and inability to get up from her bed are behind her. Shehas not had a fall since her medication was reduced.Martha is a composite case based on several olderadults designed to illustrate some of the common <strong>issue</strong>sfacing older adults today. A health professional mightconsider this episode to be self-neglect. Martha didn’tquestion her physicians about why she was taking allthat medication so in some way, she played a role in theevents. The professional staff at the facility continued toadminister the medication as ordered by the physician inspite of some concerns about its role in the deteriorationof Martha’s well-being. Were they neglecting Martha?But what was the physician’s role? Is it neglect for aprimary care physician to ignore adverse outcomes afterchanging prescription drugs and doses? Is it neglectto ignore the outcome of an emergency room visit? Isthe ER physician practicing good geriatric medicine byadding another medication without fully determiningthe cause of the fall that brought her in? There are manyshades of grey when it comes to <strong>abuse</strong> and neglect ofolder persons. And there are many factors involved in<strong>abuse</strong> and neglect that are often overlooked – such asmedication.All over America there are older adults who areexperiencing complicated health events as a resultof “misadventures” with medication. Neglecting thepotential adverse consequences of medication that isinappropriate, mismanaged, unneeded or overused canresult in a life cut short or diminished dramatically inquality.28
The Role of MedicationMismanagement in Abuseand NeglectMaura Conry, Pharm D, MSW, LCSWThe effects of neglect and self-neglect as related tothe mismanagement of medications can be devastatingfor older patients. The critical task of ensuring thatmedications are taken safely and appropriately isperformed by caregivers, most frequently women, whomay be in need of care themselves. Emergency rooms,hospitals, and doctor’s offices are filled with personswho make life-threatening mistakes due to a simplemisunderstanding, often due to lack of information,of how to use medications safely, further taxing ouralready overburdened health care system. This majorpublic health crisis is escalating at a rapid rate with fewsolutions in sight, and is expected to worsen for sometime to come. Strategies are urgently needed to helpcaregivers perform the basics of medication safety in thehome, and to learn how and where to find solutions.Recent studies indicate that as many as 28% ofhospitalizations and deaths in the <strong>elder</strong>ly are relatedto medication misadventures. Approximately 95% ofthese events are predictable and 66% are preventable.Adverse drug events rank fifth among the greatestand most preventable health threat to the <strong>elder</strong>ly, onlylagging behind congestive heart failure, breast cancer,hypertension, and pneumonia. The costs are estimatedto account for $76.6 billion in hospital expenses, 17million emergency room visits, and 8.7 million hospitaladmissions yearly. It is estimated that medication-relatedproblems cause as many as 106,000 deaths annually. The<strong>elder</strong>ly are particularly impacted because they use 30% ofprescriptions and 40% of over-the-counter drugs in theUnited States. At the same time medication use in the<strong>elder</strong>ly increases, their physiological ability to metabolizeand excrete drug products diminishes, making themmore sensitive to increases in pharmaceuticals.The problem is worsening as safety nets thatonce helped prevent many medication mishaps arerestructured out of health care. In the past, families usedone physician and one pharmacy for most health-relateddrug products. A single family physician provided mostcare, and specialists were consulted rarely. Physiciansand pharmacists knew their patients well, and consultedwith each other regularly when medication problemsoccurred. This physician-pharmacist teamworkprevented most medication mistakes without the patientknowing that the physician and pharmacist had workedin consultation. Over-the-counter and alternativehealth products were purchased at the same pharmacyallowing the pharmacist the opportunity to overseenon-prescription drug choices and provide guidancewhere information existed about prescription and nonprescriptioninteractions to prevent further medicationmishaps.Today patients often consult multiple physicians andspecialists, each of whom prescribes pharmaceuticalswithin their specialty with little to no access to orconsultation of medical records from other physicians.Regular check-ups and other preventive care visits arescheduled for a mere 15-20 minutes, providing littleopportunity for in-depth assessments; the same is truefor acute care visits to a primary care office where onlythe current condition is evaluated. Patients may notunderstand the importance of informing the physicianof medications from other physicians, much less thenumber of non-prescription and health store items theyuse regularly, oversight which can lead to medicationrelatedcomplications.The use of multiple pharmacies compounds theproblem. Medications are obtained through communitypharmacies, mail-order houses, internet sites, overseasproviders, physician samples and more. Each pharmacyperforms a computerized safety check on medicationspurchased directly from them, but has no way ofchecking for inappropriate dosing, interactions, andduplications from other pharmacies. Partial recordsexist in many pharmacies, but less often in one placeanymore, circumventing the life-saving computerized29
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