Clinicians have become more aware of the increasing complexity of caring for older adults. Multiple patient comorbidities coupled with numerous medications, both prescribed and over the counter, challenge clinicians to responsibly develop and monitor an appropriate and safe plan of care. This plan encompasses aspects such as identifying health concerns for which pharmacological management may be beneficial, using evidence-based medication regimens to both treat and prevent problems, applying complicated medication regimens to more effectively manage chronic illnesses, and recognizing medication side effects that could have serious consequences if left untreated. The articles in this geropharmacology focus issue touch on each of these aspects and highlight serious concerns related to pharmacological interventions in the care management of older adults.
The article by Woods, Guo, Kim, and Phillips on pages 30–39 explores medication-related problems in a study of assisted living facilities in one western state. The authors note that data compiled during a 2-year period from state surveyors’ reports demonstrated that approximately 62% of the facilities surveyed received a medication-related citation. Further, the variability in state regulations obscures an accurate understanding of the problem. Of particular concern is the finding that complex medication regimens are delivered by unlicensed personnel, thereby increasing the risk for negative health consequences. The authors stress the need for more nursing oversight in the delivery of care.
The underutilization of prevention measures for venous thromboembolism (VTE) in both younger and older hospitalized patients is described in the results of a study conducted by Lee and Zierler (pages 40–48) at an academic medical center. The study compared prevention practices and clinical outcomes in adults 65 and older with those 18 to 64 at risk for or diagnosed with VTE. Pharmacological prophylaxis was used in 70% of eligible older adults and 57% of eligible younger adults. However, nearly one quarter of eligible older inpatients did not receive any VTE prevention measures. The 3-month mortality rate was higher in older patients compared with younger patients, despite the lower rate of VTE in older inpatients. Prevention measures were underused in both groups.
Depression is frequently undiagnosed and undertreated in older adults. Left untreated, this mental health problem can have serious consequences and negative health outcomes. Depression is a treatable illness. The newer class of selective serotonin reuptake inhibitors offers an approach to treating this problem. In her article on clinical outcomes of treating depression (pages 22–27), Smith emphasizes that clinicians need to be aware of the side effect of hyponatremia with the use of this class of antidepressant agents. Older adults are especially at risk for hyponatremia, and serious consequences can result if it is left untreated, as demonstrated in the clinical example.
Pain is widely prevalent in long-term care facility residents. Like depression, persistent or chronic pain is often unrecognized and undertreated. Potential barriers exist that reflect both health care provider and patient factors. To address these barriers to optimal pain management and to clearly enumerate the responsibilities of skilled nursing facilities to effectively treat and prevent pain, the Centers for Medicare & Medicaid Services (2009) recently released a new pain management guidance and investigative protocol, F-Tag 309. This new surveyor guidance, discussed in the article by Planton and Edlund on pages 49–56, focuses on identifying, assessing, and treating the underlying causes of pain, as well as continually evaluating the resident’s outcomes and changing interventions as needed. Further, the guidance endorses an interdisciplinary team approach in the development of a pain management plan specific to each resident and the involvement of the patient and family in the plan of care. Ongoing education for health care providers on all aspects of pain management is also emphasized, as the staff turnover rate in long-term care settings is high. While nonpharmacological interventions should be included whenever possible and are encouraged by the new surveyor guidance, pharmacological interventions are often necessary in treating pain in older adults.
Kane, Ouslander, Abrass, and Resnick (2009) noted that while “medical care in general is awakening to the importance of good chronic disease care, geriatrics has been at it for years” (p. 79). Those committed to the care of older adults with chronic disease both support and promote several key aspects essential to the care of this patient population, including:
- Proactive monitoring of disease management to avoid adverse drug-drug and drug-disease interactions.
- Simplifying medication regimens when possible and eliminating unnecessary medications to avoid problems in administration and dosing.
- Diagnosing common problems that are often undiagnosed and untreated, such as pain and depression.
- Implementing timely interventions to avoid negative health outcomes.
- Maintaining a patient-centered focus that involves an interdisciplinary team approach to care management.
The increase in the aging population and the prevalence of chronic disease in this group clearly point to the need for more critical oversight in the use of pharmacological interventions in chronic disease care.
Barbara J. Edlund, PhD, RN, ANP, BC
Professor and Coordinator
Gerontological and Palliative Care Nurse
College of Nursing, Medical University of
Charleston, South Carolina