The Science of Medication Management and Nonpharmacological Alternatives
A complex medication schedule is a very common occurrence and presents challenges to both the patient and the clinician. Such a situation arises particularly in the elderly and with patients who have multiple chronic medical problems such as hypertension, hypercholesterolemia, diabetes, arthritis and other conditions. This problem is especially compounded with the additional occurrence of a neurodegenerative disorder such as Alzheimer’s or Parkinson’s disease which can affect cognition or motor control. Additionally, over-the-counter medications, vitamins and supplements also contribute to medication challenges.
Optimizing medication management to achieve the safest and best outcome requires attention, organization and planning. Sometimes it may require a team approach, which involves the patient, the patient’s family, the clinician, the pharmacist, and perhaps others such as psychologists, dieticians and occupational, physical and speech therapists who can provide nonpharmacological support to reduce the medication burden or side effects.
The Medication Schedule
Humans weren’t invented to take medication. Even when prescribed just one medication such as an antibiotic for an acute illness, many patients have difficulty taking the medication completely as ordered. Forgetfulness, conflicts in work schedule or aversion to side effects can all contribute to an irregular medication schedule.
Challenges maintaining a consistent medication schedule are multiplied when more than one medication is required. As the number of medications prescribed rises, difficulty of maintaining the medication schedule increases exponentially. Taking two medications is not just twice as hard, but more like four times as difficult. The reason for this is that medications may conflict, may need to be taken at different times or may need to be taken at different frequencies. Using aids such as timers and medication dispensers can help lessen the burden of medication schedule requirements.
Medication Side Effects
Medications are designed to stimulate or inhibit a target such as a receptor or an enzyme system, which can, in turn, produce the desired pharmacological and medical response. Few medications, however, are so selective that they affect the desired system only and have no other effects (also known as “clean drugs”). For instance, an anti-cholesterol drug may affect muscle enzymes and cause muscle pain and weakness. Antihistamines may cause dry mouth or constipation. Pain medications may affect motivation and alertness.
Certain foods such as grapefruit or papaya can interact with medications and increase the chances of a side effects. Therefore, it is important to read the package insert to be aware of side effects and any foods that may have an effect on the medication.
Side effects of medication usually increase with age. One reason is that metabolism slows down a great deal after age sixty. The liver may only have about one-tenth of the normal ability to metabolize a medication, which means that a small dose may need to be prescribed. Alcohol and smoking can also affect medications.
Many medication side effects are acute, but some only occur after taking the medication for several days or months. When taking multiple medications, the side effects can be additive—rarely do the side effects of one medication cancel out the side effects of another and increase overall tolerability.
When considering adding medicines to your medication list, you should always ask, “Do the benefits outweigh the side effects?”
When multiple medications are involved, extra care should be taken regarding drug-to-drug interactions. A drug-to-drug interaction occurs when one medication affects the functioning of another, either rendering one medication ineffective or raising one of the medications to a toxic level.
When visiting the doctor, it is very important and absolutely necessary to provide an updated and complete list of all medications, supplements, vitamins, etc., that your loved one is taking for the clinician to review. For example, St John’s wort, which is an over the counter supplement that is sometimes taken for depression, is a monoamine oxidase inhibitor that can interact with pain medications. This drug-to-drug interaction can lead to serious side effects, including death.
Having a list of all medications and supplements is especially important when multiple specialists and doctors are involved. This proactive step by the patient and the patient’s family is really worth the effort. The more medications the patient takes, the greater the chance for a drug-to-drug interaction. Sometimes less is more.
Medication management can sometimes be simplified by working on improving symptoms without prescribing a medication, or by supplementing medication with a nonpharmacological technique that can help lower the prescribed dosage of medication. For instance, physical therapy may be useful to treat knee pain rather than taking painkillers. Other nonpharmacological interventions for pain may include hypnosis, acupuncture, yoga, tens units, physical and occupational therapy and, in certain cases, surgery. For conditions that are affected by food, a consultation with a dietician might be helpful.
Poor sleep is a common problem that is often treated with medications prescribed by a clinician or self-prescribed over the counter by a patient. Rather than taking a sleeping medication that may have side effects, try a nonpharmacological approach that incorporates good sleep hygiene like the examples listed below.
Sleep problems may benefit from daily moderate exercise, avoidance of alcohol or stimulants at night and reducing exposure to exciting or intense television, computer games or exercise just before retiring. Reading or relaxing before trying to sleep is important. If one can’t sleep then one should get out of bed and read or work on something. Avoid long naps during the day. One may need to see a sleep specialist to see if other conditions exist such as obstructive sleep apnea or restless legs syndrome.
Other conditions such as anxiety may benefit from cognitive behavioral therapy which can be monitored by a psychologist or psychiatrist. Cognitive impairment may benefit from moderate physical exercise. Aggressive and disruptive behavior in patients with dementia may benefit from behavioral interventions such as de-escalation approaches, distraction and redirection and attention to the environment.
By R. Malcolm Stewart, MD
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