Medication management in the older adult: A narrative exploration

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Excerpt

The United States is facing a dramatic transformation of social and economic significance that will impact health care. This transformation is referred to as “the gray tsunami”; a metaphor for the potentially catastrophic impact on health care brought forth by the increase in numbers of older adults (Reams, 2013). During the next decade, the proportion of the global population aged 65 and above is set to outnumber the proportion of children less than 5 years for the first time. Between the years of 2010 and 2030, the number of individuals aged 65 and above is expected to increase dramatically as the Baby Boomers age (Hobbs & Damon, 1996; U.S. Department of Health and Human Services [USDHHS], 2011). The percentage of individuals aged 65 and above is expected to increase by 36% to 55 million by 2020. By 2020, the population between 65 and 74 years will grow 74%. Furthermore, U.S. Census Bureau statistics suggest that the number of “old‐old” adults, those greater than the age of 85, will also increase 19% to 6.6 million (USDHHS, 2011). This increased volume of older patients will impact the healthcare system (NCHS, 2015), a system that is already overburdened and stressed.
One of the key markers in today's healthcare delivery system is the use of prescription medications. The likely use of more medications will increase as the population ages, predisposing the opportunity for polypharmacy. A definitive definition of polypharmacy has not been agreed upon. The literature refers to polypharmacy as taking five or more medications, overmedication, or taking unnecessary medications. Whether referring to the number of medications or taking too much, or unnecessary medications, polypharmacy sets the stage for multiple drug‐to‐drug interactions (Campanelli, 2012; Maher, Hanlon, & Hajjar, 2013).
Polypharmacy leads to adverse drug events (ADEs), especially in older adults, who already experience declining health because of physiologic changes of aging, multiple comorbid conditions, and having multiple providers. Approximately 90% of individuals aged 65 and above take one medication. Estimates exist that suggest 44% of men and 57% of women aged 65 and above take five or more medications. And, about 12% of both men and women take 10 or more medications (NCHS 2015; Woodruff, 2010). Past studies suggest that up to 42% of ADEs in older adults are preventable with most problems occurring at the ordering and monitoring stages of care. Total healthcare expenditures related to potentially inappropriate medications (PIMs) exceed $7.2 billion (AGS, 2012; Resnick & Pacala, 2012).
The aging population, coupled with the extensive use of prescription and other medications, signals a shift in research priorities for the country. The National Center for Healthcare Statistics (NCHS) notes care of the older adult and medication management are key areas that must influence and shape healthcare research (NCHS, 2015). Nurse practitioners (NPs) are facing and will increasingly be facing the challenges of caring for an aging population daily in practice. There are many challenges to geriatric pharmacotherapy: more new drugs are available each year, off‐label indications are expanding, increasing popularity of herbals, multiple comorbid states, medication cost, and the effects of aging on pharmacokinetics and pharmacodynamics.
In 2006, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (APRN Consensus Model) addressed the declining numbers of applicants for certification as adult gerontological clinical nurse specialists (AGCNS) or gerontological NPs (GNP) by eliminating the GNP track and presenting the new adult‐gerontology NP (AGNP) track (Gerontological Advanced Practice Nurses Association [GAPNA], 2015). The Gerontological Nurse Practitioner national certification examination was retired by AANP in 2012 and ANCC in 2015 (AANP, 2016; ANCC, 2016).
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