bleed is increased and therapy may have to be adjusted. One sign associated
with the use of these medications is easy bruising. This is not necessarily unexpected, but if the
COTA believes that the amount of bruising is excessive, he or she may wish to refer the patient
to have the medication therapy evaluated.

         Another common complaint of elders is pain, which can be either chronic (such as
arthritis pain) or short-term because of an acute injury. The use of OTC pain medications is
common when elders choose to self-treat. These medications include acetaminophen, aspirin,
ibuprofen, and naproxen. Commonly observed side effects associated with these agents include
gastrointestinal distress (which may be a symptom of a more serious condition such as a stomach
ulcer) and increases in blood pressure because some of these medications can cause fluid
retention. With more severe pain, prescription medications are used. Most prescription pain
medications (primarily narcotics such as codeine, hydrocodone, oxycodone, and morphine) exert
their action in the central nervous system and therefore may cause dizziness, drowsiness, and
confusion. These symptoms add to the risk of falls and may make successful therapeutic
intervention by the COTA a challenge if the client is unable to fully participate because of
cognitive impairment.

       Many older persons experience a variety of psychosocial, psychiatric, and cognitive
disorders. Drugs that may be used to treat such diagnoses include antipsychotics, antidepressants,
anti-anxiety agents, and medications used to slow the progression of cognitive impairment, such

as those used in the treatment of Alzheimer’s dementia. These medications are all active in the
central nervous system and therefore have the potential to affect sensorium, alertness, and
balance. Additionally, some of them may have effects on other body systems causing
disturbances in sleep and bodily functions (dry eyes, dry mouth, urinary retention, constipation,
elevated heart rate, and the inability to perspire). Some of the agents used to treat psychosis also
cause extrapyramidal symptoms that may manifest as abnormal movements of the limbs, head,
neck, and the tongue. Sometimes these symptoms can be controlled with another medication or
by discontinuing the offending agent. However, other times the benefit of continuing the
medication may outweigh the risk associated with developing these symptoms, and the client and
COTA may need to find a way to work around them. Furthermore, use of these medications is
likely to aid the COTA in working with a client when symptoms of these types of disorders are

        Sleep disturbances are frequently encountered by the older person. Such disturbances
include the inability to fall asleep, early morning awakening, and daytime drowsiness. Sleep-
inducing medications are often used to help older persons sleep. However, it is important to note
that as people age, they need fewer hours of sleep, and education of elders is necessary to help
them differentiate between insomnia and the normal aging process as it pertains to sleep. Some
sleep agents may cause clients to be drowsy during the morning hours, which may interfere with
the therapy process. Proper sleep hygiene (going to bed and getting up at the same time each day,
minimizing daytime napping, using the bed for sleep and sex only, and avoidance of caffeine and
exercise late in the day) can make a large difference in the client’s ability to fully participate in
therapy. If daytime drowsiness is a concern, the COTA may wish to inquire about the use of
sleep agents (both prescription and OTC) to determine whether a change needs to be made.

       As persons age, the diagnosis of diabetes becomes more common. Drugs used for the
treatment of elevated blood glucose are associated with several side effects that may be observed
by the COTA. The most common of these is hypoglycemia, or low-blood glucose. Symptoms
associated with hypoglycemia include sweating, dizziness, weakness, tremor, elevated heart rate,
and confusion. These symptoms may be more common if the client has not had a normal amount
of food before therapy. Additionally, diabetes can cause impaired sensation in the extremities,
also known as neuropathy. This can result in numbness or extreme pain and may present a
substantial challenge for the COTA. It is important that therapy be tailored for elders with
impaired sensation to ensure that they remain safe during therapy and in their living environment.
Medications are available to help with the pain of neuropathy, and the COTA may wish to refer
patients if the pain interferes with quality of life.

        Although not a normal part of aging, urinary incontinence may be frequently encountered
in the elderly population. Incontinence presents its own challenges such as those associated with
frequent toileting and skin breakdown as a result of excessive exposure to moisture. Medications
used to treat one type of incontinence, overactive bladder or “urge” incontinence, can cause a
multitude of side effects similar to those mentioned as associated with the psychoactive
medications (dry eyes, dry mouth, urinary retention, constipation, elevated heart rate, and the
inability to perspire).

Strategies for Minimizing Medication Problems in Elders
There are multiple reasons why older adults may be at higher risk for medication problems than
younger persons. It is imperative that health care providers ensure that clients can safely manage
their medications. Psychiatric diagnoses, such as dementia and depression, are common in this
population and may affect the client’s ability to manage drug therapy without assistance. Often
the first indication that there may be a problem in this area is the inability to manage other daily
tasks such as keeping good finances or managing basic household responsibilities.

       The older generation is often apprehensive when it comes to questioning health care
providers, and this may lead to a lack of active participation in their own care. In many cases, a
medication regimen can be simplified, but if the health care provider is not asked to do this, it is
unlikely to occur. Additionally, if information about medications or their side effects is not
readily offered, an older person might not directly ask about such things, and this may lead to
underrecognition of side effects. It is also important that clients understand why they are taking
each medication and its intended purpose so that they may self-monitor for problems.

        There are many reasons that clients may not adhere to a medication regimen as
prescribed. Over-adherence may occur, either by mistake because clients cannot remember
whether a medication has already been taken, or because they may believe that “if a little is good,
more must be better.” On the other hand, under-adherence also occurs for various reasons.
Avoidance of side effects may lead a client to skip doses. Additionally, if money is a concern,
clients may choose to alter their regimen by deliberately taking a medication less often than
recommended. Cutting pills in half and taking partial doses is another common occurrence when
saving money is an issue.

       Self-treatment of symptoms or side effects with OTC medications may also result in
problems. Although OTC medications are available without a prescription, it is incorrect to
believe that they are without risks. Drug interactions may occur with medications that have
previously been prescribed. It is also incorrect to believe that “natural” products are inherently

safe because they, too, may interact with other drugs and cause side effects that may be more
difficult to recognize because of a lack of regulation and standardization.

Application of the Occupational Therapy Process to Self-Medication
Medication routines of clients are often not addressed by OT.2 This is evident in the lack of
literature on self-medication programs and OT interventions with medication routines.
Medication routines are instrumental activities of daily living (IADL). According to the
Occupational Therapy Practice Framework: Domain and Process (second edition), medication
routines are classified as a health management and maintenance IADL.3 Thus, assessment of
routines and instruction in proper use of medication should be dealt with as part of activities of
daily living (ADL) routines.4 Participation in one’s medication routine includes obtaining
medication, opening and closing containers, following prescribed schedules, taking correct
quantities, reporting problems and adverse effects, and administering correct quantities by using
prescribed methods.

Client Factors
Values, beliefs, spirituality, body functions, and body structures that reside within the client and
may affect performance in medication routines should be analyzed by the registered occupational
therapist (OTR) and COTA. This section overviews how each of these client factors can
potentially impact one’s medication routine.

Values, Beliefs, and Spirituality
A variety of factors related to adherence to medication routines has been researched, including
people’s values and beliefs. The self-regulations theory5,6 is a patient-centered understanding to
such factors that affect adherence. The theory suggests that people attempt to understand their
illness by developing a representation of their illness, its causes, its effects, the duration of the
illness, and whether the illness can be cured or controlled. In this view, it is thought that people
are motivated to reduce their health-related risks and will work on eliminating health threats in
ways that are congruent with their perceptions.

       In addition to forming representations of illness, it is hypothesized that clients also form
representations of their treatments.7 Researchers have demonstrated the link between values and
behaviors.8-10 Decisions about taking medication are likely to be affected by the beliefs about the
medicines, the illness, and the treatment providers.11 Values are often the underpinnings of
behaviors. People typically decide what is important for them and then act on such decisions.
Although a paucity of literature exists on the influence of spirituality on medication routines,

persons diagnosed with terminal illnesses have reported a high level of spirituality (and they have
been correlated highly with psychological adaptation and positive health outcomes).12-14

Bodily Functions
Bodily functions are “physiological functions of body systems (including psychological
functions)” (p. 635).3 Bodily functions affect one’s ability to perform and participate in an
occupation. Medication routines require extensive performance from multiple bodily functions,
including the following:
   Mental functions
   Sensory functions and pain
   Neuromusculoskeletal and movement-related functions
   Cardiovascular, hematological, immunological, and respiratory system function
   Voice and speech function
   Digestive, metabolic, and endocrine system function
   Genitourinary and reproductive functions
   Skin and related structure functions

Mental Functions
Both long-term and a working memory15 are required for independent self-medication. Elders
need long-term memory to understand which condition is being treated and the purpose for the
medication(s) they take. Understanding and remembering the nature of the regimen also is
required for self-medication. Elders use long-term memory to remember where the medication is
stored. Working memory, which includes simultaneous storing and processing of information, is
needed to avoid under medication or overmedication. This frequently occurs when elders do not
remember whether they took a medication. Various items such as programmable alarms or
auditory devices that exclaim, “time to take your pill,” and pill storage boxes can aid self-
medication. Home health aides and pharmacists may assist in filling self-medication boxes. A fee
may be charged for this service. One advantage of involving home health aid or a pharmacist is
that they can make sure the elder is actually taking the medicine, as prescribed, when it is time to
refill the storage container.

       A great deal of problem solving is needed to properly self-medicate. Elders must decide
whether to contact the physician when changes in a condition occur. For example, Ken goes to
his physician because he wonders whether his frequent headaches indicate that his blood pressure
medication is not working or whether he needs a new prescription for his glasses. Problem
solving also is needed to determine when refills need to be obtained and how to safely store

medication. Even more complex is the problem solving that is needed to determine Medicare
prescription plan options.16 Some pharmacies and health care agencies will provide
individualized consults for elders who need assistance in understanding and choosing such plans.

        Elders must be motivated to comply with their medication regimen. Depression,
uncertainty, misunderstanding, financial worries, lack of confidence, side effects, and social or
cultural taboos are all factors that may contribute to a lack of motivation. For example, Hazel, a
74-year-old woman with a history of heart failure and high blood pressure, sometimes takes her
captopril tablets once a day instead of three times a day. Hazel does this when she feels “better”
to save money. In addition, some elders are embarrassed by the diagnosis of depression, or other
emotional disorders, and are reluctant to take prescribed antidepressants or other medicines used
to treat psychological problems.

Sensory Functions and Pain
Visual perception skills may be required by elders who take multiple medications. Visual
perception skills include color discrimination, depth perception, and figure-ground perception.
Visual acuity and perception are required to distinguish between different containers of
medication and to read instruction labels. If needed, glasses should be worn when elders self-
medicate. Adaptations may be used to assist elders who have visual impairments (Figure 13-1).
Magnifying lenses and large type or contrasting print may be helpful. For severe visual
impairments, different size, different shape, or multicolor containers can be used for medication
storage. Instructions for administration can be tape recorded to relay information that cannot be
read. Depth perception skills are needed to obtain pills in a multipartition container. Figure-
ground perception also is needed to see white pills in a white pill box. COTAs should suggest
that elders use colored pill containers for white pills.
       According to the Deafness Research Foundation, there is a relationship between age and
hearing loss. For example, 30% of adults who are ages 65 to 74 years and 47% of adults age 75
years and older have a hearing impairment.17 COTAs should remember this when educating
elders, family members, and caregivers. The ability to hear is important for elders to understand
patient education, medication dosages, and changes. COTAs should provide both verbal and
written instructions when educating elders. For example, Kathy, a COTA, meets with Vladimir,
who has difficulty hearing, to review his discharge program. She first checks to make sure
Vladimir is wearing his hearing aid and then reviews the information in his client education
packet. Kathy speaks slowly and clearly and is sitting directly at eye level with Vladimir. She
also frequently asks Vladimir whether he has any questions and encourages him to repeat back to
her what he understands (see Chapter 16).

Neuromusculoskeletal and Movement-Related Functions
Usually a great deal of fine motor coordination, finger dexterity, and some degree of strength are
needed to open and close medication containers and use syringes. Fine grasp patterns are required
when picking up pills or tablets. Therefore, elders with conditions such as rheumatoid arthritis or
Parkinson’s disease may have difficulty opening childproof containers. Non-childproof tops can
be provided by the pharmacist, if requested. If nonsafety caps are dispensed by the pharmacist, it
is essential that elders store their medication out of the reach of children.

       Manipulating medication containers requires strength. Occasionally, a medication routine
involves crushing pills or splitting them in half. Such assists as pill crushers and pill splinters can
help an elder who has poor hand strength. Elders should never use a razor blade to cut tablets.
Many medications are released over time (known as extended or sustained release) and should
not be crushed. A pharmacist is an invaluable resource person to find out whether a tablet can be
crushed. Furthermore, sometimes a liquid form of the medication (if available) may be a better
choice for an elder who needs to crush several medicines.

        Elders taking medications need to have a way of getting prescriptions filled on a regular
basis. Elders who do not drive or are wheelchair-bound may need to seek out community
resources to obtain rides to medical appointments and the pharmacy. Some pharmacies will
deliver medications for a fee. In addition, some communities have volunteer programs that
provide this transportation service at no cost. For example, Antonio is unable to drive because of
his poor vision, but he is able to renew prescriptions by using a free transportation service
provided by his church. Automated systems are available at many pharmacies, which allow
people to renew their prescriptions over the phone. Some pharmacies also provide automatic
refill service for maintenance prescription medications.
       It is estimated that 35% to 68% of persons over age 65 have some degree of swallowing
dysfunction.18 Patients and caregivers (N = 477) were surveyed about swallowing medicine.
Results of the survey included 68% of persons reported opening a capsule or crushing a tablet,
whereas 64% reported not taking their medication because of difficulty swallowing. Health
professionals must facilitate medication routines of patients who cannot properly swallow
medications by reviewing regimens, omitting medications that are unnecessary, and determining
alterative forms of medications when needed.

Cardiovascular, Hematological, Immunological, and Respiratory System Function
Some medications, including nebulizers and inhalers, require the ability to inhale medication
through the mouth or nostrils. Inhalers are used to deliver medication directly to the lungs. A

nebulizer is a type of inhaler that is used to spray a fine mist of medication through the use of a
mask. A mouth piece is often connected to a machine and plastic tubing to deliver the medication
to the person. Inspiration must be satisfactory to receive the medication.

Voice and Speech Functions
Elders must be able to communicate their medication regimen with health care providers and
caregivers. Health care providers must reciprocate communication in an effective manner.
Demonstration, web-based, verbal, and written formats can be used for communication. Elders
may find it helpful to keep names, phone numbers, and addresses of health care providers and
agencies in a regular place so they are available for emergencies. Posting this information on the
refrigerator may also be helpful. For example, Greta has been deaf since birth but is able to
communicate by using a notebook that contains information regarding her past and present
medical condition. She stores this notebook in a drawer in the nightstand by her bed. She also has
notified family members where the notebook is located in case of an emergency.

Skin and Related Structure Functions
Some topical medications must not be applied to open wounds. Thus, the skin must be free from
wounds, abrasions, and cuts.

Activity Demands
Medication routines involve activity demands. According to the Occupational Therapy Practice
Framework, activity demands are “aspects of an activity, which include the objects and their
properties, space, social demands, sequencing or timing, required actions and skills, and required
underlying body functions and body structure needed to carry out the activity” (p. 638).3 Aspects
of activity demands include the following:
   Objects and their properties
   Space demands
   Social demands
   Sequence and timing
   Required actions and performance skills
   Required body functions
   Required body structures
  Table 13-3 offers examples of activity demands typically involved in medication routines.

Performance Skills

Performance skills include the abilities demonstrated while performing the actions.3 Skills
include motor and praxis, sensory perceptual, emotional regulation, cognitive and
communication and social skills. Examples of performance skills required during medication
routines are presented in Table 13-4.

Occupational Therapy Process
According to the Occupational Therapy Practice Framework,3 evaluation, intervention, and
outcomes comprise the process of occupational therapy. Evaluation includes the occupational
profile and analysis of occupational performance. Intervention constitutes the plan,
implementation, and review. Finally, the outcomes are the determination of success of the
desired outcomes. The following outlines the process as applied to medication routines.

        The occupational profile is “the initial step in the evaluation process that provides an
understanding of the client’s occupational history and experiences, patterns of daily living,
interests, values, and needs. The client’s problems and concerns about performing occupations
and daily life activities are identified, and the client’s priorities are determined” (p. 646).3
COTAs often assist in gathering information from the client during the profile. Questions and
items to be used as part of the occupational profile related to medication routines include the
   Tell me about any medications you take. Don’t forget to include prescriptions, OTC
       medications, supplements, and natural products.
   Tell me about any vitamins or nutritional supplements you use.
   Describe your routine of taking medications.
   Describe any concerns you might have about your medication routine.
       Depending on the issues that arise from the occupational profile, the therapist may
determine to analyze the person’s performance related to the medication routine. Analysis of
occupational performance is “the step in the evaluation process during which the client’s assets,
problems, or potential problems are more specifically identified. Actual performance is often
observed in context to identify what supports performance and what hinders performance.
Performance skills, performance patterns, context or contexts, activity demands, and client
factors are all considered, but only selected aspects may be specifically assessed. Targeted
outcomes are identified” (p. 646).3 For example, a therapist may suspect that the elder’s grip
strength is insufficient to open a medication container and thus test grip strength using a
dynamometer or asking the person to open his or her medication container(s). Based on the
analysis of occupational performance, the therapist is able to plan intervention.

        The intervention plan consists of “a plan that will guide actions taken and that is
developed in collaboration with the client. It is based on selected theories, frames of reference,
and evidence. Outcomes to be targeted are confirmed” (p. 646).3 For example, the therapist may
use a rehabilitative frame of reference and focus on the person’s abilities and compensate for
disability. Thus, the therapist may decide that the person’s grip strength is not sufficient to open
childproof medication containers and has the client practice opening a container that is not
childproof. The therapist may provide information on how to request such containers for future
prescriptions. This action is the intervention implementation, or the “ongoing actions taken to
influence and support improved client performance. Interventions are directed at identified
outcomes. Client’s response is monitored and documented” (p. 646).3 The therapist will then
review “the implementation plan and process as well as its progress toward targeted outcomes”
(p. 646.).3 The following section addresses ideas for medication intervention with elders.

Assistive Aids for Self-Medication
Many commercial or homemade aids can assist individuals with self-medication.19 Each aid has
advantages and disadvantages.

Commercial Aids

Calendars are helpful for tracking medication schedules. A pocket calendar or a calendar hung
near the place where medication is taken can be used to mark each time medication is taken. At
the end of the day, marks are counted to make sure that the medication schedule was followed.
The advantage of using calendars is that the medications are stored in their original containers
and remain properly labeled. Calendars are also inexpensive and readily available. The
disadvantage of using a calendar is that it requires some basic reading, comprehension, and
memory skills to mark the calendar each time medications are taken.19

Pill storage boxes/storage boxes
For people who take medications on a regular basis, a pill box or pill reminder is a useful item.
Pill storage boxes are containers with compartments in which to put medications (Figure 13-2).
Pill boxes are easy to use and can be useful to adhere to one’s medication schedule regardless of
whether one is at home or traveling. Pill boxes are organized daily, weekly, or monthly. Some
have the capacity to organize medications throughout the day (e.g., breakfast, lunch, and dinner).
Added features such as locks or timers and alarms can be ideal when safety is a concern or when

a cognitive reminder is needed. Some boxes are made to look like jewelry. There is certainly one
likely to be available to suit one’s needs and style.

         Pill boxes require manual dexterity skills to open and close and to manipulate pills.
Visual discrimination also is required to identify desired pills. Pill boxes usually do not provide
tight storage for medications that require tight containers, such as nitroglycerin. In addition, the
pills are no longer in labeled, childproof containers.

        There are advantages and disadvantages for using daily and 7-day pill boxes.19 An
advantage of a daily pill box is a better chance of taking all daily doses. Any errors made in
setting up this pill box would be experienced for one day only. A disadvantage of a daily pill box
is that each compartment could contain several unlabeled pills. The elder would have to identify
the medication(s) by physical appearance. This is a serious safety concern if pills are similar in
size, shape, or color, especially if the elder has impaired vision or is easily confused.

        Weekly pill boxes store medication for 7 days. The design of some pill boxes allows the
separation of multiple daily doses. These boxes often consist of four rows and seven columns.
The four rows are marked with times of the day (morning, noon, evening, and bedtime), and the
seven columns are marked with the day of the week. The advantage of using a 7-day pill box is
that setup is required once a week only. The disadvantage is that setup requires more accuracy.19
If there is a mistake, it may occur seven times.

        A pill box with an alarm is an option for elders who must take their medication at specific
times. The advantage of this type of pill box is that it alerts elders of the medication schedule. A
disadvantage is that elders must be able to read, understand, and follow in-depth instructions.
These devices often need to be programmed and may require very fine manipulation to set the
clock or the alarm. If the device breaks, repairs may be difficult and expensive. Another
disadvantage is the risk of not hearing the alarm when it sounds.

Insulin holders
Insulin holders are intended for one-handed use. The device holds an insulin bottle so that a
person can manipulate a syringe to obtain the proper amount of fluid. Often the device has
suction cups or a nonskid surface to prevent the device from sliding on a table top.

Pill splitters
Pill splitters are useful devices when a pill must be split for proper dosage or to reduce the pill
size for easier swallowing (when appropriate). Pill splitters are often lightweight and use a
leverage design to reduce the amount of strength needed to use it. As previously stated, a razor
blade should never be used to cut a tablet.

Pill crushers
A pill crusher is a device used to pulverize tablets into a fine powder. Similar to the design of pill
splitters, pill crushers use a leverage system so that an abundance of strength is not required. Pill
crushers can be beneficial when individuals have difficulty swallowing whole tablets.
(Remember that not all tablets can be crushed or split.)

Talking and shaking alarms, watches, and prescription bottles
For elders who experience difficulty remembering to take their medications or what their
medication routine is, several devices such as talking or shaking alarms and talking prescription
bottles may be beneficial. Talking alarms are devices that are programmed to send a “beep,”
voice message, or visual cue when it is time to take a medication. Shaking alarms can be clipped
to the bedding to wake elders when it is time to take their medication. The device can be put in
one’s pocket when in public and it will provide a quiet vibration to indicate the medication time.
A talking prescription bottle is a device attached to a prescription bottle. A pharmacist or
physician records the prescription information into the device. To operate, one pushes a button
on the device to play a recorded message about the contents; how many pills to take, when, and
what for; and any warnings. The talking prescription bottle is intended for those who have low
vision or hearing impairments. It is also beneficial for elders for whom English is a second
language or for elders who have difficulty reading.

Homemade Aids

Medication diary
A medication diary is another aid for tracking medication use (Table 13-5).

COTAs may assist elders in making a diary, which can be kept in a notebook. This information
can then be shared with other health care professionals, as needed.

Storage cups
Storage cups can be made at home by using small plastic or paper cups that are stacked and
ordered according to the number of times the medication must be taken throughout the day. The
cups should be marked in relation to when medications are taken (for example, morning, noon,
dinner, and bedtime) (Figure 13-3). After the morning medication is taken, the “morning” cup is
moved to the bottom of the stack. This allows the next medication dose to be on the top. This
system requires that elders have good manual dexterity, visual-perceptual, and memory skills. A
similar system can be made using egg cartons. For liquid or powder medications, a system can be
set up using small, labeled, airtight containers. Using a homemade system is simple and

inexpensive. However, using a homemade system may cause medication to be exposed to
improper storage conditions.19 Also, pills in open view may tempt small children who live in or
visit the elder’s home. This risk can be reduced by storing the medication out of view and reach.

Self-Medication Program
A formal self-medication program may prevent problems with polypharmacy.2 The program is
designed to (1) use an interdisciplinary team approach, (2) educate elders about their
medications, (3) develop elders’ motor skills for proper administration, (4) offer practice
opportunities to elders, (5) assess elders for any adaptive devices that may be useful, and (6)
evaluate elders’ skills in medication administration before discharge.

       The elders’ intervention plan should include interventions to maximize independence
with self-medication. Depending on elders’ limitations and deficits, COTAs should engage them
in simulated medication tasks. An example of such a task is using small, colored candy pieces to
practice color discrimination and fine prehensile patterns. Reading and comprehending general
labels can aid in reading medication labels. Opening and closing medication containers should be
practiced. In addition, elders should master any adaptive aids before being discharged from OT.

       Relatives, friends, and home care personnel who assist in the delivery of medications
often have not been included in discussions of medications.20 Family and caregivers should be
able to name the elder’s medications, describe the purpose of each medication, and describe any
precautions associated with each medication. COTAs can refer to Box 13-1 to help educate
family and other caregivers. Box 13-2 addresses safety issues for COTAs’ consideration.

Case Study
Pat is an 83-year-old woman living at home with her 85-year-old husband. Pat is currently under
the care of two physicians: her primary medical physician and a psychiatrist. Pat has a recent
history of falls and has significant bruising on her forehead. One of her falls occurred in the
middle of the night while she was attempting to walk to the bathroom. Additionally, she
complains of dizziness and pain in her knees, which affects her ability to participate in events
outside of her home.

        Two weeks ago Pat fell and fractured her hip. Her mental status fluctuates. Her husband
is in charge of administering medications. Her problems and medications are listed as follows:
<unnumbered table>

  Disease State                         Medication                                Dosage
Congestive heart        Furosemide (diuretic or water pill)                40 mg po bid

failure                Metoprolol XL (beta blocker)                       100 mg po once daily
                       Lisinopril (ace inhibitor)                         10 mg po once daily
Anxiety                Lorazepam (anti-anxiety)                           0.5 mg po tid
Osteoarthritis         Naproxen (pain reliever)                           500 mg po bid
Depression             Sertraline (antidepressant)                        50 mg po once daily
Insomnia               Diphenhydramine (nonprescription sleep aid)        25 mg po hs prn
Prevention of blood    Warfarin (blood thinner)                           2.5 mg po once daily
clots after surgery
<# unnumbered table>

Case Study Questions
1. Which medication-related problems might be of concern to COTAs?
2. Could any of Pat’s current medical problems be caused by her medications? If so, which
medications cause which side effects? (Refer to Table 13-2.)
3. What other factors may place Pat at risk for polypharmacy and medication-related problems?
4. The COTA is concerned about the frequency of Pat’s falls and the risk for another hip fracture
but is unsure whether any medications are contributing to the falls. What is a reasonable course
of action to address this plausible medication-related concern?
5. What skills for safe self-medication are affected in Pat’s case?
6. What assistive devices may help with her medication routine and why?
7. Who should be involved in a self-medication program to help Pat with her medications?

Chapter Review Questions
1. Considering the information in the chapter, explain why the COTA is an important player in
the health care team to address medication issues with elders.
2. What are some reasons for polypharmacy among elders?
3. What is one side effect of each of the following: diuretics, OTC and prescription pain
relievers, antidepressants/antipsychotics, and insulin? (Refer to Table 13-2.)
4. What resources and personnel are available to address the concerns or questions of COTAs
regarding medications?
5. Explain skills needed for safe self-medication.
6. What aids are available to elders with poor vision, memory, or hearing, or lack of
7. What should be included in a medication diary?
8. What are some essential components to a self-medication program?
9. What information should COTAs provide to educate caregivers?


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   framework: Domain and process, 2nd ed. American Journal of Occupational Therapy, 62,
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   Current Research and Applications, pp. 19-45. Singapore: Harwood Academic.{AU: Provide
   6 author names before using et al}
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   41(3), 277-286.
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   Clinical Psychology, 63(10), 979-999.{AU: Provide 6 author names before using et al}
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16. Tseng, C. W., Dudley, R. A., Brook, R. H., et al. (2009). Elderly patients’ knowledge of drug
  benefit caps and communication with providers about exceeding caps. Journal of the
  American Geriatric Society, 57, 848-854. {AU: Provide 6 author names before using et al}
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  medication administration to patients with dysphagia. Dysphagia, 24, 49-56.
19. Meyer, M. E. (1993). Coping with medications. San Diego, CA: Singular.
20. Wieder, A. J., & Wolf-Klein, G. P. (1994). When medications change, tell the caregiver, too.
  Geriatrics, 49, 48.

{Figure Legends}
Figure 13-1
This magnifier device consists of a plastic cylinder in which the medication and syringe fit at
each end and permits elders with visual impairments to view amounts easily.
Figure 13-2
Various pill boxes are available with compartments for single or multiple daily and weekly
Figure 13-3
Storage pill cups can be made at home by simply using small plastic or paper cups.

                                               Box 13-1
                Guidelines for Caregivers Who Administer Medications
  Elders most at risk to experience problems with medications are those who are:
   Seeing more than one physician
   Taking many medications
   Using more than one pharmacy
  Keep track of the following information on the elder(s) you are caring for:
   All of the prescription drugs the elder is taking
   All of the nonprescription (OTC) drugs the elder is taking
   All other medicinal items the elder uses from a health food store or supermarket
   When and how much medicine to give
   What results to expect from the medicine
   Any physical or mental change in the elder (report to physician)
   What to do if a dose is missed
  The need for the medications should be reevaluated at least every 3 to 6 months.

  Do not save unused medication for future use without the physician’s approval. Take the entire
course of any antibiotic that is prescribed.

  Do not share medications with anyone. Closely check expiration dates and dispose of expired

  If you are not clear about what the directions you are given mean, clarify them with your
pharmacist or the prescriber. For instance, look at the following directions:
   Take as directed.
   Take before meals.
   Take as needed.
   Take four times a day.
   What does four times a day really mean?
   Does it mean every 6 hours? Does it mean with meals and at bedtime?
   Does before meals mean before each meal or on an empty stomach?
   How often is it safe to take a medication prescribed on an “as needed” basis?
  These are the types of questions that a patient or caregiver should ask.

  Written directions should always be given, and “take as directed” should not be considered
adequate direction.

  To reduce the risk for aspiration and swallowing problems, never give tablets or capsules
while the elder is lying down. Always give medications with plenty of fluids to reduce stomach
upset unless directed otherwise.
Medication storage
   Store medications properly. Keep them in a cool, dry place, away from the sunlight and away
from children. Keep the label on the medication container until all medicine is used or destroyed.
If traveling, take the original medicine container with you in case of an emergency.
Medication disposal
   Do not flush medications down the toilet unless the label or instructions specifically tell you to
do so. Find out whether there is a drug take-back program in your community by calling your city
or county. If such a program is not available, discard medications as follows:

    Take the drugs out of their original containers. Mix them with an undesirable substance (kitty
litter, used coffee grounds). Seal the mixture in a disposable container and place in the trash.
Make sure that personal information and prescription numbers are made illegible, and discard the
original medication containers.

  Take precautions with the following:
   Chewable tablets: Elders often do not like chewable tablets because they can interfere with
      dentures. One option is to have the elder suck on the tablet to dissolve it. Chewable
      tablets should not be swallowed whole.
   Crushing tablets or opening capsules: Many pills should not be crushed because they are
      designed to be long-acting. Other pills should not be crushed because the contents may
      cause stomach upset or inflammation.
  Always check with the pharmacist. Occasionally, a liquid substitute is available.
   Liquid medications: Because liquid medications are difficult to measure accurately, ask the
      pharmacist for a measuring device to ensure the correct dose.
   Applying ointments: Because medications applied to the elder’s skin will have an effect on
      your skin, wash hands after each application. Use gauze or gloves to apply.
   Applying patches: Always remove old patches. Know how often and where to apply the patch
      on the body. Remove old patches gently because elders have delicate skin. Notify the
      pharmacist if the skin becomes irritated or the patch does not stick.
   Giving injections: Practice administration techniques with a nurse or pharmacist.

     Tube feedings: Tube feedings with medication require special instructions. Liquid
        medications, if available, work best when medicine needs to be given down a feeding
        tube. Some medications may actually directly interact with the enterable supplement.
        Contact the pharmacist for instructions on exactly how to give the medication.
Discharge plans from the hospital or nursing home
  This can be a very confusing time! Medications often change while the elder is in the hospital.
Everyone must know which medications to take and which not to take.
     Know about any generic drugs. Tablets or capsules may look different and have a different
        name, but the medications contain the same ingredient in the same amount. Keep an
        accurate list or bring all of the medications when visiting every doctor. Shop at one
        pharmacy to avoid medication duplication. If moving to another area, ask the pharmacist
        to forward your prescription records to your new pharmacist.
     Monitor the elder’s nutrition, diet, and fluids. Pay attention to the elder’s appetite, and notify
        the physician if there are any concerns such as weight gain or loss. Know whether the
        elder requires a special diet, including foods/liquids to avoid and to encourage.
        Administer medication by offering plenty of liquids, unless otherwise instructed.

                                              Box 13-2
     Safety Gems for COTAs to Consider with Medication Provision and Elders
     Critically consider and bring forward concerns about possible common medication side
         effects for symptoms that the elder may be exhibiting.
     Be aware of possible medication side effects that may cause symptoms that could lead to
         safety issues such as falls or cognitive impairment. (Refer to Table 13-2.)
     Share results of assessments (particularly cognitive, communication skills, neuromuscular
         and movement, and sensory assessment findings) with members of the treatment team to
         help inform others about the elder’s ability to safely manage and self-administer
     Communicate any medication issues, such as the alteration of medications to save money or
         difficulty with a particular dosage form (for instance, those that need to be swallowed),
         with appropriate team members.
     Make appropriate adaptations so that elders can safely take medications.

                                      Table 13-1
                             Common Drug-Related Terminology
                  Abbreviations                                         Definitions
PO                                                   By mouth
IM                                                   Intramuscular

IV                                                 Intravenous
SC or SQ                                           Subcutaneous
PR                                                 Rectally
SL                                                 Sublingually (under the tongue)
QD or Q Day                                        Once a day
BID                                                Twice daily
TID                                                Three times daily
QID                                                Four times daily
QOD                                                Every other day
PRN                                                As needed
AC                                                 Before meals
PC                                                 After meals

                                      Table 13-2
                 Disease States, Medications, and Common Side Effects
    Disease                           Medications                        Common Side Effects
Cardiovascular     ACE inhibitors (e.g., lisinopril, enalapril,          Low blood pressure,
(high blood        captopril, benazepril, ramipril, fosinopril)          dizziness, muscle pain,
pressure,          Angiotensin receptor blockers (ARBs): (e.g.,          low heart rate, irregular
congestive heart   losartan, valsartan, irbesartan, candesartan,         heart rate, drowsiness,
failure, high      olmesartan)                                           urinary frequency or
cholesterol,       Beta blockers (e.g., metoprolol, carvedilol,          incontinence, increased
irregular heart    atenolol, propranolol)                                fall risk, fluid in the
rhythm, chest      Calcium channel blockers (e.g., amlodipine,           extremities/swelling,
pain, heart        felodipine, nifedipine, diltiazem, verapamil)         cough
attack, stroke)    Cholesterol medications (e.g., atorvastatin,
                   simvastatin, lovastatin, rosuvastatin, pravastatin,
                   gemfibrozil, fenofibrate, niacin, ezetimibe)
                   Diuretics (e.g., hydrochlorothiazide, triamterene,
                   furosemide, bumetanide, chlorthalidone,
                   Miscellaneous (e.g., clonidine, doxazosin,
                   prazosin, terazosin, minoxidil)
Blood thinning     Warfarin, clopidogrel, aspirin, ticlopidine,          Bleeding, bruising
agents             prasugrel, enoxaparin, heparin, dalteparin
Pain               Nonsteroidal drugs (e.g., aspirin, ibuprofen,         Bleeding, bruising,
medications        naproxen, celecoxib, meloxicam, diclofenac,           gastrointestinal pain,
                   ketorolac)                                            swelling of the
                   Narcotics (e.g., codeine, hydrocodone,                extremities, dizziness,
                   oxycodone, morphine, fentanyl, methadone)             drowsiness, increased fall
                   Miscellaneous (e.g., acetaminophen, tramadol)         risk, confusion, nausea,

Psychiatric       Antidepressants (e.g., sertraline, fluoxetine,      Drowsiness, dizziness,
medications       venlafaxine, mirtazapine, bupropion, citalopram,    confusion, seizures,
                  escitalopram, amitriptyline, trazodone)             extrapyramidal side
                  Antipsychotics (e.g., quetiapine, risperidone,      effects, nausea, diarrhea,
                  haloperidol, olanzapine, aripiprazole)              weight loss
                  Anti-anxiety agents (e.g., diazepam, alprazolam,
                  lorazepam, buspirone)
                  Drugs for cognitive impairment (e.g., donepezil,
                  rivastigmine, galantamine, memantine)
Sleep disorders   Diazepam, alprazolam, temazepam, lorazepam,         Drowsiness, dizziness,
                  trazodone, zolpidem, eszopiclone, zaleplon,         increased fall risk,
                  diphenhydramine                                     amnesia, hallucinations
Diabetes          Metformin, glipizide, glyburide, pioglitazone,      Low blood sugar,
                  rosiglitazone, insulin, exenatide, sitagliptin      dizziness, tremor,
                                                                      sweating, headache,
                                                                      confusion, nausea
Urge              Tolterodine, oxybutynin, dicyclomine,               Dry mouth, dry eyes,
incontinence      solifenacin, darifenacin, trospium                  urinary retention,
                                                                      constipation, elevated
                                                                      heart rate, inability to

                                   Table 13-3
           Activity Demands and Examples Related to Medication Routines
    Activity Demand                    Examples Related to Medication Routine
Objects and their          Common objects used in medication routines include pill bottles,
properties                 pill storage boxes, syringes, inhalers, tubes, gloves, etc.

Space demands              Space to complete a medication routine commonly requires
                           appropriate lighting to see what one is doing, ample room to
                           manipulate any equipment or objects used, and proper space for
                           medication storage. Occasionally, medication must be stored in
                           special environments—for example, environments that adhere to
                           recommended temperature ranges and restricted exposure to
Social demands             Medication routines require communicating when one may need
                           medication to refill prescriptions or report outcomes or concerns to
                           one’s physician(s).
Sequence and timing        Medication routines often require timing of medication.
                           Occasionally, medications must be taken properly throughout the
                           day. For example, sequencing the medication routine involves
                           selecting the container, opening the container, securing the
                           medication tablet, and swallowing the medication.

Required actions and       Skills used to perform medication routines include opening and
performance skills         closing containers, manipulating any objects needed in medication
.                          routines, etc.
Required body functions    Body functions needed in medication routine often include mental,
                           neuromusculoskeletal, and speech functions.
Required body structures   Body structures often needed to perform medication routines include
                           use of hands, eyes, etc.

                                       Table 13-4
                   Examples of Skills Needed for Medication Routines
       Skill                                         Example
Motor and praxis   Planning and executing movements to successfully open and close
skills             medication containers; maintaining balance while taking medication;
                   adjusting posture, for example, to extend neck when applying eye drops.
Sensory perceptual Sensing that a pill is on your tongue and ready to be swallowed; feeling
skills             relief after an anti-itch cream has been applied to an itchy and irritated
                   area; seeing the volume marks on a syringe.
Cognitive skills   Ability to recognize when one needs a prescription refill; ability to
                   remember taking medication, judging whether the symptoms being
                   addressed are getting better, worse, or staying the same.
Communication and Ability to communicate with family, caretakers, pharmacists, and
social skills      physicians about one’s medication routine; ability to answer questions
                   posed by health care providers and caretakers about medication routine.

                                      Table 13-5
                             Contents of a Medication Diary
     Section                                         Information
1: Demographics       Name
                               Phone number
                               Date of birth
                               Medication allergies: date of occurrence and type of reaction
                               Vaccinations (year, date)
                               Flu shots (year, date)
2: Health care        List names and phone numbers of all health care providers (tape their
providers             business cards here).
3: Past medications   List all medical conditions that required treatment with medication over
                      the years.
                      List all medical conditions that currently require treatment with
4: Special            List all adaptive or special equipment required (such as a nebulizer,

equipment             ostomy products, and incontinence products). Include the brand, size, and
                      model, and the supplier’s name and phone number.
5: Recent             Enter the name of new medications used, the date, the reason the
medications           medication is being used, the strength of the medication, and how often
                      the medication is taken each day.
                      Keep track of any dosage changes, discontinuation, the date, and the
                      reason for the change or discontinuation.
6: Over-the-counter   List any over-the-counter medications used for the eyes, ears, skin, and
medications           other organs and tissues.{AU: Edit OK?}
                      Enter how often the medications are used.
7: Questions for      List any questions to ask the doctor or pharmacist.
health care

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