Pharmacists Face Challenges When Dispensing Medications to Elderly Patients

Brown Bagging Is an Essential Educational and Safety Tool to Help Older Individuals With Adherence.

Brown bag consults can be essential educational and safety tools to measure and ensure quality care. By asking patients to bring in all their current medications, including OTC, mail-order, specialty, and herbal products, pharmacists can guarantee appropriate and up-to-date care.

Pharmacists are key providers in the continuum of care, consistently identifying potential problems and concerns that may require follow-up with prescribers or a medication therapy management (MTM) session. It is essential that a pharmacist’s workflow allow for brown bag consults, which can do the following:

• Develop the pharmacist—patient relationship to help create better individualized service, forge patient loyalty and trust, and prevent medical errors
• Provide insight into a patient’s lifestyle and quality of care
• Show how well patients understand their conditions and medications

Offering to review medications one-on-one can give pharmacists the opportunity to connect with patients by serving as trusted medical professionals in the community. Brown bag sessions for patients living with chronic disease states do not have to be time-consuming scheduled events. They can be offered anytime a pharmacist thinks that a patient needs follow-up care after a typical counseling session.

Dispensing medications for elderly patients can be complex and challenging. There are many barriers that may prevent elderly patients from taking their medications as prescribed. These impediments include cognitive impairment, cultural differences, fixed budgets, lack of social support, and poor medical knowledge, each of which can make it difficult to accurately assess elderly patients and their medical needs. Drug-related adverse events and problems in the elderly are prevalent. There also is the specter of frequent hospitalization. Nonetheless, the impact of such complications may be lessened by a positive patient—pharmacist relationship. Communication, a friendly pharmacy atmosphere, and drug use monitoring are critical to establishing a helpful and trusting environment.

CL is an 88-year-old woman who is a returning customer. She stops by at least once a week to ask medical questions, refill medications, or shop in the store. CL lives with her 86-year-old sister. CL’s husband died a few years ago, and her children are grown and live out of state. CL and her sister take care of and often run errands for each other. CL is not technology savvy, and she relies on her health care team for medical information. She stops by the pharmacy to pick up her refill prescription for her cholesterol medication. CL is also picking up refill prescriptions for her sister. You notice that CL is refilling prescriptions early. You also make note in her profile of some other medications that she recently refilled early or late. In addition, you notice that CL is not acting like herself and appears disorganized. You ask her how she is doing, and CL asks you to repeat the question. She is unable to explain how she is taking her medications or what conditions they treat. You briefly review CL’s adherence issues, note that she is on multiple medications, and conclude that she would be an ideal candidate to participate in a medication review. You ask whether she would be interested in bringing in all her medications and reviewing them with you for proper use. CL is happy to participate. She sets up an appointment to meet with you in 2 days when she has free time and you have overlap coverage.

To prepare for the session, you pull up CL’s pharmacy profile so that you can compare it with what is in her brown bag. You find the following:

• Alendronate, 70 mg, weekly
• Alprazolam, 0.5 mg twice daily, as needed
• Atenolol, 25 mg, daily
• Atorvastatin, 20 mg, once daily
• Fluoxetine, 20 mg, every morning
• Metformin, 500 mg, twice daily

CL arrives for the appointment and empties her brown bag. You notice these additional medications:

• Adult multivitamin with iron, once daily
• Aspirin, 81 mg, daily
• Calcium citrate, 500 mg, twice daily
• Lisinopril, 5 mg, daily
• Omeprazole, 40 mg, daily
• OTC brand Advil (ibuprofen), 200 mg, as needed
• OTC famotidine, 20 mg, twice daily
• OTC brand Tylenol PM, 20 mg, as needed for sleep
• Rosuvastatin, 20 mg, daily
• Vitamin D, 1000 IU, twice daily

As you review the medications for accuracy, you notice some of the medications are for CL’s sister. CL tells you in confidence that because of insecurity about maintaining her independence and a limited budget, she is not always able or willing to seek medical advice. She admits that she gets confused and shares medications with her sister. CL has not renewed her eyeglass prescription in more than 2 years and mentions that she has trouble reading the newspaper and other fine print. She also acknowledges that she has been having difficulty hearing and remembering specific information that she does not immediately write down.

You ask CL about her health-related goals. She tells you that she wants to maintain a satisfactory quality of life and also stay out of the hospital. You and CL talk about the dangers of using medications not prescribed to her, duplicate therapy, and safety. You briefly discuss her diet, some nonpharmacologic ways to help prevent memory loss, and some of the concerns you have about her hearing and vision. CL should be referred immediately for proper follow-up care, lab work, and treatment, as you are unsure how long she has been taking medications not prescribed to her. Because of your brown bag session, CL is very interested in participating in the MTM session you offered as a follow up and thanks you for your help.

What else would you suggest to her before her MTM session? How would you help CL? Would you have made additional or fewer recommendations?

Jill Drury, PharmD, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.