There was much excitement at the beginning of 2020, with milestone events personally and professionally planned for us all. As we close out 2020 and head into 2021, it is imperative that we pause, reflect, and incorporate valuable lessons about how to deliver programs and services to older adults and those that care for them. Drawing from more than 20 years of clinical pharmacy experience, 2020 was one of the most trying due to the emotional toll of battling an invisible enemy that disproportionately impacted older adults. This quote from Steve Maraboli, a motivational speaker, writer, and behavioral scientist, encapsulates that toll: “It is important that we forgive ourselves for making mistakes. We need to learn from our errors and move on” (Wise Sayings, n.d.). The importance of learning, even in trying times, is why the current article highlights medication safety issues learned during 2020 that can inform best practice, as well as shares enduring resources and public health action steps needed in the future.
Medication Safety Issues During the Covid-19 Pandemic
Older Adult Awareness
In Spring 2020, as early data were published on COVID-19 cases in China where the virus appears to have first emerged, many studies noted the higher risk of fatality and severe outcomes in older adults. That risk became emergent as COVID-19 spread in long-term care and assisted living facilities in the early part of the year. To help meet the need for timely risk-mitigation strategies, the Peter Lamy Center on Drug Therapy and Aging collaborated with the U.S. Depre-scribing Network to create a resource with strategies to optimize medication administration in long-term care/assisted living facilities with rational, patient-centered approaches, such as discontinuing unneeded medications or supplements to decrease the frequency of medication passes and limit the potential for person-to-person spread from nursing staff to residents (Brandt & Chou, 2020). This guide (access https://www.pharmacy.umaryland.edu/centers/lamy/optimizing-medication-management-during-covid19-pandemic) has been used by health professionals around the world in guiding clinical decision making to reduce COVID-19 transmission risk for older adults in long-term care facilities. Overall, the efforts to disseminate new data on COVID-19 transmission and risks in older adults, and work such as the medication optimization guide from the Lamy Center and U.S. Deprescribing Network, have helped increase provider and health care staff awareness on best practices to mitigate risk. Less attention in the earlier literature on the novel coronavirus focused on community-dwelling older adults.
To that point, O'Conor et al. (2020) report an ongoing survey of community-dwelling Chicago residents related to the COVID-19 pandemic. Their sample is predominantly older adults (N = 673; 35.8% of participants between ages 60 and 69 years, 29.1% ages ≥70 years). The researchers assessed health literacy related to COVID-19 in their survey by asking respondents to describe three COVID-19 symptoms and three preventive actions. Although most participants identified three symptoms (71%) and three preventive actions (69.2%), multivariable analyses showed that women were more likely than men and African American individuals were less likely to report socially distancing than other races/ethnicities. That trend of greater likelihood of African American individuals with lower income to have not practiced preventive measures was also observed, although no overall association could be demonstrated. Instead, health literacy was the only variable that showed a statistically detectable relationship with preventive action, emphasizing the importance of interventions to increase health literacy in older adults. The impact of structural racism and other systemic factors may yet be revealed by further study.
Furthermore, medically complex patients are at risk for medication side effects, errors, and emergency department visits and hospital readmissions. A recent qualitative study comprised of home health providers discussing 22 medication errors led to two predominant themes: fragmented system of care and vulnerable patients in vulnerable situations (Squires et al., 2020). The study is part of a program for medically complex older adults with a team of nurse practitioners and pharmacy and social work students, illustrating that the complexity and multiple layers of care necessitate an interprofessional approach (Squires et al., 2020). A program to increase health literacy and provide social connection during the ongoing COVID-19 pandemic has been implemented through a collaboration of the Geriatric Workforce Enhancement Program at Johns Hopkins University, and the University of Maryland, Lamy Center's interprofessional aging in place course. This course connects professional students in health professions programs at University of Maryland, Baltimore with community-dwelling older adults through two residential sites for older adults with low income, and one community health service provider. Programs directly address COVID-19 preventive behaviors, as well as broader topics that may impact an older adult's ability to age-in-place in the community. Because community-dwelling older adults may be at increased risk for adverse outcomes related to COVID-19, but may lack the oversight of health care professionals compared to older adults in long-term care settings, programs to increase health literacy may be critical to limiting morbidity and mortality due to COVID-19 in this population. Of note, O'Conor et al. (2020) found that increased health literacy impacted their survey respondents' medication safety behavior—those with better health literacy were more likely to have obtained a supply of their chronic medications in case of being unable to leave home.
Medication Shortages During COVID-19 and Implications on Older Adults
The U.S. Food and Drug Administration (FDA) continues to actively monitor the availability of medicines. The current standing of drug shortages known to the FDA is tabulated and searchable (access https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm). In light of the volatility of the supply chain for medications even before the pandemic, it is imperative that we educate older adults and caregivers on key questions to ask. There is a consumer-friendly site through the Institute for Safe Medication Practices (access https://www.ismp.org) that provides helpful information on this topic as well as other medication safety concerns (e.g., storing and discarding medications).
A recent community-based survey of >1,000 older adults was conducted noting only a small percentage (2.7%; n = 31) of changes in availability of medications during the pandemic (Brown et al., 2020). This finding is encouraging in light of the ongoing concerns that economic, clinical, social, and structural factors can cause many individuals to go without essential medicines every day (Alexander & Qato, 2020). Fortunately, rapid mobilization of pharmacists and transformation of the distribution system, such as mail delivery, have helped mitigate some of these challenges (Badreldin & Atallah, 2020). Despite these changes, there is more work to be done, and not a moment to lose. For instance, federal and state preparedness efforts should focus on what the World Health Organization (2019) considers essential medicines, which are medicines that satisfy the priority health needs of the population and should be available in the health system at all times, in adequate amounts, with quality ensured, and at a price the individual and community can afford. Such medicines include, but not are limited to, antibiotics, antivirals, antidiabetic agents, cardiovascular drugs, respiratory agents, contraceptives, psychotropics, and analgesics.
Initiatives and Resources to Improve Medication Safety
Jennings et al. (2020) conducted a systematic review pooling results from 27 studies with a total population of 128,580 patients aged ≥65 years, of whom 20,153 (16%) experienced significant adverse drug reactions (ADRs) while hospitalized. Studies were heterogenous, with the oldest included study dating from 1965 (accounting for 500 patients), and included an international sample (Jennings et al., 2020). Beyond those potentially confounding factors, the authors note that the methodologies used in these studies to identify and detect ADRs varied, and severity of ADRs was not possible to extract. With those weaknesses noted, this publication is the first meta-analysis of ADRs in hospitals. Drug classes most associated with ADRs are diuretics (19.8%), antibacterial agents (14.8%), antithrombotic medications (12.2% [vitamin K antagonists accounted for 3.4%]), and analgesics (10.9% [opioids accounted for 8.6%]) (Table 1). The study presents a list of 20 drug classes that account for 94% of ADRs reported in this meta-analysis (Jennings et al., 2020), potentially of use to guiding monitoring of older adults in inpatient settings.
Top 10 Medication Classes Associated With Adverse Drug Reactions
ADRs, especially in older adults, may occur more frequently with inappropriately dosed medications. Drago et al. (2020) report on implementing geriatric dosing in a U.S.–based, tertiary care academic medical center through modifying proposed doses that appear in the electronic health record (EHR) when physicians order medications. If a patient was older than 75 years, the EHR, by default, presented prescribers with reduced doses based on the American Geriatrics Society Beers Criteria®, the STOPP criteria, and Lexi-Comp. This approach of modifying the EHR's order set was meant to limit alert fatigue and preserve the existing prescriber work-flow. The study reports average dose and total daily dose 12 months prior and 12 months post-implementation regarding several classes of medications requiring dose adjustment, such as sleep agents, cardiac medications, and opioids. The data show that these modified order sets resulted in lower doses being prescribed (Drago et al., 2020). The authors note that they do not have data on incidence of ADRs, and that a prior study showing lower doses given in geriatric populations in the emergency department showed lower incidence of ADRs, but was underpowered statistically (Drago et al., 2020). Ongoing efforts continue to evaluate the integration of technology in the clinical workflow to improve medication use and safety.
Clinical Implications for the Interprofessional Team
The pandemic has produced unprecedented challenges necessitating a comprehensive and interprofessional response from the medical community. Interprofessional initiatives, such as the Age-Friendly Health Systems (AFHS) 4Ms framework, help health systems prioritize what Matters to patients, Medications, Mentation, and Mobility in an effort to increase quality of care and safety. The MedStar Center for Successful Aging (CSA), the practice whose efforts at adopting the 4Ms have been recently published, assessed their approach to new patients pre- and post-implementation (Guth et al., 2020). Although the numbers are small (N = 67 in the pre-intervention group, N = 55 in the post-implementation group), the authors do not present findings on statistical differences between groups. It appears that the CSA practice had already assessed the elements of the 4Ms framework prior to explicitly adopting it. The authors go on to describe how the 4Ms framework informed the implementation of high-risk medications rounds and impacted care coordination between practice and community partners, such as Meals on Wheels. The explicit use of the 4Ms framework was also seen favorably by providers (e.g., physicians, nurse practitioners, pharmacists, social workers) in the practice, as assessed via survey (Guth et al., 2020). Movements such as this are critical during challenging times due to creating a culture of support and collaboration to reduce workplace stress and burnout.
Interprofessional practice and patient care has adapted to greater use of telehealth. The Centers for Disease Control and Prevention (2020) note that rules enabling broader access to telehealth and wider reimbursement for telehealth have increased its use, potentially limiting the exposure of patients seeking care, and preserving the supply of personal protective equipment at health systems. Segal et al. (2020) describe implementing telehealth in their health system based in Washington state during the initial spread of COVID-19. Overall, their experience shows that in the ambulatory clinic setting, pharmacist work-flows were adaptable to telehealth, reporting that pharmacists used video technology to remotely observe patients' injection techniques, and that telehealth encounters and documentation were at times shared with multiple providers at the same time (Segal et al., 2020). Although they report a total of 139 offers of telehealth encounters, which were accepted by 116 patients, a granular report on exactly what types of pharmacists or other clinical intervention occurred in each visit is not available. Overall, they seem to show that many aspects of pharmacotherapy could be adapted during the public health emergency, with medication reconciliation and patient counseling adaptable to tele-health, especially supported with video. Challenges to telehealth involve technology and connection issues and patient's reluctance with privacy concerns. Preliminary findings suggest that the expansion of telehealth enacted through the emergency response to the COVID-19 pandemic may positively impact care in the future (Segal et al., 2020).
As a result of lessons learned in 2020, clinicians are better prepared to operationalize improvements in medication safety, with several key themes having emerged.
Necessity is the Mother of Invention: Collaboration among organizations has led to advancements in medication safety as well as innovations to combat public health concerns. Hopefully, these partnerships will continue well beyond the pandemic to advance the science and care of older adults.
Knowledge is Power: The findings that health literacy gaps contribute to worse outcomes in African American individuals with COVID-19 speak to the opportunity to develop targeted educational messages for this population. The best approach to educating about social distancing, mask safety, and sanitizing strategies can be tailored to the specific learning needs of the population.
Mail Delivery of Medication: Standard mail delivery can facilitate access to needed medications by older adults who should not be exposed to individuals who may be COVID-19 positive. This increased access can reduce burden on older adults and those who care for them.
Decision Support: Predetermined order sets and decision-support algorithms simplify prescribing and improve medication safety. Ongoing efforts and support will be needed to scale up sustainable efforts.
Age-Friendly Systems: Focusing on what matters to older adults will help tailor medication regimens and goals of care that align. This social movement shows promising results on medication safety and reduced use of high-risk and potentially inappropriate medications.
Telehealthier: Although tele-health may improve access to care, equal access to the technology and infrastructure that enables these approaches to health care in the pandemic remains a work-in-progress.
This past year has impressed the importance of collaboration and support to overcome challenges providing care to older adults. Ongoing surveillance and research are paramount to improve medication safety. As the largest consumer of prescription and over-the-counter medications, older adults need to be engaged and empowered to have their voices heard. Ongoing efforts are needed to co-design education as well as training programs to address medication safety in older adults. Furthermore, aligning initiatives, such as the AFHS, with technology and workflow improvement ideally will also improve medication safety for older adults not only in the United States but globally.
- Alexander, G. C. & Qato, D. M. (2020). Ensuring access to medications in the US during the COVID-19 pandemic. Journal of the American Medical Association, 324(1), 31–32 doi:10.1001/jama.2020.6016 [CrossRef]
- Badreldin, H. A. & Atallah, B. (2020). Global drug shortages due to COVID-19: Impact on patient care and mitigation strategies. Research in Social and Administrative Pharmacy. Advance online publication. doi:10.1016/j.sapharm.2020.05.017 [CrossRef] PMID:32446652
- Brandt, N. J. & Chou, J. (2020). Optimizing medication management during the COVID-19 pandemic: It takes a village. Journal of Gerontological Nursing, 46(7), 3–8 Retrieved July 27, 2020, from. doi:10.3928/00989134-20200605-02 [CrossRef]
- Brown, J. D., Vouri, S. M. & Manini, T. M. (2020). Survey-reported medication changes among older adults during the SARS-CoV-2 (COVID-19) pandemic. Research in Social and Administrative Pharmacy. Advance online publication. doi:10.1016/j.sapharm.2020.11.005 [CrossRef] PMID:33221267
- Centers for Disease Control and Prevention. (2020). Using telehealth to expand access to essential health services during the COVID-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html
- Drago, K., Sharpe, J., De Lima, B., Alhomod, A. & Eckstrom, E. (2020). Safer prescribing for hospitalized older adults with an electronic health records-based prescribing context. Journal of the American Geriatrics Society. Advance online publication. doi:10.1111/jgs.16640 [CrossRef] PMID:3253762
- Guth, A., Chou, J., Courtin, S. O., Ford, C., Hennawi, G. & Brandt, N. (2020). An interdisciplinary approach to implementing the age-friendly health system 4Ms in an ambulatory clinical pathway with a focus on medication safety. Journal of Geronto-logical Nursing, 46(10), 7–11 doi:10.3928/00989134-20200909-02 [CrossRef]
- Jennings, E., Murphy, K. D., Gallagher, P. & O'Mahony, D. (2020). In-hospital adverse drug reactions in older adults: Prevalence, presentation and associated drugs: A systematic review and meta-analysis. Age and Ageing, 49(6), 948–958 doi:10.1093/ageing/afaa188 [CrossRef]
- O'Conor, R., Opsasnick, L., Benavente, J. Y., Russell, A. M., Wismer, G., Eifler, M., Marino, D., Curtis, L. M., Arvanitis, M., Lindquist, L., Persell, S. D., Bailey, S. C. & Wolf, M. S. (2020). Knowledge and behaviors of adults with underlying health conditions during the onset of the COVID-19 U.S. outbreak: The Chicago COVID-19 Comorbidities Survey. Journal of Community Health, 45(6), 1149–1157 doi:10.1007/s10900-020-00906-9 [CrossRef] PMID:32780294
- Segal, E. M., Alwan, L., Pitney, C., Taketa, C., Indorf, A., Held, L., Lee, K. S., Son, M., Chi, M., Diamantides, E. & Gosser, R. (2020). Establishing clinical pharmacist telehealth services during the COVID-19 pandemic. American Journal of Health-System Pharmacy. Advance online publication. doi:10.1093/ajhp/zxaa184 [CrossRef]
- Squires, A., Ridge, L., Miner, S., McDonald, M. V., Greenberg, S. A. & Cortes, T. (2020). Provider perspectives of medication complexity in home health care: A qualitative secondary data analysis. Medical Care Research and Review, 77(6), 609–619 doi:10.1177/1077558719828942 [CrossRef]
- Wise Sayings. (n.d.). Looking forward sayings and quotes. https://www.wisesayings.com/looking-forward-quotes/#ixzz6f6E4i0Kn
- World Health Organization. (2019). World Health Organization model list of essential medicines: 21st list 2019. https://apps.who.int/iris/bitstream/handle/10665/325771/WHO-MVP-EMP-IAU-2019.06-eng.pdf?ua=1
Top 10 Medication Classes Associated With Adverse Drug Reactions
|Rank||Drug Class||n||Key Drugs (Events, n)|
|1||Diuretics||473||Sulfonamides (furosemide , bumetanide )|
|2||Systemic antibacterial||354||Penicillins (106) Cephalosporins (54) Quinolones (29)|
|3||Antithrombotic agents||292||Vitamin K antagonist (82) Heparin (84)|
|5||Respiratory/airway disease drugs||113||Adrenergic (78) Beta agonist (62)|
|6||RAAS system agents||98||ACE inhibitors (39)|
|8||Systemic corticosteroids||77||Glucocorticoids (60)|
|9||Cardiac therapy||71||Digoxin (39) Vasodilators (12) Amiodarone (10)|
|10||Diabetes medications||61||Insulins (39)|