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R&E Foundation Update

17 Jul 2018 12:15 PM | Anonymous

Medication Saving Behaviors in Older Adults: Identifying and Managing a Barrier to Effective Healthcare

Authors: Kristin Hegna, PharmD, St. Louis College of Pharmacy, Resident at UnityPoint – Meriter

Melanie VanDyke, PhD, St. Louis College of Pharmacy, Associate Professor and Licensed Psychologist

Medication hoarding in older adults is a barrier to effective healthcare that is difficult to define, identify, and manage. The DSM-5 classifies hoarding disorder as a problem with discarding possessions (regardless of their value) because of feeling the need to save things and experiencing distress about their disposal. Hoarding disorder is further characterized by clutter that interferes with the use of living space and clinically significant distress or functional impairment.1 Excessive clutter may create an unsafe living environment and pose both tripping and fire hazards. Medication hoarding differs somewhat from generalized hoarding behavior: medications have inherent value, and medication hoarding may not substantially contribute to household clutter. However, the accumulation of unused or expired medications in the home carries the additional risk of accidental (or intentional) medication misuse and diversion.2 

In order to identify and manage medication hoarding, healthcare providers have a new tool: the Medication Saving Behaviors (MSB) scale. The 6-item MSB scale was developed and validated with a population of women who manage medications for their older family members.3 Key components of MSB include distress in acquiring, storing, and discarding medications; avoidance of medication disposal; and difficulties with medication management due to the quantity of medications in the home. Of note, this accumulation of medication may impact both the patient and their family.

Identifying MSB in the Health-System Setting

The ability to identify problematic medication accumulation is challenging in the inpatient setting, where medications are handled by hospital staff and providers may not have knowledge of the patient’s household supply of medication. However, medication reconciliation serves as an opportunity to identify at-risk patients. In line with the 2017 Joint Commission’s National Patient Safety Goals, medication reconciliation is critical in identifying and resolving discrepancies in medication use.4 Ideally, providers should contact their patients and the family members involved in patient care. This communication provides insight into the difficulties associated with medication management, including the acquisition, storage, and disposal of drugs.

In addition, a Brown Bag Review of a patient’s supply of medications provides an important safety check. A potential “red flag” for identifying MSB is the presence of expired and leftover (no longer prescribed) medications, as MSB are correlated with the quantity of expired and leftover medications in community dwelling older adults. However, the number of prescribed medications is not associated with MSB,3 so a patient should not be identified as at-risk for medication hoarding based solely on having more medications prescribed.  Therefore, a thorough review of all of the medications in the patient’s home is recommended to assess the risks of MSB.

Clinical Implications of MSB

Older adults are at a higher risk of adverse events due to increased use of medications, and older adults with hoarding disorder report a greater number of chronic medical conditions and a higher risk of falls.5 Since MSB are significantly related to generalized hoarding behaviors,6 the potential for exposure to unsafe medications is particularly relevant in older adults with hoarding disorder.  Therefore, healthcare providers may consider asking patients with a history of hoarding behaviors about their current MSB. 

Additionally, MSB are significantly correlated with medication adherence problems.6 The Adherence to Refills and Medications Scale (ARMS) is an important tool for patients with chronic diseases states and low literacy levels.  For instance, research using the ARMS demonstrates that patients with coronary heart disease who have better medication adherence show significantly better blood pressure control over patients who are less adherent. 7 Medication nonadherence is a known barrier to effective healthcare, resulting in higher rates of morbidity, mortality, and an estimated annual cost of $100-$300 billion USD.8 Due to the relationship between MSB and medication adherence problems, medication hoarding may worsen health outcomes and increase healthcare costs.

Management of MSB in the Health-System Setting

Just as it is difficult to identify MSB during an inpatient visit, the management of MSB within the health-system setting is likely to be challenging. Hoarding and other chronic conditions require long-term follow-up after hospitalization. When a patient identifies hoarding behaviors, a health-system pharmacist may ask follow-up questions about medication storage and adherence. During transitions of care, it may be helpful to counsel all patients who are prescribed risky medications, such as opioids, about safe storage and disposal practices.  This communication is not consistently practiced: a study of more than 1000 adults with recent opioid medication use  found that just over half of the patients recalled receiving information on safe storage (51%) or proper disposal (55%), with pharmacists being the medical professional most likely to address these issues.9

In addition to direct patient care, a health-system pharmacist may provide additional services to support family caregivers, particularly when frequent medication changes are made. Medication regimens that were adjusted four or more times in the previous year were significantly related to decreased adherence.10 Another factor related to MSB and poor adherence is caregiver self-efficacy. Caregivers who are less confident in their ability to handle medication-related hassles reported more MSB, worse medication adherence, and more medication-related hassles.6 Pharmacists have the opportunity to reduce caregiver burden by providing thorough discharge counseling, clear medication instructions, safe storage and disposal information, and positive feedback to caregivers about specific strategies they use successfully. By supporting family caregivers, pharmacists may ultimately reduce MSB and improve health outcomes. 

Further research is required to create a standardized approach for identifying and managing patients with MSB.  By recognizing the risk factors of MSB, providers can target at-risk patients and their families for appropriate interventions. Healthcare providers may improve medication adherence and reduce the risk of medication misuse and diversion by successfully addressing MSB.

Pharmacists who are interested in discussing medication hoarding or want an updated version of the scale, please contact Melanie.VanDyke@stlcop.edu.

References:

1. American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013

2. Disposal of unused medicines: What you should know. U.S. Food and Drug Administration website https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm. Updated June 13, 2018. Accessed June 26, 2018.

3. VanDyke MM, Steffen A. Medication savings behaviors of older adults: Scale developed to assess family caregiver perspectives. Clin Gerontol. 2017;40(4):258-267. doi: 10.1080/07317115.2016.1276114

4. National patient safety goals effective January 2017: Hospital accreditation program. The Joint Commission website https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2017.pdf. Accessed June 26, 2018.

5. Diefenbach GJ, DiMauro J, Frost R, et al. Characteristics of hoarding in older adults. Am J of Geriatr Psychiatry. 2013;21(10). doi: 10.1016/j.jagp.2013.01.028.

6. VanDyke MM, Chow M, Dinh A, et al. Presentation: Medication hoarding: Women managing medications for older family members identify a hoarding-related risk factor. Poster presented at: Anxiety and Depression Association of America and St. Louis College of Pharmacy Student Research Symposium; 2018 Apr; Washington D.C. and St. Louis, Missouri.

7. Kripalani S, Risser J, Gatti ME, et al. Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease. Value Health. 2009;12(1):118-123. doi: 10.1111/j.1524-4733.2008.00400.x.

8. Neiman AB, Ruppar T, Ho M, et al. CDC Grand Rounds: Improving Medication Adherence for Chronic Disease Management — Innovations and Opportunities. MMWR Morb Mortal Wkly Rep 2017;66. DOI: http://dx.doi.org/10.15585/mmwr.mm6645a2.

9. Kennedy-Hendricks A, Gielen, A, McDonald E, et al. Medication Sharing, Storage, and Disposal Practices for Opioid Medications Among US Adults. JAMA Intern Med. 2016;176(7):1027-1028. doi:10.1001/jamainternmed.2016.2543.

10. Choe E, VanDyke M, Griggs, et al. Presentation: Assessing potential caregiver strategies associated with improved medication adherence in a community-based sample of older adults.  Poster presented at: St. Louis College of Pharmacy Student Research Symposium; 2017 Apr; St. Louis, Missouri.

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