Best Practices for Improving Patient Outcomes in Older Patient Population - Episode 4
Stephanie Chow, MD, MPH: Medication cost does have a significant impact on the aging population. In a population that doesn’t have income or has a fixed income, that is often not working any more, every dollar matters. Even with Medicare covering 80% of the cost, there are still co-pays and costs tied to every prescription. Patients who also have Medicaid have more coverage, more assistance. There are also some drug programs, different insurance programs that patients can sign up for that have additional prescription coverage.
These are things that really do impact a patient’s ability to be adherent to medication plans. In addition to the complications of organizing medications during the time of day, during the frequency, this is something that a geriatrician or a primary care provider does need to consider.
It’s important to recognize that the costs of medications are pretty nebulous. The costs depend on the insurance of the patient and the pharmacy that they’re going to. There are many different factors that will change the cost.
For patients who are struggling with covering the cost of their medications, it’s important to involve a social worker, if there is 1 available, to really help with identifying medication coverage plans or wavers that can be applied for, or different pharmacies, or different ways to help support the patient who, financially, may not be able to afford the medication at hand.
It’s really important for geriatricians to examine the list of medications. For many of our patients who are older, they have acquired more comorbidities and more medications along their lifetime. At some point, they may have acquired more medications than they actually need. So the concept of deprescribing and only prescribing what is necessary, avoiding polypharmacy in the interaction of multiple medications in a negative way, often is something that geriatricians and primary care providers need to be on top of.
There is the American Geriatrics Society Beers Criteria of potentially inappropriate medications. A new issue came out in 2019. This is a list of medications that are categorized into groups of what is not recommended, what is potentially inappropriate, in different classes of medicines for providers to look at to see whether a drug is something that they should be prescribing for their patient, depending on the patient’s health status. This is something that the American Geriatrics Society has come up with. It is something we encourage primary care providers to use all the time.
When patients get admitted into the hospital, we often—as geriatricians who are part of the inpatient service—make recommendations for discontinuing medication. In the geriatrics clinic, we are often revising and reconciling medication lists on a daily basis. We see it less so in our particular clinic, but certainly, it’s a common thing for patients who are older to have multiple medications built up, especially if they have more than 1 specialist who may be prescribing. And so the lists need to be repeatedly reconciled. Perhaps the patient or their family members don’t remember. Then, all of a sudden, you have more than 1 medication on the list that is not necessary. So it’s important for the provider to really examine the list. It is a common risk with our older patients to have overprescribing of unnecessary medications.
It’s also important to examine some protocol lists—a list of medications that may be administered to a patient—but to also realize that if it’s an older patient, perhaps all those standard medications may not apply for the older age group. And so you really need to examine, for example, Benadryl. This is something we don’t recommend for our older patients, but it is something that’s commonly prescribed for the average population for allergies as an antihistamine.
For our older patients who see multiple specialists and more than 1 physician—this is something that’s very common in New York City because there are so many physicians—it is something we can’t get away with and is something that we have to acknowledge. For our older patients, or for patients who have difficulty coordinating or organizing their medical care or remembering what changes have been made, it is a tricky thing for the primary care provider to navigate. It is very important for the primary care provider or the geriatrician to have good communication with the specialists to maintain an accurate medication list, so the whole analysis of polypharmacy, deprescribing, inappropriate medications, can correctly be reconciled.
It is a really common struggle for geriatricians to work with patients who have a difficult time adhering to their medications. It’s even a challenge with the younger population. At times, taking a medication 3 times a day, or remembering it and changing it around is difficult. If you’re an older individual and you have some memory challenges, obviously it will be more difficult. Working with the pharmacist can be helpful. There are pillboxes that are by-the-week. There are even pillboxes by the entire month. If you have a nice pharmacist, there may be the option of blister packing, so that the patient can just open 1 pack and receive all their morning medications, or their afternoon or evening medications, at once.
There are some pharmacists who will actually provide a giant pillbox container for the entire month. There are home delivery services where the pharmacy may be able to deliver the packages every month. There are a lot of mail order pharmacies as well.
Pharmacists, themselves, are an underutilized resource. Patients can actually go to the pharmacist and receive counseling and instruction on what medications do what and how to best take them. Obviously, the geriatrician would be able to go over this as well in the clinic. However, for patients who may require multiple reminders, it may be a good idea to have them establish a good relationship with their pharmacist.
In New York, where I practice, there are many, many pharmacies, so it’s very easy to find a variety of services. It’s good to explore the different choices for the patient. If the current 1 is not working, you can, perhaps, enlist the help of a social worker or a care coordinator who may investigate best pricing and best options for pill management. They can also explore the best kinds of instruction programs, and perhaps, if home delivery or mail order is available, that may also be an asset.
Transcript edited for clarity.