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Medication management in chronic disease in vulnerable elders

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					Medication Management in Chronic
  Disease in Vulnerable Elders

   Kirsten Bibbins-Domingo, MD, PhD
    Sharon Youmans, PharmD, MPH
           Tuesday, November 9, 2010
          Scope of the problem
• 20% of elderly taking ten or more medications
  – Can arrive at this just by following guidelines for
    management of multiple chronic illnesses

• Multiple meds -> side effects
  – 5-35% have adverse drug reaction
  – 10% admission for adverse drug reaction

• Multiple meds -> costs
  – We don’t correctly identify who is at risk.
Medications for chronic   Social Vulnerabilities
        illness
 Creating a safe space in Limited income
                           our practices
  to discuss the intersection Limited access
     Adherence                of medication
                             Food insecurity
     use/adherence and vulnerabilities
                           Competing demands
 Aligning medications
  with goals of care      Literacy/Numeracy
          What is my patient taking?
• Med reconciliation - Brown Bag

• Non-judgmental questions
•   “I know it must be difficult to take all your medications regularly. How often do
    you miss taking them?”
•   “In the past XX months, have you noticed any side effects, unwanted
    reactions, or other problems with medications you have taken?”



• Brown bag review
     – What they have, organization
     – Understanding: “how do you take this one?”; “what do you take it
       for?”
     – Adherence
     – Ask about efficacy and side effects
           It Takes a Village

• Family

• Caretakers

• PHARMACIST!
Barrier                          Potential Solution   Additional Issues in
                                                      socially vulnerably
                                                      elderly
Forgetting to take

Patient believes drug is
not needed, is ineffective, or
that too many drugs are
being taken



Difficulty taking
(e.g., opening pill
bottles, swallowing)


Cost


                                                 Adapted from Steinman JAMA 2010
Barrier                  Potential Solution          Additional Issues in
                                                     socially vulnerably elderly

Forgetting to take;      Use pill organizers,        Consider language and
limited organizational   medication calendars,       literacy.
skills                   blister
                         packs, electronic           Pill organizers are not a
                         dispensing devices;         one-size fits all (need to
                         simplify                    tailor to the needs of
                         regimen and reduce pill     specific patient)
                         burden; encourage
                         active family/caregiver     Delivery of medications
                         involvement; use
                         Internet-linked or          Working closely with
                         electronic adherence aids   neighborhood pharmacist
                         and reporting systems
Barrier                    Potential Solution           Additional Issues in
                                                        socially vulnerably elderly


Patient believes drug is   Work collaboratively with    Pay attention to language
not needed, is             patient to address           and literacy
ineffective, or that       concerns and establish
too many drugs             shared goals of care;        Assess competing
are being taken            provide educational          demands
                           materials using teach-back
                           approach; assess drug        Important role for
                           effectiveness; simplify      simplifying regimen
                           regimen and reduce pill
                           burden                       Consider medication
                                                        discontinuation
                                                             RCT showing
                                                             improved patient
                                                             outcomes
Barrier                Potential Solution             Additional Issues in
                                                      socially vulnerably
                                                      elderly
Difficulty taking      Substitute with easier-to-     Recognize additional
(e.g., opening pill    use medications (e.g.,         issues:
bottles, swallowing)   liquid if trouble
                       swallowing; ordering easy-     •Access to food
                       off
                       caps); simplify regimen and    •Access to correct storage
                       reduce pill burden; use pill   for medications
                       cutters, oral dosing           (homeless)
                       syringes, insulin syringe
                       magnification, spacer for      •Timing of medication
                       Inhalers                       effects/side effects (i.e.
                                                      diuretics)

                                                      •Competing demands



                                              Adapted from Steinman JAMA 2010
Barrier           Potential Solution           Additional Issues in
                                               socially vulnerably
                                               elderly
Costs/Insurance   Substitute with lower-cost   •Episodic insurance
                  medications (e.g.,           coverage for medications
                  generic vs. brand name)
                  and reduce                   •Additional insurance
                  unnecessary ones; assess     rules that make
                  prescription drug            adherence more complex
                  insurance and direct              •Need a TAR
                  patient to apply for              •Specific pharmacy
                  low-income subsidy and            •30 day refill
                  prescription drug
                  assistance programs          •Starting/Stopping for
                                               financial reasons
                                                    •Prioritize
                                                    medications



                                        Adapted from Steinman JAMA 2010
Barrier                          Potential Solution   Additional Issues in
                                                      socially vulnerably
                                                      elderly
Forgetting to take

Patient believes drug is
not needed, is ineffective, or
that too many drugs are              Pharmacists can have
being taken
                                  invaluable input for each of
                                         these issues.
Difficulty taking
(e.g., opening pill
bottles, swallowing)


Cost


                                                 Adapted from Steinman JAMA 2010
      The Pharmacist Perspective
• Roles and responsibilities

• Access to Patients’ Health/Medical Information

• Partnering with Healthcare Providers

• Partnering with Patients, Family Members, &
  Caregivers
                Discussion
• Share stories of challenges with medication
  management
                Conclusions
• Conduct holistic medication reviews with
  patients
  – Duplication of therapies
  – Medications that can be discontinued

• Use the community pharmacist to assist you
  with:
  – Medication Therapy Management Issues
  – Medication costs & Drug Insurances
  – Medication Adherence

				
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