Medication Management

I just returned from a wonderful weekend spent with four friends from college.  We have been friends ever since we pledged Kappa Kappa Gamma in the mid seventies, some 30 years ago.   We live in four different states and cherish our yearly “girl’s” weekend.  Throughout the year, we keep in touch by cell phone and e-mail.  However, there is nothing like being together, sipping wine and sharing family news, career challenges, and our love of new shoes.  Discussing the pros and cons of reaching the half century mark always comes up too.  Among us you will find wives and widows, mothers and stepmothers, and daughters of aging mothers and fathers. 

In years past, our conversation revolved around our children.  We looked to each other for advice and support as we coped with the terrible twos, middle school independence and aggravating adolescents.   Something different happened this year.  Caregiving was still a topic of conversation, but centered on our parents, rather than our children.    We are all caregivers, with a parent or parents that are facing issues common among older adults:  chronic illness, medication management, cognitive decline, financial concerns, fall risk, and driving conflicts.   

Each one of us expressed concern and a willingness to help.  We wanted to help our parents remain independent and honor their wishes.  Yet, we had so many questions!!!  All weekend long, we discussed and debated how best to help our parents.  Without realizing it, we became a caregiver support group and were comforted by sharing our concerns, ideas and strategies with dear friends.  We have continued the support by raising issues, asking questions, and providing updates via group e-mails.   We haven’t yet joined the facebook revolution, but have formed our own informal eldercare exchange network to help us cope with our aging parents. 

I feel incredibly fortunate to have such a caring group of friends.  Their support has helped me through all stages of life and continues to prop me up when I’m concerned about my Mother and how best to help her.  I encourage every caregiver to find either an informal or formal support group.  Talk to your friends , neighbors and colleagues about caregiving.  My guess is you will find someone else who is an active caregiver.  Also, explore formal support group opportunities offered by organizations such as the Alzheimer’s Association, local hospitals and/or assisted living and long-term care facilities.

The SCANS content team headed by Jean Bandos along with the development team announced today that the SCANS Version 1.3 - May release is now available.  SCANS Version 1.3 is a major content release to the SCANS Knowledge Base.

In order to make more real-world tools for eldercare available more quickly, Jean and the team have devised a "rolling release".  For 3 months beginning in May another group of resources, processes, and tools will be made available to geriatric care managers at My Health Care Manager and our affiliates.

The May release contains 57 new and/or revised resources, processes and tools.  Some sample items include: 
 

• Behaviors and Alzheimer's Disease
• Grief Education
• Activities of Daily Living Education
• Depression and Alzheimer's disease
• Early Stages and Impact on Health
• Memory & Cognition Questions
• Memory Care Unit Checklist
• Memory Care Unit Education
• Mild Cognitive Impairment
• Sobriety Programs Resource
• Handyman Resource
• Private Handyman Contractor Checklist
• Smoke & Carbon Monoxide Detectors
• Daily  Money Management Education
• Financial Planning Education
• Trust Education
• Verifying Funeral Arrangements
• Veterans Benefit Information
• Elder Law Resource & Checklist
• Medication Management Procedure
• Medication Reconciliation
• Polypharmacy
• How to Find a Pain Specialist
• Pain Education
• Pain Resources
• Pain Visual Analog Scale
• Arthritis
• Heart Failure
• Hypertension Education
• Family History - Cancer Education
• Family History - Dementia
• Family History - Diabetes Education
• Family History - Heart Education
• Seat Belt Education
• Cataracts Education
• Glaucoma Education
• Hearing Aid Education
• Sensory Changes
• Assistive Devices
• Hospice Education
• Spiritual Connections

For the last several months, we have been discussing safety concerns for the older adult.  We all know that medication management and fall risk prevention are instrumental to healthy aging, but a holistic picture is what is most important to assist in aging in place and maintaining good “health”.  As the boomers age, we will see more and more written on wellness, well-being, and just overall aging tips. 

But what is key to a healthy life style?

According to American Geriatrics Society it is

1. Not smoking
2. Drinking alcohol in moderation
3. Exercising
4. Getting adequate rest
5. Eating a diet high in fruits and vegetables
6. Coping with stress and
7. Having a positive outlook.  

These are important, but I feel that whether you are elderly or young, you need to understand your overall health issues, have social connections, be at peace with where you are in life, have a purpose, live in a safe environment that supports your needs, and keep your brain functioning. 

Good Morning America does a segment that highlights individuals celebrating their 100th or older Birthday.  Today a man was 107! I am always amazed at the life history of those over 100...  The majority have remained both physically and intellectually active and have remained connected with society.  Amazing, they never reference how many fruits and vegetables they have eaten!!   So stay connected… and do your brainteaser and always learn something new each day. 

My colleague Jennifer brought another in home communication device/service to my attention recently.  It's called Celery. 

You may remember a previous blog (click here) on the Presto Printer; a great way to communicate with parents living independently at home of in a retirement community. 
Celery is a service which combines FAX and Email capability.  It allows a caregiver or remote family member to send an email to a FAX machine in their loved one's home.  This can include a text message and even pictures.  The FAX is hooked up to a standard phone line so you don't have to obtain Internet service or have a computer.  The exciting part is that the receiver can hand write a reply and FAX it back to a special Email service that will match it to a preset list of authorized email accounts and send the message on as an image.  This makes the communication two-way.  For more on Celery see their web site http://www.mycelery.com/. 

This could be used to reduce social isolation, provide reminders about heath care, improve medication management, and just keep in touch with distant and busy family members.

In several of my past blogs, I discussed safety concerns and the older adult.  One the main concern is medication safety. Not just the management of medications but how many are actually taken.

It is often reported in the news about a medical error made and the impact it has on individual lives.  Those articles are frequently about hospitals errors.  But have you ever thought about the older adult and how they manage at home...?  The impact our current health system has on managing medications...?  How chronic illnesses such as congestive heart failure, diabetes, and arthritis impact the older adult and his/her caregivers...?  Different providers – prescribing different medication – generic versus brand names.  multiple medications with multiple doses all affect the medication management and the safety of the older adult.

Let’s look at the key safety issue: polypharmacy (multiple medications).  
A caregiver may ask what defines polypharmacy or how many pills or too many?  The answer would have to be that different entities in the current health care system define Polypharmacy differently.  I have seen it defined as low as two or more medications, but in general it deals with using more than three to five medications or herbal supplements for longer than 90 days in a given year.  In my career I have witnessed shoe boxes filled with medications that have numbered over 20 different medications- especially when dealing with multiple chronic diseases, over the counter medications, herbs, and vitamins.

Where should the caregiver and/or older adult start in trying to deal with their medications?
First, realize that the main problem with polypharmacy is that it increases the clients’ risk for drug interactions.  Drug interactions occur when one medication or herbal supplement reacts negatively with another medication when they are taken together. It is important to report any side effects to your physician.
 
The following are some steps you can take to prevent drug interactions:

• Provide a complete list of your medications and herbal supplements to your physician and/or pharmacist
• Discuss how each medication/herbal supplement works inside the body.
• Verify with your physician that you are receiving the recommended dose of each medication/herbal supplement.
• Verify with your physician that you are receiving the recommended form of each medication/herbal supplement you are taking (pill, liquid, tea, extract).
• Determine how many times a day your medications/herbal supplements should be taken.
• Discuss any side effects that might be experienced.
• Discuss the common prescription medication interactions.
• Discuss the common herbal supplement interactions.

If you can not complete a list of medications, take them all into your physician or pharmacist and have a list made for you. 

The National Institute on Aging is a great resource for learning more about medication managements, herbs, vitamins and safety concerns - learn more by clicking here.

I'm going to cheat just a little bit and pre-announce to my blog readers that SCANS Version 1.0 is about to go into production release. 

This is the Knowledge Repository Edition of SCANS.  It provides Health Care Managers at My Health Care Manager and our Affiliates with a comprehensive knowledge base of best practices in geriatric care. 

It contains information on all of the most common problem areas encountered when caring for aging parents.  More importantly it provides concrete geriatric care solutions, step by step actions, and powerful, practical tools for implementation.    Some examples of the issues addressed by SCANS include:

• Behavioral Issues
• Caregiver Support
• Cognitive Issues
• Family Communications
• Continence Problems
• Emotional Concerns
• Environmental Issues
• Information Management
• Intellectual Engagement
• Medication Management
• Nutritional Needs
• Pain Management
• Prevention/Wellness
• Provider Coordination
• Service Coordination
• Social Support
• Spiritual Well-being
• and many more

Our Director or Research, Jean Bandos, puts it this way:

"My Health Care Manager is in the process of developing an advanced technology Knowledge Management and Decision Support System that will change the way geriatric care management is delivered. This system is directly concerned with the caregiving challenges of the senior and their family ...  (this) Knowledge  management and Decision Support System will assist the Health Care Managers in delivering complete, comprehensive, and predictable services."

Our Research and Development team is particularly proud of delivering this first version to commercial use in less the 4 months of receiving a major grant from the Indiana 21st Century Research and Technology Fund of the Indiana Economic Development Corporation.

More advances are in the works...

Laurie recently posted a comment about her mom having problems mixing up her medications.  This is a very common problem.  The average person over age 65 is taking 8 prescription medications.  Someone who is battling chronic diseases may be taking many more. 

The number of medications is confusing in the best of circumstances, but clearly other challenges like declining vision, cognitive issues, or problems with manual dexterity make medication management a daunting task. 

Some of the posts in my blog can help.  See Technology in Day-to-Day Medication Management and Create Your Medication List Now.  You can also click here for our full blog list on Medication Management where you will find lots of additional advice and insight.

You can also ask question directly of a Health Care Manager by joining our Caregiving community.  Click here for that link.

In past blogs I've talked about the 17 dimensions My Health Care Manager uses to build the Personal Health Record.

We've spent a lot of time on some of the most used data like the medication list, provider list, and other "current state" information.  By "current state" I'm referring to information which is primarily valuable for it's current data values.  For example, when you are caring for aging parents it may be of some very slight interest which doctors your parents went to 3 years ago, but the current doctors are far more important.  The same would be true in medication management.  It's the current prescriptions and treatment plans that are most relevant.

However, 10 of the 17 dimensions deal with "longitudinal data".  That is, data that should be measured over time.  If you are primary caregiver it is very easy to miss major changes because they happen incrementally. 

It's just like watching children grow up.  Parents, who see their kids every day, know they're growing, but its the Aunt from across the country who's stunned by how much they've grown each Thanksgiving.  Parents can get a sense of this themselves by looking at pictures.  So it is with eldercare.  The people closest to the situation need to take an actual "snapshot" of the key data items and periodically look at those for problem areas.

My Health Care Manager does this through the use of a formal assessment.  At least annually and at every major health event key areas like Activities of Daily Living, Socialization, and Cognitive Skills should be assessed, scored, and tracked. 

Let's return to the question of the impact of technology.  In particular, to the impact on a key issue facing seniors and caregivers, medication management.  We've touched on the fundamentals - preparing and communicating the medication list with simple computer tools.  What we haven't spent much time on is the day to day management of medications.

Technology can help.  For example, one of the tools My Health Care Manager makes available to seniors and their families is a weekly medication schedule.  This schedule provides a map of the all medications with the day and time and dosages they are to be taken over the course of the week.  This schedule can also provide a variety of additional information such as sliding insulin scales or even life style guidance for exercise or other activities.  In many cases our clients will actually record daily health monitoring results on the form (like blood sugars, blood pressures, and so on).  This is a great way to help aging parents and their care givers stay on top of the weekly regimen.  

There are some limits.  We have found that people dealing with Dementia (Alzheimer's disease or other forms) need the assistance of a caregiver to use a tool like this.  Often they will also need reminders through the course of the day to prompt taking their medications.  Technology can help here, as well.  There are a number of medication reminder systems emerging in the market.

There are several innovations available to help seniors organize and remember to take their medicines.  Although not necessary for many older adults managing multiple medications, some can benefit by having their medicines pre-sorted and dispensed in pouches that are organized by time of day and day of week.  We’re moving to a system like this as Mother’s filling a 28 compartment pill tray with 14 prescribed medicines and OTC pills each week becomes even more challenging with her aging.  This pre-loaded dispensing solution has been used in nursing homes and some hospitals for several years, but some companies are now offering the program to individuals in their residences.  But before making any change of this type, be sure to check the Medicare Part D prescription medicine plan to be sure the vendor is recognized in the insurance company’s plan. 

Other higher-tech aids are in development that include pill trays that automatically open at the right time and track results (although it is impossible to remotely know if the pills were actually taken).  We’ll be seeing more use of technology in assisting with eldercare- something I imagine caregivers will welcome wholeheartedly.  Many developments are underway by inventors and large health technology companies, and I’ll use a future blog to describe some of the more promising ones.

Even though Mother was safe and secure in Independent Living (IL) in a Continuing Care Retirement Community (CCRC), we quickly realized that managing her prescription and over-the-counter (OTC) medicines was a challenge of its own.  With 10 prescription medicines and 4 OTCs, the variables of continuing supply with many expirations and prescription renewals combined with generic vs. brand names, dosages and time-of-day preferences were an overwhelming task for her … and her caregivers!  Fortunately, we devised a Weekly Schedule and medicine reconciliation program that allowed her to manage her own meds (with our assistance) that has now become a My Health Care Manager computer-based decision aid.  However, loading her pill tray every week and managing the time for her diabetes blood sugar tests and consumption of the pills became (and remains) an ongoing challenge.  Until becoming exposed to the issues of polypharmacy and older adults, I didn’t understand that normally-prescribed medicines and dosages affect many seniors differently – sometimes even causing symptoms such as confusion and loss of balance.  Even multiple medication regimes that were tolerated in the past can at any moment cause problems or unwanted symptoms.

When trying to get my hands around the multiple medications challenge, it became clear that no single health care provider had information on everything that was being taken by Mother.  Each knew what he or she had prescribed, but the rest of their knowledge was based on answers given to the common question, “What medicines are your taking?” at office visits.  Often confused over generic vs. brand names, dosages, and omitting OTC products, older adults often can’t be counted on to correctly answer this important question.  In developing My Health Care Manager’s suite of decision aids, we added a letter that the senior can choose to send to all of their health care providers (or only to the ones they designate). The letter lists the providers, their prescribed medicines, and any other OTC products being taken by the senior.  Several doctors have remarked that this simple summary of information is not available from any single source in our health care system.  You might try this important task on your own if you are immersed in eldercare.  We’ll have more on managing medicines in my next blog.

Today, many families are separated by distance and may see each other only a few times a year.  For those with aging parents, the holidays spent together can often be when adult children notice changes in their parents or loved ones.  You may notice that your mom seems forgetful or has had a change in cognition, your father has less mobility than the last time you saw him, or maybe your aunt's arthritis symptoms have worsened.  This can be a difficult situation, especially for long distance caregivers.

It's important that their geriatricians or health care providers be notified of changes in their behavior, symptoms, or overall well-being.  You can ask your loved one to accompany them to doctor visits, or employ the help of a geriatric care manager if you are unable to be there.  This will help you understand the situation, their diagnoses, and the treatment plans given to them by the doctor.  Encourage them to ask their doctor questions if they don't understand their doctor's recommendations or their prescribed medications, especially if they have multiple prescriptions.  Many of us are not familiar with the health care system, and it can be daunting.  Geriatric care managers can help explain the situation, help you weigh your options, and work to make sure that your loved ones are getting the quality of care that they deserve.

It can be hard to be a caregiver, and it can also be hard to realize that you may need to step into that role.  Don't be afraid to ask your friends and family for support. 

Have a wonderful holiday season.

With the Hollywood writers strike, some of those writers may be treating this time as a much-needed break from the daily grind, as they are only required to work 20 hours a week manning the picket lines.  Unfortunately, as most caregivers know, caring for aging parents is a full-time job.  And this is often on top of the full-time hours put in at a paying full-time job.  It can often be tiring, emotionally and financially draining, and very hard.

For family caregivers that are in need of a well-deserved respite, don’t hesitate to ask for help...  Don’t hesitate to take a well-deserved break!  Accept the help that your family and friends offer or hire outside help to give you a few hours (or a few days) of help each week.  Caregiver burnout is real – especially for working caregivers.  Understand that you must first take care of your own health, and that asking for help or accepting help may make you a better caregiver in the long run by reducing your stress levels and allowing you some respite.

Providing care for a loved one, organizing their health care and managing appointments, checking on their home safety, spending time with them to prevent isolation, AND doing all of the other duties that come with the territory is extremely time consuming, sometimes confusing, and sometimes stressful.  If you find yourself ‘in over your head’ or just needing some advice, you may consider enlisting the help of a geriatric care manager.  Geriatric care managers can help facilitate communication within your family, give you advice on avoiding caregiver burnout, and offer tips and tricks to help you manage the health conditions of your loved one (whether it be helpful ways to remind your mother with diabetes to check her blood sugar, tips on communicating with a senior suffering from Alzheimer’s, ways to improve your father’s quality of life or help manage your uncle’s arthritis, or a better way to manage the multiple medications prescribed to your grandmother).

Today is the last day of National "Talk About Prescriptions" month - so hopefully you have spoken with your aging loved one- especially if they are taking multiple medications. However, I would also like to encourage everyone to talk about another kind of prescription- not for a medication, but for glasses or contacts.  Our vision deteriorates as we age and this can affect our mobility.  Home safety is incredibly important for preventing falls- and one key to preventing falls is recognizing a change in vision.

A recent study proves that worse vision or 'visual field deficit' is associated with falls- especially peripheral vision deficits.  The study also provides information about the occurrence of falls among older adults and the association of falls with a greater likelihood of hospitalization, nursing home admission, and death.  The bottom line: making sure your loved one has regular exams by a health care professional- including vision exams- is a smart move!  You may also speak with your geriatrician or health care professional for more information on preventing falls.  To read the study abstract issued by the  Institutes of Ophthamology at Johns Hopkins School of Medicine and the University College in London, please click here.