• Methods of paying for therapy other than drug samples need to be identified at the time the therapy is initiated (Mitchell et al., 2001) (Evidence Grade = D).
• When possible, generic drugs should be considered (Carlson, 1996) (Evidence Grade = D).
• Information about the Medicare prescription benefit may be obtained from http://www.medicare.gov/MedicareReform. Clients with questions should be referred to this reference.

Noncompliance:

Assessment

• Clients should be asked the following compliance questions:
  • Are they taking the medication(s) as prescribed (Schaffer & Yoon, 2001)
  • If they have any questions about their medications (Fineman & Delice, 1992)
  • How often they forget to take their medication (Horne, Weinman, & Hankins, 1999)
  • How often they miss a dose of their medication, or adjust it to suit their own needs (Horne, Weinman, & Hankins, 1999) (Evidence Grade = C)
• A complete history and physical exam to ascertain whether the client is responding to the therapy as expected (Bedell et al., 2000; Donovan & Blake, 1992; Edelberg et al., 2000; Johnson, Williams, & Marshall, 1999) (Evidence Grade = C).

Assessment Action

• Pre-poured pillboxes, automatic dispensers with voice-activated message, and regular or video-telephone call reminders have been useful for enhancing medication compliance for older community dwelling congestive heart failure patients (Fulmer et al., 1999) (Evidence Grade = D).
• Organizational charts with over-the-counter medication organizer improved adherence for old-old subjects (Park et al., 1992) (Evidence Grade = D).
• Although forgetting is the most common reason for missed dose (Conn, Taylor, & Stineman, 1992), numerous interventions have been employed successfully to help individuals remember to take their medications. The following are suggestions of possible external and/or internal cues that may help to decrease forgetting:
  • Leaving the pills in a prominent place
  • Planning medication taking around activities at the beginning of the day
  • Rereading instructions to increase recall
  • Reading regimen instructions slowly
  • Mentally repeating instructions
  • Concentrating hard when receiving instructions
  • Trying hard to learn about new medications
  • Concentrating hard to learn medication times by repeating the process out loud each time (Gould, McDonald-Miszczak, & King, 1997)
  • Considering the association between medications and daily activities such as taking the prophylactic aspirin in the middle of the largest meal or taking the daily vitamin when brushing teeth in the morning (Schaffer & Yoon, 2001) (Evidence Grade = D)
• Patients should be given a medication list to carry with them that is updated at each visit (Conn & Edwards, 1999; Haynes, Wang, & Gomes, 1987) (Evidence Grade = D).

Outcome 2: Decrease Polypharmacy

Medication Review: It should be completed every 6 months or with any medication change.

Assessment

The Medication Review prompts the examiner to query the record and/or the patient regarding the following:

1. Is the indication for which the medication was originally prescribed still present?
2. Are there duplications in drug therapy (same class)? Are simplifications possible?
3. Does the regimen include drugs prescribed for an adverse drug reaction? If so, can the original drug be withdrawn?
4. Is the present dosage likely to be sub-therapeutic or toxic in light of age and renal status?
5. Are any significant drug-drug or drug-illness interactions present? (Hamdy et al., 1995) (Evidence Grade = C)

Assessment Action

1. To simplify the regimen, combination drugs and alternative routes should be considered and used if at all possible. The use of combination tablets improves adherence when compared to dual therapy (Carlson, 1996; Lau et al., 1996; Melikian et al., 2002; Dezii, 2001) (Evidence Grade = B).
2. Once a day dosing should be followed if at all possible. Decreasing antihypertensive medication dosing from 3 to 1 times daily has been shown to dramatically increase adherence (Eisen et al., 1990; Gambert, Grossberg, & Morley, 1994; Pullar et al., 1988) (Evidence Grade = C).
3. Medications that fail to meet any of the Hamdy et al. criteria should be discontinued (Carlson, 1996; Hamdy et al., 1995; Hanlon et al., 1992) (Evidence Grade = C).
4. Medications should not be prescribed to counteract side effects of other medications (Bergman-Evans & Ranno, 1998; Hamdy et al., 1995; Rochon & Gurwitz, 1997) (Evidence Grade = C).
5. Laboratory studies may require more frequent monitoring (Kane, Ouslander, & Abrass, 1999; Turkoski, 1999) (Evidence Grade = D).
6. Professionals should screen regularly for drug interactions that may result from the drug regimen (Carlson, 1996; French, 1996) (Evidence Grade = D).

Outcome 3: Avoid Adverse Events

Assessment

• The Cockcroft-Gault Formula (See Appendix A.3 in the original guideline document) is a useful method for estimating creatinine clearance based on age, weight, and serum creatinine levels (Kane, Ouslander, & Abrass, 1999). It will be calculated and recorded at least yearly on the Medication Assessment Tool. A decreased creatinine clearance <50 mL/min is a risk factor for drug related problems (Evidence Grade = C).

Assessment Action

• In general, lower doses should be initially used with the elderly, and upward titration should be performed at a slower rate (French, 1996; Hamdy et al., 1995; Turkoski, 1999) (Evidence Grade = D).
• For identified renal failure, dosage for drugs renally excreted will need to be adjusted. Examples of these agents are digoxin, aminoglycoside antibiotics, radiographic contrast media, agents affecting the rennin angiotensin system (e.g., angiotensin-converting enzyme [ACE] inhibitors), or those inhibiting renal prostaglandin production (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs]) (Fang, 2000) (Evidence Grade = D).

The Drugs Regimen Unassisted Grading Scale (DRUGS) Tool (See Appendix A.4 in the original guideline document):

Assessment

• The DRUGS will be administered at the initial visit and at least annually thereafter for clients who are self-administering their own medications (Edelberg, Shallenberger, & Wei, 1999; Edelberg et al., 2000) (Evidence Grade = C).

Assessment Action

• If inability to self-administer medications is identified with the DRUGS tool, specific measures should be undertaken to correct the situation. (Edelberg, Shallenberger, & Wei,  1999; Edelberg, et al., 2000.). For instance, problems with identification, dosage, or timing could be addressed with adherence aids such as weekly pillboxes. Problems with access could be rectified by ordering non-child resistant packaging (Fulmer et al., 1999) (Evidence Grade = C).

Nonprescription Medications:

Assessment

• Professionals need to directly inquire regarding the use of over the counter, herbs, and vitamins as part of the drug history of older adults. Specific questions should be asked in the review of systems such as "What medicines or herbs do you use for a headache, muscle aches or pains, nausea, or constipation?" (Astin et al., 2000; Conn , 1992; Ellor & Kurz, 1982; French, 1996; Gambert, Grossberg, & Morley, 1994) (Evidence Grade = C).

Assessment Action

• Professionals need to counsel patients regarding safety and possible efficacy of nonprescription products. If duplications, interactions, adverse drug reactions/side effects, or high cost are identified, professionals and patients should collaborate on a plan to correct the problem (French, 1996; Willis & Gutirrez, 2003) (Evidence Grade = C).

Outcome 4: Maintain Functional Status

Assessment

• Functional status will be assessed using two standardized instruments: Scale for Instrumental Activities of Daily Living Scale (See Appendix A.5 in the original guideline document) and The Activities of Daily Living Physical Self-Maintenance Scale (See Appendix A.6 in the original guideline document) (Lawton & Brody, 1969) (Evidence Grade = C).

Assessment Action

• If changes in functional status are related to proposed or existing medications, the benefits should be carefully weighed against the harms and discussed in detail with the patient (French, 1996; Gambert, Grossberg, & Morley, 1994; Murphy & Cleveland, 2004, Simonson & Florkowski, 1996) (Evidence Grade = C).

Definitions:

Evidence Grading

1. Evidence from well-designed meta-analysis
2. Evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (e.g., assessment, intervention, or treatment)
3. Evidence from observational studies (e.g., correlational descriptive studies) or controlled trials with inconsistent results
4. Evidence from expert opinion or multiple case reports.

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