However, the problem is that studies that seek to find ways to improve adherence do not equally as well study the probable increase in ADEs in their study population. This is evidenced in the AHRQ analysis on medication adherence solutions. Only three studies looked at ADEs as a possible negative outcome with none documented, but there was lacking homogeneity to conclude anything, most likely because they were not looking in great enough detail with the right screening tools. Not unlike why so many studies don’t match up on ADEs in older adults: “You see what you look for and recognize only what you know”. i.e. If you have a shallow knowledge base and don’t know how to recognize probable ADEs in older adults, you will not find them. What leads me to believe that specific research needs to be done is having searched the literature and finding that in the HIV/AIDS population there is good evidence that increasing adherence increases the incidence of ADEs. Since adherence is so critical in being successful at managing HIV/AIDS, they look at this closely, where as other studies do a cursory review.  So why wouldn’t that apply to other populations? Other drugs are toxic and other populations are not immune from ADEs.

But if you know that improving adherence in older adults can increase the risk for ADEs, then on a case-by-case basis you proceed with caution and monitor closely with the intent of improving adherence to achieve specific, realistic goals, but monitor for the development of ADEs. We not uncommonly find that people become dizzy from blood pressure medications after starting an adherence program, so we adjust doses downward. It then lends wisdom that a practitioner may consider lowering doses before starting an adherence program if there is documented poor adherence. Adhering to a well-designed drug regimen is probably one of the most effective forms of health care, when properly implemented.

Looking deeper at the possible causes, Dr. Hines ascribes lack of medication reconciliation as one cause, where medications are not reconciled in detail which leads to duplicate drug therapies and drug interactions, thought to cause adverse drug events in about 26% of all ADE cases. He also states that patients may not ascribe adverse effects to medications and will not ask for changes in drug therapy. Yet a well-educated patient is more likely to recognize symptoms as an adverse event, implying that patient education upon discharge is critical. One possible solution is to create a comprehensive medication plan that travels with the patient after discharge so critical lab monitoring occurs, along with key educational points on how to properly take medication, in addition to a list of key symptoms that can be likened to the medication therapies the person is taking. Lastly, designing a drug regimen that the patient can adhere to is also important, especially for people discharged after an episode for congestive heart failure. Poor adherence is strongly associated with readmission to the hospital in those with congestive heart failure.

In summary, medications play a key role in mitigating risk and improving survival and function, but when not well managed they can lead to adverse drug events that cause harm and lead to readmission to the hospital. Some data suggest that the adverse events will show up about 14 to 21 days after hospital discharge implying that a well-designed medication plan can prevent a large number of readmissions.

Here are some other links that refer to adverse drug events after discharge from hospitals.

http://bennet.senate.gov/newsroom/press/release/?id=3d5c9532-be2a-4a3f-baa9-3f9196d394aa

http://hospitalmedicine.ucsf.edu/improve/literature/discharge_committee_literature/reengineering_systems/role_of_pharmacist_counseling_in_prevent_ade_after_hosp_schnipper_ama.pdf

http://psnet.ahrq.gov/primer.aspx?primerID=11

http://www.caretransitions.org/documents/Promoting%20effective%20transitions%20of%20care%20-%20JHM.pdf

http://www.ncbi.nlm.nih.gov/pubmed/15903284

So the next step is to get her a medication box so she has some structure to those medications instead of a bunch of bottles on the kitchen counter that Albert Einstein would have trouble with remembering how to take correctly. OK, so Albert is not a good example since he was known to wear two different colored socks, if he remembered to put socks on at all. But the point is that she now has a rather complex medication regimen, along with impaired vision, weakness in her legs and is at further risk of decline due to her being home bound. Believe it or not, you can actually help mom manage this situation, with a little help. You may not be able to do all of the above on your own, but with the help of a geriatric pharmacist you can incorporate some small changes and help mom stay at home and avoid a serious adverse drug event that could land her in the hospital. One critical step when medications are being added, as in the example above, is to have medications screened for drug interactions and also for risk of adverse effects that can affect function and quality of life.

Resources to help with a situation like this can be found at ElderDrugs or another local geriatric pharmacist, or perhaps a geriatric care manager. The links to find these professionals are:

Certified Geriatric Pharmacist- http://www.ccgp.org/consumer/locate.htm

Geriatric Care Manager- http://www.caremanager.org/displaycommon.cfm?an=1&subarticlenbr=306

Older adults don’t have to experience premature functional decline but can stay in their homes longer and live a higher quality of life with their remaining time. Finding the right resources for your mother or father, aunt or uncle, or someone you are close to is at your fingertips. Not just any health care professional knows the idiosyncrasies of older adults but the Certified Geriatric Pharmacist or Care Manager got into this business because they have a passion for helping older adults age in place.

• Always look for non-drug options to manage your risk of disease. This is the best way to avoid over-medicating yourself. For example, non-drug methods to manage mild to moderate pain in osteoarthritis can be effective, yet the use of NSAIDs, drugs like ibuprofen or naproxen, are wrought with risk of GI bleeding, a leading cause of emergency room visits, hospitalization and death in older adults.
• Always make sure the benefits outweigh any risks since the benefit of many medications as we get older declines, while the risk of an adverse effect increases. This means you are holding your physician responsible by providing the clear evidence that what s/he wants to prescribe has clear evidence of benefit in older adults. Many times the prescriber is inferring from studies done in younger-old adults that the same benefit will be incurred in older adults. One such outcome was realized with the use of spironolactone for congestive heart failure. In younger-old adults it reduced hospital admissions and saved lives. But in older adults it increased hospital admissions and mortality rates, primarily due to high potassium levels. This is an adverse drug effect from spironolactone. This is a segue into the next key point.
• Get and stay engaged in your health plan by monitoring. Understand what you and your physician need to monitor in order to avoid serious adverse effects from your medications. Ask the question: What are possible adverse effects and how do we monitor to prevent them from happening? Is it blood sugar? Is it blood pressure? Etc. Take responsibility.
• When starting a new medication for a valid reason, ask your physician AND pharmacist if they checked for any and all drug interactions. This is critical! Several drugs were shown to be key in causing harm in older adults and led to emergency room visits because one drug caused an enhanced effect of another. A couple examples are: A sulfa antibiotic for a bladder infection added to someones regimen that contains an oral medication for diabetes, like glyburide or glipizide, and the result was severe low blood sugar. Or a potassium-conserving diuretic (water pill) added to someones regimen that contained lisinopril or enalapril and the result was severely high potassium levels, which can be lethal. Ask and don’t assume that drug interactions were screened whenever a new drug is added to your regimen, even if it is a short course for an antibiotic.
• Avoid taking medication known to cause harm in older adults. These are called PIMs or potentially inappropriate medications.  One such list is called the Beers List, developed by Dr. Mark Beers, MD. Many of these medications can cause cognitive impairment, over-sedation, contribute to or cause falls, among other things. Refer to our article “Beware! Drugs that may cause harm”.
• Take medications properly. One significant example is the use of eye drops. Timolol eye drops, when not administered properly get absorbed into the body and cause profound effects on blood pressure and heart rate. One study measured that timolol eye drops is the leading risk factor for falls in people with glaucoma. However, by using the proper method of administration you can reduce systemic absorption by 2/3rd’s thereby reducing the risk of any adverse effects. Refer to our article “Eye drops: Systemic side-effects”.
• Last but not least, whenever you feel different or just not right, always suspect a medication. My role is to presume a drug guilty until proven innocent. You should do the same and then hold the health care system accountable for investigating and ruling out all possible drug-related causes. When a client of mine told me his Zocor was causing memory loss I at first did not believe him. But we continued to purse his claim and, lo and behold, it is now accepted that statins do cause memory loss in some people. Always suspect the drug until proven otherwise and trust your instincts.

There you have it, your short guide to optimizing your health by optimizing your medication regimen.

Not adhering to a well-designed drug regimen can cost you your health and independence. It is proven that people with congestive heart failure experience more hospital admissions when they don’t adhere to there medication regimen. People with Parkinson’s disease also experience declining function when not adhering to their medication regimen. Not adhering to medications when you have high blood pressure will increase your risk of stroke and not adhering to your antidepressant medication will increase your risk of decline. All of the above examples are evidence-based and improving adherence will greatly increase your chances of staying at home and remaining independent. But what can you do to adhere to your medication regimen especially when your regimen is complex?

Develop a routine- Simply by developing a routine that has triggers to remind you to take your medication can be a big help. Taking your once daily medications with breakfast is a good start. Unless, of course, you need to take a medication on an empty stomach first thing in the morning. Then perhaps it’s best to start your routine with that medication in your med-box in plain view as you head for the coffee pot. Another trick is to place certain medications in key spots that you frequent at certain times of the day. For example, say I take my asthma inhaler first thing in the morning because it’s right where I have my shoes to put on before going out to get the paper. What I can do to remember to take it twice a day is to leave it there where all my change and wallet get dropped on my in from work. Simple! Lastly, buying an alarm wrist-watch is a simple way to have triggers in place throughout the day. After all, some people have to take medications up to 6 times a day!

Med-Box- A simple medication box can help by providing structure and the visual triggers to take your medications at certain times of day. However, it may not be that simple since we can be quite active and if that box is out of sight, it’s out of mind. It is not uncommon to have lower adherence when taking medications more than once a day. We also don’t want our medications to run our lives! We want then to help us and not tie up our time. After all, if I’m retired I don’t want a part-time job managing my medications! So what else can I do?

Technology- Argggh! The dreaded “T” word- Technology! Don’t sweat it because technology can be transparent, out of your way, and quite useful. It’s worth a try. There are several ways that technology can assist you in adhering to your medications yet not become invasive of your life. You can subscribe to several Internet reminder services that can send text messages to your cell phone, call you with an automated voice response that reminds you to take your medication, or go as far as to deliver your medications in an automated pill box. The choices are numerous and can be confusing. But we can help sort all that out.

Links: Here are some links related to each category of assistance.

Reminders:

1) http://www.lifelinesys.com/content/medication-dispensing-service/index.jsp

2) http://www.medication-reminders.com/

3) https://www.pillphone.com/PillLogin.htm

4) http://www.lifelinesys.com/content/lifeline-products/carepartner-reminders.jsp

Automated Boxes:

1) http://www.lifelinesys.com/content/medication-dispensing-service/index.jsp

2) http://www.medreadyinc.com/

3) http://www.autopills.com/

Other options: Keep in mind, complex regimens can be simplified and one best way to do that is to work with a pharmacist to eliminate unnecessary medications and supplements, consolidate doses into long-acting forms, and change some times of the day you take medications. We have had good experience with eliminating several medications for each client while still attaining their goals and maintaining their health. It takes an expert to provide this service and we caution you to not go it alone.