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What happens when Elderly Persons Skip or Miss necessary Medication

When anyone skips or misses necessary medication, the results can be serious. When elderly persons skip, miss, or MIX medications, the results can be catastrophic. Such was the case with my maternal grandmother. My mother would put her medications in the little daily compartments and label them for her. Later, Mom would find pills throughout my grandmother’s house… even in the closet in her shoes! Mixing medications caused my grandmother to envision giant spiders on the wall and people in the room who were not there… and more.

With my paternal grandmother, the effects of missing medication is general confusion and lethargy. That’s exactly what happened this summer. One afternoon about 4:15, the phone rang, and it was my grandmother, whom we call Mam-ma (pronounced Mam-maw). Mam-ma sounded absolutely horrible. She said, “Well, I am gonna have to go to the doctor. I haven’t been able to pee today. And I’ve took the headache. I’ve just drunk water all day.” I questioned her… could she not go at all? was it a little or a lot? and she said yes, she could go, but it was just a dribble.

Mam-ma also said her Home Health aide took her blood pressure, and it was “95.” I questioned… was that the top number or the bottom? Mam-ma didn’t know. Finally she checked her notes, and she said her blood pressure was 95 over 57, and after a bath, it was 130/66. I asked if her feet were swollen, and she said they were not. I told her that I did not really want to take her to the ER unless she absolutely had to go, and she said, “No, I’m not going to the ER. “This was an afternoon when my grandmother’s family physician was not in the clinic, and at 4:15, it was too late to see him anyway. So I told my grandmother to get an appointment for the next afternoon, if possible, as I had a funeral to attend that next morning. She really didn’t want to wait until afternoon, but ultimately, she was not able to get a morning appointment anyway.

I talked with my sister, and she called my grandmother and got a fairly different story – much more upbeat and less “sick.” My grandmother told my sister that she had been out in the yard and filled her birdbath and watered her garden. We were in the midst of a stifling July heat wave, so my sister insisted that Mam-ma not go back outside again. We decided this was not urgent – was probably heat related – and could wait until the next day. I was beginning to think that this was more my grandmother wanting to make a trip to visit her family physician after seeing him at her dentist’s office than a true illness. Mam-ma feels a “need” to see her doctor every six months or so, whether she is sick or not. But she got a 1:30 p.m. “work-in/walk-in” appointment, so we went to the clinic to wait.

I wish I could say this was the most bizarre trip I’ll ever make to Mam-ma’s doctor, but I’m afraid to do so! We actually got into an exam room pretty quickly. Mam-ma told the nurse her spiel and we toddled to the bathroom and she gave a urine specimen. Then her physician came in, and started asking Mam-ma questions. She told him she couldn’t go to the bathroom. He asked – was she able to go at all? Oh, yes, when she took her Lasix, she went “real good” for about an hour after that, and then she couldn’t go any more.

Dr. B.: Do you feel like you need to go again?
Mam-ma: No.
Dr. B.: How often do you go?
Mam-ma: Well, after I take my Lasix, several times for about an hour, and then maybe 2 times the rest of the day.
Dr. B. (looking totally confused): So what’s the problem?
Mam-ma: Well, I need to go!
Dr. B.: Why? Does it hurt when you go?
Mam-ma: No, but it hurts down there (pointing to the lower part of her abdomen.) It’s just terrifying!
Dr. B.: What’s terrifying?
Mam-ma: Well, when you sit on the commode and you can’t go.
Dr. B.: Do you feel the urge to go?
Mam-ma: No, but I just need to go! I’ve drunk and drunk water and lemonade until I’m so full!
Dr. B.: That’s obvious – you’ve diluted your urine!

He went on to say that he thought between the Lasix and the heat of the summer, she might be dehydrated a little. I told him about the blood pressure, and how it came up with a bath, and again when she went outside. She had argued she didn’t go outside.

So I asked, have you been back outside since you watered? Dr. B. said, “That’s a good question. I was going to ask what you’ve been doing.” She said, “Well, when you have a garden, you have to keep it watered, and so I had to go out yesterday and water my garden.” He asked her about her garden. Her answers were slow – and halting – and confused, and she had a terrible time figuring out what to say and getting it out. Poor Dr. B., he was just sitting there with his arms folded, frowning, trying to figure out what the heck was happening!

I asked if she walked that morning, and she immediately said “NO!” Dr. B. shot back, “Why not?” and she said, “Well, because I didn’t feel like it!” He checked her breathing and listened to her heart and belly. He finally wrote a prescription for six Cipro pills and Pyridium for 3 days. He started telling her to take the Pyridium 3 times a day and the Cipro two, and I asked, “Can’t I just put that in her pill compartments for breakfast, lunch and dinner?” He said yes. He also drew blood to see if she had depleted her potassium.

Dr. B. was so confused about what the problem was at this point, and I tried to explain to Mam-ma – “He is saying it is normal to pee a lot after you take the Lasix and then not any more. And he’s trying to tell you that you don’t need to drink that much fluid” and she was saying, “But I need to go!” So Dr. B. asked, “What else is going on? Is there something else bothering you?” She said no. I ask, “Mam-ma, are you feeling bad somewhere else – do you hurt somewhere or something?” She said no, other than now she’s “took the headache.”

So Dr. B. started working on the computer, and I mentioned that she now takes Nexium instead of Aciphex, and he said his nurse had changed that in their files. And I added… “And, recently I discovered a bottle of Prosom (a tranquilizer) in her cabinet, and a bottle of Darvocet (narcotic painkiller)!” He asked where that came from, and I said, “You prescribed it – I think in April 2007!” He started looking through his records, and Mam-ma said, “No, you gave me a 90-day supply 90 days ago, and I need a refill!” He whirled around and looked at her and said, “I prescribed that in 2005, and you need to get rid of it!” I asked about the Darvocet, and he said, “It’s probably not any good now, either, and I need to write a new scrip.” I said, “Wait a minute… why does she even need that?” He answered, “She really doesn’t.” I told him I could get rid of that, too!

Then I told him, “You know, she takes a lot of extra-strength Tylenol. I buy a lot of that.” He asked how much, and Mam-ma started in, “Now I don’t take that much of that!” I said, “Mam-ma, I bought you a bottle a few months ago with 100 tablets, and it was buy-one-get-one-free, and just a week or so ago you had me buy another bottle.” Dr. B. asked her if she took Tylenol every day, and she said, “No, I don’t take it every day… I just take one tablet every night to sleep.” He laughed, and then he asked me if it was Tylenol PM. I told him no… just extra-strength Tylenol. Mam-ma was saying, “No it’s not, no it’s not… it’s Equate!” Dr. B. said, “You really don’t need that Tylenol – that’s what the Ativan is for, but I’m going to allow you – for now – to take ONE Tylenol at night if you want, but NO MORE!” And I brought the Darvocet and Prosom home with me and got rid of it.

Dr. B. asked Mam-ma something – I can’t remember, and she said, “I don’t care,” very blankly, and he asked, “what do you mean you don’t care?” and she said, “I just feel so bad that today I just don’t care about anything. I just don’t care.” and she stared blankly across the room, and Dr. B and I just sat and looked at her for about 30 seconds. It was bizarre. So we gave the blood sample and gathered our things and left – but Mam-ma was so confused she had trouble finding the lab to give her blood… and she had just been down that hallway to give the urine sample. Dr. B. said no infection showed in the urine sample, but just in case there was some, the Cipro would head it off… and the Pyridium would relax the bladder, and he suspected she was having some spasms. That was all he could come up with!

I went to the pharmacy and got the Cipro and Pyridium. I had filled Mam-ma’s medicine compartments two days earlier on Tuesday – when my husband and I visited her. Now as I added the Cipro and Pyridium, I discovered her Friday and Saturday night medicines were missing – and it was only THURSDAY! I asked her about it, and she said she got mixed up and took the wrong day… but everything else was right. So, I replaced the daily medications for Friday night and Saturday and put in the new meds… and I started her Cipro for suppertime that night, so she would take it with food. I handed Mam-ma a Pyridium and told her to take it, and to take another at suppertime.

I left my grandmother’s and went to Wal-Mart to buy groceries, and my husband called me. “Mam-ma has called and wants you to call her when you get home.” So I phoned her, and she said, “You shoulda told me to take food with that medicine. I just threw up everything in my stomach!” I told her I really didn’t think that she needed to eat with the Pyridium, and it had been so soon that I wondered if something else wasn’t going on. She insisted it was the Pyridium, and she added… “All that yellow stuff came up.” I pointed out that the pill was brown. “Yeah, I know,” she said, “all that reddish brown stuff came up.” I told her she didn’t have to take any more of those pills, and she said, “But I NEED them! I’m gonna take the next one at supper with food.”

I surmised that if Mam-ma took two extra doses of night-time medication on Tuesday, THAT is what lowered her blood pressure – and possibly upset her stomach! At night she takes Coreg for high blood pressure, Synthroid – a thyroid medication, and Nexium for acid reflux. So in three days, she had two extra doses of those!

In essence, this whole little episode and trip to the physician was caused by over-medication. Once my grandmother got back on track and took her medications correctly for a few days, she was her old self. The blood pressure normalized and her confusion cleared to the point she would say, “I was just out of it.” That was an understatement!

Armed with this information and experience, I didn’t panic when a few months later, Mam-ma once again became lethargic and confused. My grandmother is 97 and lives alone in her own home. She has a very busy social/church calendar, and after several night-time events, she had “forgotten” to take her night-time medicine. She had also skipped a couple of morning doses… and she insisted, “but I always take my morning medicine with my breakfast.” Clearly she did not… it was still there, while the noon and night-time doses were missing.

My grandmother has just received a clean bill of health from her cardiologist during a six-month check-up, so overall, these mixups are not causing a major problem – yet! For others, this issue may be more compelling. If the elderly person still drives, this could be a serious safety issue. Thankfully my grandmother no longer has a car. However, we are always concerned about falls and broken bones. A few years ago, her cardiologist increased her blood pressure medication because of a consistent rise in her blood pressure readings. This resulted in a potassium depletion. As Mam-ma staggered down the hallway in her house, she fell. She banged her head and received a very deep bruise in her back that resulted in a three-month stay in the nursing home for rehab.

Ultimately, my maternal grandmother mixed her medicines so much that she became incoherent. Coupled with a diagnosis of Parkinson’s Disease, this mixup virtually took her mind… and her speech. She spent her last seven years in the nursing home, much of it unaware of reality and unable to recognize pretty well everyone except my mother and me. Virtually the same thing happened to my best friend’s mother.

Often, medications for seniors are complicated. My grandmother has one prescription that requires a whole tablet in the morning and a half tablet at noon. Another calls for one tablet in the morning and one at night. It sometimes takes a rocket scientist to figure out the dosages and get everything in the right compartments. I can’t imagine trying to remember what to take when without a set of those daily compartments for each time throughout the day when medication is taken!

Is there a solution for this? Yes and no. Careful monitoring is necessary… but this is a slippery slope. We could call my grandmother three times a day and remind her to take her medicine, but she would be upset by this and feel we didn’t trust her. We also cannot be there 24/7 to monitor the old bottles of whatever she has saved and tucked away “in case I need one,” as she did with a bottle of Darvocet she tucked behind her dinner plates in the kitchen cabinet. (I removed them per her doctor’s orders.)

Certainly, if your senior is still driving, you must assess all medications and the possible ramifications of mixing/missing doses and operating a car or other machinery. Other things to consider include:

* Does the senior need a walker or cane for assistance in case he/she becomes unsteady?

* Has the senior’s house been hazard-proofed? Have you removed loose throw rugs, installed grab bars in the bathroom (especially around the tub and/or shower), and handrails on all steps? Are the pathways clear and open so that the senior doesn’t have to maneuver an obstacle course of furniture and other stumbling blocks?

* Does someone monitor the senior’s daily medication and/or assist with dispensing doses to compartments for daily use?

* Do you have a complete, up-to-date list of all medications the senior takes? Realize that even the best, most “current” list may not account for over-the-counter (OTC) medications your senior adds, but list all you know about and realize there may be more! Keep a copy in your wallet for emergency trips to a hospital or clinic… and post one on the refrigerator for medical personnel and others in case of an emergency.

* Have you discussed with your senior’s physician(s) and pharmacist(s) the possible interactions between all medications being administered, as well as any OTC additions? Be sure to mention vitamins, pain relievers such as aspirin or Tylenol, cough syrups, and any other “added” medications to provide these medical personnel with the most accurate picture of your senior possible.

Mixing and missing doses of necessary medication is not just an issue or concern for elderly persons – it can have devastating results at any age. But there seems to be an escalation in the incidence of this as we age, and the ramifications seem to be more immediate – and often have a more long-lasting effect. Even more cognizant and seemingly competent seniors may need a gentle discussion occasionally of all medications they are taking, just to be sure everything is okay. Some people rarely take as much as an aspirin, while others mix and match on a daily basis. Knowing which personality type you are dealing with will help gauge how involved in this issue you need to become.

My grandmother watches me dispense her daily medications every two weeks and says, “I could do that myself.” My husband looks at me and asks, “When did you become a pharmacist?” It IS complicated, and truly beyond my grandmother’s capabilities now. I just smile and tell her, “That’s okay… this way I know what is in these little boxes. If there is ever a problem, I’ll know what was there and be able to tell the doctors what you took.” I assure her it’s more for MY peace of mind… so *I* won’t worry. As long as it is MY problem and not hers, she seems okay with it. If I come to a point where I feel she is not being properly medicated and it is affecting her overall health and safety, I will have to consider another option. For now, I am holding my breath, saying a prayer, and checking her medications at least once a week.