Kim LD, Koncilja K, Nielsen C. (2018) Medication management in older adults. Cleveland Clinic Journal of Medicine. 85(2):129-135. doi: 10.3949/ccjm.85a.16109.
This is a review article about polypharmacy and the impact it can have on an older population. Older patients are more likely to have multiple medical problems, including renal insufficiency, which can negatively impact clearance and potentially increase the risk of adverse drug-drug interactions. This article highlights commonly utilized medications that may not be appropriate for use in an older population. The medications reviewed are: statins, anticholinergics, benzodiazepines, non-benzodiazepine hypnotics, antipsychotics, and proton pump inhibitors. The authors also reviewed tools to evaluate proper medication management. They covered the BEERS criteria, which provides evidence-based recommendations for medication usage, rationale for use, and grade the strength of the recommendations. They also reviewed STOPP/START criteria, which are screening measures designed to aid in safer prescribing in an older population. They concluded that periodic comprehensive review of medications to revisit the risks v. benefits of the current medication regimen is needed when working with an older population.
I chose this article because many rehabilitation psychologists work with older patients who are on a plethora of medications, often for many years without augmentation. It is important to understand how this patient population is at greater risk for poorer outcomes because of decreased clearance, medication interactions, etc . In particular, the risks associated with long-term benzodiazepines in an older population can raise the risk of hip fracture, impaired driving, and cognitive impairment.
We are uniquely positioned to see patients more frequently than their PCP and can often hear about problems first. Tapering a patient from long-term benzodiazepine can be challenging for the prescriber, so coordinating care with the prescriber and addressing resistance and anxiety responses from the patient becomes very important. This can also be done with pain medications as well as z-drugs (e.g. sleep aides like Zolpidem). We can leverage our knowledge about CBT for sleep, CBT for mood management, non-pharmacological behavioral interventions to improve sleep, etc. to teach patients alternative coping strategies. The article is laid out effectively and it is accessible for non-prescribers. The tables are particularly useful as references.
THIS MONTH’S REHABILITATION SCIENCE SPOTLIGHT was chosen by Timothy Shea, PsyD, Colorado Rehabilitation & Occupational Medicine, member of Division 22’s Science Committee.