What Medications Are Your Older Patients Taking?

Psychiatrists who treat older patients should review their patients’ medications very carefully, particularly when they are seeing a patient for the first time after a referral from a hospital, said speakers at the American Association for Geriatric Psychiatry 2023 Annual Meeting in New Orleans in March.

“More than 60% of medication reconciliation errors occur during transitions of care, usually on hospital admission, but then they perpetuate down the line” with each transition, such as from general hospital to psychiatric hospital, or upon discharge to home or another facility, said Paula Lester, M.D., in a presentation titled “Medication Reconciliation: Paperwork Saves Lives.” She is an associate professor of medicine at New York University (NYU) Long Island School of Medicine. “This is even more true for psychiatric patients, especially geriatric psychiatric patients because they have more frequent and longer admissions, and they have more care transitions.”

Lester added that older patients with mental illness often end up being transferred from a general hospital to a psychiatric hospital or vice versa, and that the electronic health record systems may not integrate well with one another. Furthermore, hospitalists in other specialties may be unaware of possible interactions between psychiatric medications and the medications they prescribe, she said.

“The more entrenched people become in their fields, the less they know about medications outside their fields,” Lester said, noting that this may also happen among psychiatrists. “There are so many new medications, for example diabetes medications and cholesterol medications, that if you trained 20 years ago, you might not be very familiar with them and might not be aware that they interact with the medications you tend to prescribe [in psychiatry].”

Mark Shen, Pharm.D., a clinical pharmacist in care transitions at NYU Langone Hospital–Long Island, advised psychiatrists to try to use two sources of information when taking a complete medication history, such as the patient, caregiver, other physicians involved in the patient’s care, or the discharging hospital.

“One source might not be fully correct, and the other source might not be fully correct. It’s up to you to match those two lists together and come up with a list that makes sense,” Shen said.

Shen also suggested asking open-ended questions when speaking with patients, such as the following:

If patients do not take a medication as prescribed, psychiatrists should ask them why, Lester said.

“Sometimes there are good reasons why, [such as] side effects or they’ve taken it before and had a bad experience so they’re afraid of taking it again,” Lester said.

She added that older patients are at increased risk of adverse events from medications, even when there seems to be no error in prescribing.

“Geriatric patients can be more sensitive to the effects of their medications and changes in their medications and dosing,” Lester explained, noting that the risk for adverse events rises even more when older patients have multiple comorbidities for which they take medication.

Cognitive impairment, difficulty swallowing, trouble keeping track of multiple medications, and patient fatigue with medication regimens also factor into whether older patients take their medications as prescribed, Lester said.

“[Older patients] may be more likely to resist adding medications. They might be thinking ‘I’m already on 10 pills; what do you want from me? This is my entire day—take this one two hours before I eat, take that one three hours after I eat, take the other ones at bedtime, and these other ones in the morning,” Lester said.

Once psychiatrists have a thorough understanding of what medications their older patients are actually taking and why, they can work with them and other members of their health care team to determine a medication regimen that is not only appropriate, but also one that the patient will stick to, Lester said.

“Taking a good medication history takes time, but it’s worth it.” ■