Mismanagement - Self-medication management by older people

2.5 Self-medication management by older people

2.5.4 Mismanagement

Older people’s self-medication management is a seldom researched topic, despite it being known that they are at high risk of medication mismanagement. The main reason for the high risk is that their medication regimens are often unclear or have not been guided precisely by the prescriber. And in unclear situations there´s not a person who can help nearby, or easily available to ask for advice. Older people often have many medications and different doses, times, and administration methods (Swanlund et al., 2008). Furtermore, there are findings that suggest that older people do not take their drugs in a proper way (e.g., Yasein et al., 2013). Both human and environmental factors contribute to medication mismanagement among older people (Bergman-Evans, 2006; Johannesson et al., 2015). Human factors include many things. For example, faulty communication between the health-care professionals and the older people, the older people’s lack of knowledge, alcohol-drug interactions (ADRs), use of OTC medications and herbal products, cognitive, sensory and motor impairments and polypharmacy. Environmental factors are, for example, the high cost of prescribed medications, inappropriate medication storage, and the lack of clearly marked expiration dates. The most usual errors connected with medication mismanagement comprise mixing OTC and prescription medications, quitting prescriptions, taking wrong dosages, using incorrect techniques and eating inappropriate foods with specific medications. (Bergman-Evans, 2006; Swanlund et al., 2008; Yasein et al., 2013; Johannesson et al., 2015.) Much evidence indicates that non-adherence to prescribed drug regimens can lead to symptoms that also result in falls, injures and hospitalization (Bentz et al., 2014; Laatikainen, 2020).

2.5.5 Polypharmacy, multiple medications, and supporting efficient self-medication management by older people

Polypharmacy and multiple medications are common with older people in Finland and it´s quite a studied topic. There´s evidence about risks and harms of polypharmacy and multiple medications for older peoples´everyday lives (Jyrkkä, 2006; Alanen, 2007; Ahonen, 2011; Taipale et al., 2011; Hyttinen, 2018.)

The use of antipsychotic medication in the home and long-term institutional care in Finland is found to be among the highest in the world (e.g., Alanen, 2007). Alanen’s dissertation study found that the use of antipsychotics was three times more common in long-term institutional care than in home care. Also, home-dwelling older people use quite a lot of sedative drugs in Finland, drugs with sedative properties are among the most highly used drugs in home-dwelling older people (Taipale et al., 2011). The use of sedative drugs has been associated with many serious consequences in older people lives for example with falls and fractures, cognitive and memory impairment and impaired physical function. The population-based study by Taipale et al., (2011) discovered that the sedative loads in an older population were associated with

female gender, impaired IADL, poor self-perceived health and loneliness (Taipale, 2011.)

Older people’s use of prescription and OTC medications have increased during recent decades (e.g., Ahonen, 2011), leading to an increase among those older adult groups that take multiple medications (Jyrkkä, 2006). Older people also often suffer from sleeping disorders and insomnia and it is typically undertreated, even though it is found that more than 50% of older people suffer from insomnia. It is also found that nonpharmacologic interventions are underused by health-care practitioners (e.g.

Kamel & Gammack, 2006; Harrison et al., 2009.)

Karttunen’s (2014) dissertation study on “Pain, Persistence of Pain and Analgesic Use in Community-Dwelling Older Finns” showed that the risk of mobility limitation was highest among analgesic users with pain and was associated with several things like older age and poor overall health, living alone, a sedentary lifestyle and poor muscle strength. Almost half of the older people with musculoskeletal chronic pain in their study hoped that the physician would be paying more attention to the management of their pain. Karttunen suggests (2014), that regular pain assessments, evaluation of the effectiveness of treatment, and developing new strategies to manage pain are needed to optimize pain treatment. In addition, adjuvant therapy with nonpharmacological approaches should be encouraged to supplement pharmacological pain management.

Polypharmacy (54%) was connected with fall-related complaints (30%) and multiple comorbidities (50%) in a Dutch study about geriatric patient profiles in an emergency department (Schrijver et al., 2013). In this cohort study, of a total of 183 patients aged 70 or more, 36% returned to the ED within 30 days, and 20% of these patients had initially presented with a fall (Schrijver et al., 2013).

Aging means changes to the human body and both diseases and their medication present differently as a result of such changes. Polypharmacy and multiple medications can lead to the risk of adverse drug events and unwanted drug interactions. It is quite common that older people use inappropriate medication and drugs prescribed for home care (Ahonen, 2011). It is also found that medication could be mostly harmful for older people. Potentially inappropriate medication (PIM) use causes preventable adverse drug reactions in older people. In a Finnish longitudinal study (Hyttinen et al., 2018), on the association of potentially inappropriate medication use the researcher found worse health outcomes (fractures, death) and health costs. In this study, hospitalized PIM-users had 15 % higher hospital costs compared to non-users during the 12-year follow-up period. Researchers highly recommend that health care providers should carefully consider these issues when prescribing PIM to older people (Hyttinen et al., 2018.)

Nurses in Finland today also have limited rights to prescribe medications if they are specially qualified for it. It is a less studied area in nursing and could have positive effects in older people’s self-medication management. Some study results suggest that nursing interventions, such as a series of motivational telephone calls, a personalized and illustrated daily medication schedule and coaching by telephone calls and home visits, will support the efficiency of older people’s self-medication management (Costa et al., 2011; Sulosaari et al., 2011; Martin et al., 2012; Marek et al., 2013; Williams et al., 2015).

Older people’s medication has been a multiprofessional research topic for several decades, and its challenges are very well known. Despite that, there still is a lack of information about older people’s self–medication management, especially concerning prescribed medicines. There is also a lack of information about successful self-medication management from the older people’s own viewpoints.

2.6 OLDER PEOPLE´S MENTAL STATUS AND ACUTE CARE SETTINGS

The literature review for this topic was performed using the key words older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged OR/ AND home-dwelling OR/AND home living connected with orientation OR confusion OR depression OR dementia OR loneliness OR apathy, OR/AND nursing (Figure 8).

Figure 8. Keywords in the literature review of older people’s mental status and acute care settings

Older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged

OR/ AND home-dwelling OR/AND home living

Orientation OR confusion OR mental status OR depression OR

dementia OR loneliness OR

apathy, OR/AND nursing

A total of 1256 abstracts were evaluated, and 29 articles were included in the literature review

(Appendix 3)

2.6.1 Mental status impairment: confusion or memory disorder

2.6.2 Cognitive impairment 2.6.3 Apathy and

depression 2.6.4 Loneliness

2.6.1 Mental status impairment: confusion or memory disorder

Impaired mental status is found to be highly prevalent in older people in acute care settings (Han et al., 2009; Rice et al., 2011). The lack of recognition of the problem is just as common (Table 8). In a cross-sectional study about delirium in older emergency department patients by Hans et al. (2009), the hypo-active subtype delirium was missed in 76% of the occasions, and if the delirium was missed in an emergency department, it was nearly always missed by hospital physicians at the time of admission (Han et al., 2009). This is an important issue also, because of its commonness. For example, delirium was the most common complication connected with the hospitalization of older adults and responsible for 17.5 million additional hospital days in the United States each year. At the same time, nurses also failed to recognize it more than 30% of the time (Rice et al., 2011.) Proper recognition and management of delirium by acute care nurses could minimize the effects of the negative sequence associated with delirium.

Faezah et al. (2008) explored the prevalence and the risk factors of delirium among older people in an acute care setting in Singapore. They found plenty of risk factors for delirium in their study. Risk factors were pain (45%), visual impairment (43%) and hearing impairment (30%). A decrease in premorbid function was seen in 64%

of the patients, and 24% of patients were restrained, 34% had poor oral intake, 25%

were dehydrated, 27% had electrolyte imbalance and 12% were newly commenced on nasogastric feeding. Constipation was prevalent in 38% of patients, 4% had insomnia, 26% had urine retention, 25% were newly put on a urinary catheter, while 13% had recent surgery performed. Infection affected 57%, of which 49% were due to UTIs, and 68% of patients were started on new medications (Faezah et al., 2008.) It is found that an acute confusional state, delirium, exists in 80% of patients in the intensive care unit and it is also a frequent, life-threatening and possibly preventable clinical syndrome among persons who are 65 years and above in a general hospital setting (e.g., Girard et al., 2008). It seems that the cause of delirium is usually multifaceted, and delirium and memory disorders are considerably interrelated.

Memory disorders are the premier risk factor for delirium. Memory disorders are also an increasing public health problem, also in Finland, for which early detection is beneficial. It is found that the identification of memory disorders in primary care is mostly dependent on clinical suspicion on the basis of patient symptoms or caregivers' concerns and is prone to being missed or delayed (Table 8).

Bradfort et al. (2009) tried to determine the prevalence and contributing factors for missed and delayed memory disorder diagnoses in primary care in their systematic review of the literature. They discovered that major additional factors included problems with attitudes and patient-professional communication, educational needs,

and system resource limits. Bradfort et al. (2009), suggest that the real prevalence of missed and delayed diagnoses of memory disorders is unknown but looks likely to be high. It seems to be important that the key steps to see the difference between delirium and behavioural and psychological symptoms of memory disorders are not only to address all evident causes, e.g., memory disorders, dehydration, infection, poly-medication, but also to prevent complications and treat behavioural symptoms.

Table 8. Phenomena connected with the mental status impairment of older people in the ED Phenomena connected with mental status

impairment

Study

Missed dementia/memory disorders Bradford et al., 2009;

Missed depression/signs of depression Chang & Chueh, 2011; Hammami et al., 2012;

Boman et al., 2015

Missed delirium/signs of mental confusion Faezah et al., 2008; Han et al., 2009; Rice et al., 2011; Hölttä et al., 2012; El Hussein et al., 2015 Real prevalence of missed or delayed diagnosis

(dementia, depression, delirium) is unknown

Bradford et al., 2009; El Hussein et al., 2015

However, it is found that missdiagnosing other diseases is more common among patients with memory disorders. Parke et al. (2013), clarified the facilitators and barriers to safe emergency department transitions for older people with dementia and their caregivers. They named four interconnected, reinforcing consequences:

being under-triaged; waiting and worrying about what was wrong; time pressure leading to a lack of attention to basic needs; and relationships and interactions leading to feeling ignored, forgotten and unimportant (Parke et al., 2013).

Little is known about the impact of the increasing number of older people with memory disorders on the treatment of patients in acute care settings like accident and emergency departments. Hynninen et al. (2015) found in their qualitative study of the treatment of older people with dementia in surgical wards that to improve the treatment of people with dementia, their close relatives need to participate in planning the nature of care for the patients. El Hussein et al. (2015) tried to find out the factors that assist in the under-recognition of delirium by registered nurses in acute care settings. They found eight quantitative studies that were deemed relevant and analyzed them. Seven major categories appeared in this study: the fluctuating nature of delirium, the impact of delirium education on its recognition, communication barriers, inadequate use of delirium assessment tools, a lack of conceptual understanding of delirium, delirium as a burden and the similarities between delirium and dementia (El Hussein et al., 2015.)

2.6.2 Cognitive impairment

Mild cognitive impairment is a quite common condition in older people. The prevalence of cognitive impairment in older ED patients is found to be quite high, approximately 30%, and it is also indepedendly associated with adverse outcome (Lucke et al., 2018). As a concept mild cognitive impairment (MCI) is defined “as by deterioration of memory, attention, and cognitive function that is beyond what is expected based on age and educational level” (Sima et al., 2015). Characteristics of older people with cognitive impairment in ED have found to be many, for example prior hospital admission, dependence in activities of daily living, incontinence, pain, issues in nutrition, and vision and hearing impairment (Schnitker et al., 2016). These factors are partly the same than risk factors for delirium of older people in the emergency care. In addition, cognitive impairment has been found to be the most important predisposing factor of the self-neglect of older people (Papaioannou et al., 2012). Several exposing factors, such as psychiatric diseases, pre-morbid personality, alcohol abuse, poor physical ability, lack of social support and a weak socioeconomic situation, were reported in this study. Self-neglect is found to be an independent risk factor for early mortality among the older people. It generally results in malnutrition, frailty and the deterioration of physical ability, therefore it increases the risk of falls and fractures. Untreated medical conditions might result in emergency visits and acute hospitalization (Papaioannou et al., 2012.)

2.6.3 Apathy and depression

It is also found that apathy is a common and serious neuropsychiatric symptom associated with cognitive decline, delirium, and disability plus it also independently predicts mortality (Hölttä et al., 2012). Demographic factors, physical functioning, diagnoses, and drugs were assessed in this study with special reference to dementia, delirium, and apathy. Mortality was registered from central registers. Of the 425 patients, 23% suffered from apathy. There was no difference in mean age, number of comorbidities, or in the mean number of medications between those with and without apathy. However, those with apathy had lower mean MMSE points, more often severe dementia according to the Clinical Dementia Rating, and higher dependence on ADL. Furthermore, patients with apathy more often suffered from delirium (Hölttä et al., 2012.)

Tsai-Yun and Ke-Hsin (2011), explored the relationship between depression and health status in institutionalized male veterans in Taiwan. Over 22% of participants in this study also exhibited depression. Those with poor general health status and relatively high levels of dependence on others for daily physical activities, or the self-perceived negative influences of chronic diseases on daily living faced the highest prevalence of depression. Also, participants with hypertension, cataracts, or liver disease had the highest prevalence of depression. The identified risk factors of

depression in this study were the self-perceived negative influence of chronic diseases on daily living and cataracts (Tsai-Yun & Ke-Hsin, 2011.)

Depression affects older people’s overall health and quality of life. Hammami et al.

(2012), suggest in their cross-sectional study of older people living at home that the risk of depression was a common psychiatric disorder. In this study, several significant independent predictors of risk of depression were found: female gender, having a low level of education, disability, a history of stroke and the use of hypnotic medications (Hammami et al., 2012). The population-based, cross-sectional study in the Åland Island´s (a Finnish self-governed province) by Boman et al. (2015), sent all women aged 65 years or older a questionnaire that included the Geriatric Depression Scale and the Inner Strength Scale, along with several other questions related to depression. The results showed that 11% of the studied women (n = 1452) were depressed and that the prevalence increased with age and was as high as 20% in the oldest age group. Non-depressed women were more likely to never or seldom feel lonely. They had a strong inner strength, took fewer prescription drugs, felt needed and were able to engage in meaningful leisure activities as well as cohabit (Boman et al., 2015.)

Many of the changes that older people face, such as the deaths of friends and loved ones, increased isolation can lead to depression. Depression in older people is often linked to physical illness, which can increase the risk of depression. Chronic pain, physical disability and higher dependency on ADLs can cause depression.

Depression symptoms can be associated with medical problems such as dementia or as a side effect of prescription drugs (Hammami et al., 2012). Symptoms of depression present in older people can be masked as a somatic disorder and are, thus, difficult to recognize. Symptoms of depression are found to be more frequent in older people with chronic diseases compared to older people without comorbidity. That can also be connected with self-harming behaviour (Almeida et al., 2012) and lead to return visits to ED. Left untreated, depression affects much more than just mood. It can impact physical health, impair memory and concentration, and prevent affected individuals from enjoying life (e.g., Tsai-Yun & Ke-Hsin, 2011.)

However, depression is not a normal or necessary part of aging, and it is very important to recognize it as early as possible. There are many studies about the prevalence of depression in an aged population in Finland and its connections to loneliness and a lack of social networks (Routasalo et al., 2006).

2.6.4 Loneliness

Loneliness is a major issue affecting older people’s quality of life (Table 9). Older people's loneliness is also associated with impaired health and depression (Peerenboom et al., 2015), increased use of health and social services (Taube et al., 2015) and increased mortality (Tilvis et al., 2011). Some research suggests that almost

one third of older people of 65 years and above report loneliness, even higher rates are found among those aged over 85 (Hauge & Kirkevold, 2012). (Table 9).

Table 9. Studies on the phenomena connected with older people and loneliness Phenomena connected with loneliness Research

Impaired health Pitkälä et al., 2009; Peerenboom et al., 2015;

Nummela et al., 2011; Eloranta et al., 2015 Increased use of health and social services Pitkälä et al., 2009; Taube et al., 2015,

Mortality Pitkälä et al., 2009; Tilvis et al., 2011,

Depression Routasalo et al., 2006; Eloranta et al., 2015;

Peerembom et al., 2015 Inner feelings, life orientation (expectations,

strength)

Routasalo et al., 2006; Tilvis et al., 2012; Hauge

& Kirkevold 2012; Taube et al., 2016

Unfortunately, loneliness of older people is a common problem in Finland. Eloranta et al. (2015), studied loneliness in Finnish older people aged 70, reporting that around one-fifth (18%) of the respondents born in the 1940 cohort suffered from loneliness at least sometimes, while the corresponding figure in the 1920 cohort was around one-fourth (26%). The analyses indicated that the effect of the cohort, born in the 1920s or the 1940s, was not a statistically significant explanatory factor of loneliness. Living status, self-rated health and memory compared to age peers were statistically significant explanatory factors for suffering from loneliness. Older people with poor self-rated health who lived alone were most likely to suffer from loneliness (Eloranta et al., 2015.)

It is also found that suffering from loneliness indicates a significant mortality risk of older people (e.g., Tilvis et al., 2011). The association between adverse health and loneliness among older people is also known. Nummela et al. (2011), in their longitudinal study about older people discovered that never or seldom experiencing loneliness was a strong predictor for good self-rated health. Loneliness was a significant contributor to poor self-rated health among older people (Nummela et al.,

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