Managing your Elder's Medication Maze

I’ve been going on and on about nutrition. And, I’m probably not done with that. After caring for elders in a medical type of mind-set for so long, it still astounds me how much more important nutrition is to medical science. But, that doesn’t mean we should forget about the medical science.

If you have contemplated managing an elder’s medication regimen, and looked around for your Elder’s supplies and medications, you probably have already encountered my sentiments about the issue. It’s scary. No, that’s not the right word, really. More like Horrifying.

Elders, more often than not, require several different types of medications to manage several different disease processes. And then a few more, to manage the effects of the original medications. It can be very confusing, even if you aren’t demented.

Imagine trying to manage your medications if you are even mildly confused and/or forgetful:
• What do you take?
• Why do you take it?
• When do you take it?
• Should you take it with food, or on an empty stomach?
• Where do you go to get more?
• Are you supposed to take it forever, or just for a short time?
• Did you take it this morning? Maybe you should take it now?
• Will you remember to order more when you run out? (or will you forget about it and not take it anymore?)
• Will you remember what to ask your doctor if you have concerns?
• What are the side effects, and what should you do about them if you have them?
• If you have side effects, will you recognize it as a side effect, or just think you have developed another disease process?
• Where did you put that new bottle of medication?
• If you feel worse, does that mean you should take more of the medication?...or maybe none at all?

This list could go on and on and on…..in ever widening circles. Many times, elders have ended up having more problems with chronic diseases because of the medications they are not taking properly. The physician would call it “noncompliance with the medication regimen.” This can be disastrous to an elder, causing hospitalizations, acute confusional states with changes in behavior, or worsening of existing dementia. It could even result in death due to drug overdose or exacerbation of the disease process not being treated properly.

So, all that being said (and maybe, but hopefully not, experienced), now you have decided you want to manage your Elder’s medications.

There is a little bit of complexity involved in managing another person’s medications. But if you do all your homework and keep some records, keeping track can be easy to do.

You need to tackle this very large task one step at a time:
1. Find and gather up all the medications your Elder takes.
2. Attempt to determine if these are in fact the actual medications your Elder is supposed to take.
3. Become well informed about the health status of your Elder.
4. Become well informed about the medications your Elder is taking.
5. Organize the medications.
6. Dispense the medications to your Elder.
7. Monitor the effects the medications have on your Elder.

Ok, looks simple enough. Now, lets go into some detail.

1) Gather together all the medications your Elder takes. This includes herbal and vitamin supplements, and over-the-counter medications. Keep in mind that your Elder, especially if s/he is a little forgetful or confused at times, may not keep all the medications in one place. Some elders have a “gift” for finding new places to put things so they won’t forget. It may make you think your Elder used to be the Easter Bunny in a past life. Anyway, good luck.

2) Attempt to determine if these are in fact the actual medications your Elder is supposed to take. The easiest way to do this is to ask the Elder’s physician. Keep in mind, your Elder may have several physicians, and hopefully they all communicate with one another. But this is not always the case. Another way is to ask the pharmacist that fills your Elders prescriptions. Again, your Elder may go to more than one pharmacy, and/or use a mail type pharmacy service. The bottles of medications you find will have the name of the prescribing physician and the dispensing pharmacy. So that would be a start. And of course, this is all assuming your Elder can’t just tell you all of this.

3) Become well informed about your Elder’s health status. That is, you need to know what diagnoses the physician(s) are treating your Elder for, as well as those not being treated. This may necessitate you going to the physician’s office with your Elder and getting the Elder’s permission to access information about her/his health status, as all of this is confidential. Once you have determined what diseases and conditions your Elder is dealing with, educate yourself about these. There are plenty of resources online to help you. WebMD as well as Medline Plus are good resources for information about health conditions.

4) Become well informed about the medications your Elder is taking. Again, there are lots on online resources for you. The sites listed above have excellent information regarding medications, as well as herbal remedies and supplements. Your pharmacist can also give you informational pamphlets or printouts about each medication. You need to know:
• What condition/disease process is being treated with the medications.
• How does the medication work.
• What effect is the medication supposed to have on your Elder’s condition.
• How is the medication best administered (with food, without food, not in combination with certain meds, vitamins or foods, etc) and why.
• If your Elder can’t swallow pills, can you safety crush this medication (some meds, like time-release compounds should not be crushed), and mix it in applesauce or ice cream or some such thing. And if not, can you get it in a liquid form.
• What to monitor while your Elder is taking it (such as changes in behavior, appetite, blood pressure, pulse rate, etc).
• And most importantly, know what the side effects or adverse reactions are likely to be, and watch for these. Elders are very prone to side effects and/or toxic levels of medications because they are not able to metabolize and/or excrete chemicals efficiently.
• Last, know what to do if you notice adverse effects or side effects. Some medications cannot be stopped abruptly, and some you must.

5) Obtain a pill organizer box that will handle the amount of medications you
need to organize. There are all kinds available. Use whatever makes the most sense for you and your Elder. Basically, you want to be able to organize medications by dose and by day. Example:
Monday am, noon, pm, bedtime
Tuesday am, noon, pm, bedtime…..etc
An example would be a pill organizer box with 7 days, and four dosing slots for each day. Or, obtain four pill organizer boxes with one dose every day for 7 days. Then label each box for the dose with an indelible pen. So you will have one box for “AM” Sunday through Saturday, one for “NOON” Sunday through Saturday, etc.


The organization depends on whether you will be dispensing the meds to your Elder, or whether the Elder will be choosing the box and dosing slot to get the meds from.
Set up the medications for a week at a time. To prevent mistakes, do this during a time when you will not be interrupted.

While you are setting up the medications the first time, count how many doses there are, and determine on a calendar when you will need to reorder. Give yourself at least a week, or however much time you think you need. Write this down. Keep this information on all the medications in one place, on one calendar, on one piece of paper, or on an internet calendar. Reference this every week when you set up the medication organizer.

The easiest way for me is to reorder when there are less than 7 days of medication doses left in the bottle after I have just set up a week's supply. So, I always have at least 7 days worth of doses before the bottle needs to be replaced. Plenty of time to get a refill.

On your ongoing medication list, you may also want to include information that may be needed later, if something happens, like a hospitalization. The hospital staff should be able to get medical information from the Elder’s physician, but they always rely on the family members anyway.
So on your list you will need to have
• Date to reorder (keep this is pencil, so you can update it when you get a new bottle of pill).
• Medication, dose, frequency
• Condition treated
• Date it was first ordered
• Any dosing changes, why and date
• Date it was discontinued, and why (this information can be important for a physician that is not familiar with the Elder’s ongoing treatment plan).

It easiest for me to keep a table with the above headings across the top, and then list each medication with the information as it comes up.

Use a highlighter to cross off a medication that has been changed or discontinued. This way, you can still read it, but when you set up medications you know it is no longer an active order. This information can be invaluable when you are managing medications for an elder that has frequent changes in doses and drugs. Keep this with you when you visit your Elder’s physician, and especially when your Elder needs hospitalization.

6) Now that all the hard work is done, all you have to do is make sure your Elder takes the medication correctly. I prefer to dispense the meds and watch the Elder swallow them. That way, there are no mistakes. The meds are not forgotten, thrown away, put down somewhere and a child, a pet, or another confused person takes them. No telling what can happen!!

7) There’s just a little more. Monitoring the effects of a medication is important for several reasons:
• You want to make sure it’s doing what is expected, and if not, you need to tell your Elder’s physician.
• You want to monitor for side effects, and if you notice any, tell your Elder’s physician.
• You want to monitor for allergic reactions, and if there is a reaction, tell your Elder’s physician.
• And finally, if the medication is not helping, you may wonder why your Elder should continue taking it and risk side effects or drug toxicity. You probably want to discuss this with your Elder’s physician.

You will probably need to watch your Elder's blood pressure and pulse rate on a weekly basis, at least. Your physician should tell you, along with parameters for when s/he should be called. For a diabetic, maybe you need to monitor blood sugars. These things are for obvious reasons. What is not so obvious, are things that may signal intolerance of the medication, toxic levels, or side effects. Watch for changes in appetite, bowel habits, behavior, cognitive function, ability to sleep, and functional ability (walking, toileting, eating, dressing, etc.) Elders quite frequently will become more confused and forgetful, and stop eating when a medication does not agree with them.

There are certain medications that must be handled very carefully with the elderly. But more about that at a later time. This article is already pretty long.

By managing your Elder's medications for them, you can avert disastrous and unpleasant moments, and maybe even hospitalizations. It does take some time and research initially, but it is well worth the effort.

As always, wishing you and your Elder Pleasant Days.

image by basykes
www.flickr.com

Concentrating Nutrients for Elders (or, Pleasant Days start with Good Nutrition, Part 2)

For the vast majority of elders, being on “a diet” is not a good thing. Even if your elder is over- weight it can be very detrimental for them to lose weight too fast, or even at all. It is far more important for the elder to get the nutrients they need than to lose weight. Younger people can “diet” because most will have nutritional reserves in their bodies to draw from. Elders usually don’t have these reserves. So always think about nutrition first, then worry about being overweight later. Of course, the elder’s physician may have some dietary concerns. These would probably only be to limit cholesterol for someone who’s cholesterol is too high; to limit calories and/or sugar for a diabetic with uncontrolled blood sugar; or to limit salt intake for someone with fluid retention problems.
It’s often hard to get an elder to eat enough protein and/or calories, which will lead to malnutrition, and lots of problems leading to very unpleasant days. These suggestions are for people who eat very small portions, don’t finish their meals, or skip meals.
Some examples:

• Use three different fruits cut into manageable pieces for your elder and mixed together with a tablespoon of lime or lemon juice as a side salad for lunch. Add a little sugar and let it sit for about an hour to make it more enticing. Fresh fruit seems to "go down" better than raw vegetable salads.
  

• Jello: exchange half of the water for orange juice. Not only does this give extra nutrients that count for part of the fruit group, but it tastes sweeter, too.

• Top fruit or jello with flavored yogurt instead of whipped topping (counts as milk, rather than just extra sugar).

• Pancakes: add an extra egg for more protein. If using a mix that calls for water, use ½ milk and ½ water.

• Mashed potatoes: use milk, sour cream or yogurt rather than just water or broth when mashing.

• Cook hot cereal with milk instead of just water.

• Add milk to coffee instead of non-dairy creamer.

• When making meatloaf, hamburgers, or meatballs: use oatmeal (the “one-minute” kind) instead of bread crumbs. (whole grain)

• Dessert: make a fruit and yogurt parfait by layering fresh fruit (which has been “marinated” in a little sugar for ½ - 1 hour) and vanilla yogurt. (Fruit ½ - 1 cup; yogurt = milk ½ - 1 cup)

• For a sandwich filling: add ½ cup of minced vegetables to tuna, diced meat or shredded cheddar cheese. It will make the sandwich more moist, easier to chew, and you don’t have to use much mayonnaise. Use pickles, olives, onions, cucumbers, lettuce, peppers, shredded carrot, celery, avocado, even pineapple.

• Offer fruit preserves (less sugar here is OK, but usually not necessary unless the elder is diabetic) and encourage liberal use for whole wheat toast at breakfast. (Fruit, up to ¼ cup for 2 slices of toast).

• Put gravies, sauces, cheese sauces on food. This will boost calories and make the food easier to chew and swallow as well. If you use cheddar cheese in the sauce it will also serve to get more dairy nutrients in, which are rich in protein and calcium.

The other problem with having to concentrate nutrients, is having to choose wisely when feeding someone who has a small appetite. It may be fun to have an ice cream cone at midday, but if this takes the place of a meal it probably isn’t worth it. If your elder likes a lot of sweets and goodies but then will not eat a meal; I would suggest having a “goody” day one day a week where one meal can be replaced with choice sweets. For most people it doesn’t hurt to have sensible desserts every day after dinner. You be the judge. Most people can get enough nutrients out of a 1600 calorie diet, and it won’t hurt them to have an extra 200 to 300 calories for dessert. You would need to use some judgment if your elder is diabetic and on a strict diet. In which case, check with your doctor about speaking with a nutritionist for a specific plan to allow some sweets into the elder’s diet. If the elder is not on a strict diet, then plan desserts made from wholesome food. Rather than cake, try fresh fruit with flavored yogurt. Low cal jello desserts with fruit and topped with low cal whipped cream, or vanilla yogurt. Even ice cream is better, since it has milk in it and not just sugar and flour.

Some elders I have cared for have had poor appetites for various reasons, mostly having to do with chronic diseases and prescription medications. One lady in particular used to make me laugh. She would always remind me not to make her meals too large. When I assured her I would try to keep the meal small, but that she needed to eat enough protein, she would smile at me and say "Oh, I know you'll sneak it in somehow." Sneaking it in was alot easier than arguing about it, which led to yet another Pleasant Day.
Here's wishing you and your Elder "Pleasant Days."

image above by serenejournal
www.flickr.com photos

Pleasant Days start with good Nutrition

After caring for several elders in our home here on the beach in Punta Banda, I am convinced that successful caregiving (meaning the elder has Pleasant Days, and so do you) starts with good nutrition.

I know, everyone says everything starts with good nutrition, right?

Nutrition for elders is somewhat different from nutrition for everyone else, for lots of different reasons.
1) Many elders don't have an appetite.
2) They don't have the energy it takes to shop for, and then prepare food for themselves let alone clean up afterwards.
3) It's common for elders to live alone (spouse has passed on and children are grown), so eating has become a chore rather than a pleasant social experience.
4) Food just doesn't taste, or smell, the same anymore. Many elders can taste "sweet" more than anything else, so all they want to eat is sweet stuff with no nutritional value.
5) Medications either destroy the elder's appetite, or interfere with absorption, or cause the body to lose valuable nutrients.
6) Many elders have difficulty chewing foods because of poor dental care.
7) Some elders have difficulty swallowing for various reasons ranging from neurological problems, to cognitive problems.
8) Degeneration of the digestive tract, and it's blood supply, from the mouth all the way through to the colon prevents adequate digestion and absorption of nutrients.
9) Many elders don't have the cognitive ability, and/or the desire, to plan out nutritious meals. They may not even remember if they have eaten or not.
10) Many elders can't physically handle much salt in their diet. Prepared foods, the kind that most elders will eat due to ease of preparation, are over-laden with salt.
11) Some elders have severe endurance problems because of heart or lung disease and just don't have enough energy or oxygen to get through the physical act of eating a meal.
12) Some elders use food, and their eating of it (or not), as a control issue when dealing with family members.

Most elders have at least one, more likely many of the above problems.

It may not seem like a big deal to some. But inadequate nutrition can be disastrous for the elderly. I'm also talking about hydration here. Ensuring your elder gets enough food (with nutritional value) and fluids is the best way to help her/him feel their best.

"Best" means:
--the elder is more energetic and able to do more for her/himself;
--s/he is less likely to become immobile because of poor endurance, so you don't end up having to lift her/him around;
--s/he feels physically better and gets sick less often;
--her/his skin remains intact with less chance of life-threatening infection;
--s/he is in a better mood and tends to be much less grouchy;
--s/he has fewer problems with memory and reasoning skills;
--s/he retains body weight and fluid so medications don't become toxic and cause horrid side effects;
--s/he is more likely to have better bowel and bladder control;
--s/he can cope with pain issues much easier;
--and s/he is more likely to have the ability to enjoy a positive social life.

I'm sure there are some things I forgot. But you get the idea. You may not believe eating food can do all that. So here's a real life example:

We once cared for an elderly man who could not walk when he came to us. His family had been at a loss when trying to care for him, and he became progressively weaker, falling frequently, until he just couldn't get up by himself anymore, and his family was considering nursing home placement because they could not care for him. After he had been with us for a week, he was walking. Not only to the bathroom and all over the house, but down the road with my husband for walks everyday. His confusion cleared, and he was able to play his favorite card game (Rummy) with us in the evenings, and write poems again. Amazing! And no, there had been no changes in his medications. It was simply the food and fluids he was getting everyday in regular meals.

Here's another likely example:

If an elder takes a diuretic for retention of fluids caused by heart problems (which is extremely common), s/he needs to eat adequate amounts of potassium to offset the potassium the diuretic will cause the kidneys to excrete. The best sources are fruits and some vegetables. The easiest way to get in enough potassium is a glass of OJ everyday, and/or a fruit salad. Everyone should eat at least 1.5 cups of fruit (includes juice) everyday.

So what happens if s/he doesn't. This:
--muscle twitches, then muscle cramps
--loss of strength in muscles
--frequent falls
--"bad mood", with grouchy outbursts
--inability to remember things and reason properly
--delusional thinking leading to paranoia
--poor judgment leading to behavior problems
--nausea
--diarrhea
--intestinal cramping
--lack of energy
--severe potassium deficit can cause problems with the heart contracting, and lead to death.

So, you really want your elder to avoid all that. But, getting an elder to eat can be a problem all by itself.

First, you need to fix any of the "reasons" for poor nutritional intake listed above that you possibly can. Simply being there to prepare the right foods and provide encouragement will remedy many of the problems.

Second, you need to get your elder to eat a balanced, nutritious diet. If you need information about what a balanced, nutritious diet consists of, go to my list of links ("Links for your assistance") and click on MyPyramid.com. The site is very easy to navigate around and has all the information you need to be able to put together a good diet. This could be helpful to you, and anyone else in your family as well. Good nutrition for yourself will go a long way to prevent overwhelming stress from being a caregiver. When I first started caring for elders in my home, I knew about basic nutrition concepts (we have 5 grown children), but when I was working in institutions I always had the benefit of a dietician to call on. This site was a fantastic find. It makes being your own nutritionist so simple.

Third, you need to provide this diet in small meals with concentrated nutrients, that are appealing and easy to eat. Examples would be a breakfast consisting of:
--oatmeal 1/2 cup with 1/2 cup milk in it,
--coffee (2 cups with 1/4 cup milk in each cup), and
--2 scrambled eggs
--1 cup of OJ.
This is soft, not too much to eat, and provides 1 of the 6 oz. of whole grain (in an 1800 cal diet), 1 of the 3 cups of milk, 1 of the 1.5 cups of fruit, and 2 of the 6 oz of protein. I would cook the oatmeal with sugar or sweetner instead of salt. You can always add whole wheat toast, each slice being another 1 oz of grain. If you need more fiber, eat whole fruit instead of drinking juice. Juice is just easier to get down for an elder who has appetite problems.

Every morning I decide what we are going to eat during the day. I write it down on a slip of paper, split up by nutritional categories (meat, milk, fruit, grain, veg) and by meals, and tack it to the refrigerator. So if I get in a big hurry or have some sort of "emergency", or the elder I'm caring for is in a particular mood that day, I don't lose track of what I'm cooking.

I don't mean to suggest that you put your elder on a calorie count "diet". Most elders don't need calorie restricted diets unless they are diabetics that have a hard time controlling their blood sugar. What you do want to pay attention to is ensuring that your elder gets enough of each food group. This will prevent any nutritional deficiencies that cause problems. And if your elder can't eat all the food listed in the diet, cut down the portions proportionately in each food group rather than leaving some out. This way s/he will get as close to a balanced and nutritious diet as you can get. As time goes on, maybe s/he will feel better and be able to eat more. And don't forget the fluids. Dehydration can cause nausea and unwillingness to eat along with all the other "miserable-ness".

A note about fluid intake before I quit. In general, the amount of fluids you need should be about the same amount of cc's (or ml's, if you prefer)as calories you ingest. So most people would need about 1800cc to 2000cc per day. This is where the "8 cups of water" idea comes from. 1000cc is a liter, or basically a quart which is 4 cups. But remember, all that does NOT need to be water. Water is good, but there is water in everything you eat as well as drink. So count all the "drinkable" fluids you take and you'll be fine. For elders, many can't handle too much fluid, especially at first. Elders are notorious for not drinking enough fluid, and being slightly dehydrated. So, if you are just beginning to care for an elder, go easy on the fluids and gradually bring her/him up to the needed amount. (gradually meaning over about a week's time). You will find out, over about a month, what your elder can handle or not. Watch for signs of fluid overload, especially for elders with heart or kidney problems. Signs of for an elder would be obvious: rapid weight gain, edema (or swelling) of extremities, higher blood pressure and/or difficulty breathing. If this happens, back off on the fluid a bit and call the elder's physician.

More about concentrating nutrients and meal planning later.

I hope I haven't bored anyone. But this is so important to your elder. It's hard enough to be old--hard for the elder, and hard for the caregiver. In my humble opinion, nutrition and hydration are more important than most prescription medications. It is the easiest way to help your elder, and yourself, have Pleasant Days.

Links for your assistance in elder care

I spend a lot of time on the web researching things about elder care for myself and for others. See "links for your assistance". There is a list of a few of the sites I found most helpful. I thought it would be good to give you a brief explanation of what these sites contain.

Caring Connection is a site by the National Hospice and Palliative Care Organization (NHPCO) that gives you information and free resources for Advance Directives and "end of life" care issues.

Senior Citizen's Resources: from the U.S. government, a variety of sites for information and resources. From the home page, at the top click on "seniors".

Elder Care Search posted by the U.S. Health and Human Services Department. This is a public service of the U.S. Administration on Aging. There are lists of resources and explanations of services available from the federal government and your local area. Just enter your city or zip code.

FDA Consumer Education: Ensuring Safe use of Medications: This site has several consumer education articles about the safe use of medications. It gives you information about what questions to ask your health care provider, how to weigh the risks and benefits of medication use, and information regarding seniors and medications.

American Academy of Orthopedic Surgeons (AAOS): this link will take you to their page on prevention of injury information. There is a helpful article on prevention of back injuries for care givers. There are also some other useful articles on prevention of different kinds of orthopedic injuries that may help for your elder as well.

My Pyramid.gov is the official site from the USDA (United States Department of Agriculture) with all the information you need to easily provide a healthy and nutritious diet for your elder and you. This is one of my secrets for successful elder care. Nutrition is everything. From the Home page click on "My Pyramid Plan" on the right side of the page. It will ask for height, weight and age of the person, then it will give you the information you need to know about nutritional requirements.

This will get us started. There will be more links added as time goes on.

My own style of managing anger and frustration

I was reading something from another blog about caring for the elderly. Someone brought up the issue of anger management. This person found that his anger would seep into his life unexpectedly and cause problems.

Managing anger and frustration is important throughout your life, but can be especially important when you are caring for elderly people, especially your parents. I am not caring for my parents any longer, but on occasion will take care of other people's parents. After years of caring for others, I found myself depressed, resentful and angry after a serious illness. Then, I was angry at myself for allowing this to happen to me. I finally realized that you can't just forget about the feelings you have. You need to deal with it somehow.

First of all, you have to know (deep inside yourself) that it really is OK to have feelings of anger, frustration, resentment, evil thoughts, etc., when you are in a care giving role. You don't need to feel guilty about this. It's natural. Adding guilt to the whole mess will only hurt you further. What counts is how you act upon these feelings. One thing you do not want to do is keep it buried within you. That negative energy will work on you and change you in ways you really don't want to think about. You need to find a preferrably physical outlet. Mental outlets, and distractions (like hobbies, social activities) are OK, but don't seem to work as well for most people.
Here is my current outlet:
After all these years, I am now lucky enough to live on the beach, so anger/frustration management for me is fairly simple.

I give it to the ocean.

You can cry, yell, scream, throw things, or simply stand with your feet in the water and close your eyes. The waves come in, you give all your negative energy, frustration, anger, whatever to them, and they leave with all that energy and it's gone. The ocean doesn't care. It will take anything you have to give it. All it leaves in return is a soothing spray of positively charged sodium ions that gently wash over you to soothe and nourish your wounded soul.

It's great. Wish you all could do it daily. But if you can't, find your own special bit of nature you can relate to. Then pour your heart out where only you, Mother Nature, and your Creator can hear you. You will be understood, and be uplifted. Be at peace.

Welcome to Pleasant Days for Elders

Like I always say, Pleasant Days for elders means Pleasant Days for their caregivers as well.

I worked in nursing homes for years as a management nurse. Yeah, one of the ones creating and implementing rules, and making sure the staff followed all the federal and state regulations. And let me tell you, there are thousands of them, thanks to the few nursing homes across the country that are considered "abusive."

After I "retired", I again found myself in a care giving role. This time, I wanted to do it "my way", because the nursing home industry, for all of society's good intentions, just doesn't have it right. With the help of my husband and daughter, we set out to create an elder "home" that would mold itself to the wishes and needs of it's clients, rather than the other way around.

Along the way somewhere, after trying to impose the "normal" rules of living in a care home upon the clients (because this is what I had done for so many years), I discovered that having pleasant days is really all everyone wants.

With this discovery came insight, one after the other. I want to share some of this, because elder care is very important, very needed, and very, very difficult.

This will also be a continuing discovery. I still care for elders here off and on. And they all teach me so much, mostly about myself. Hopefully I can be some small help to someone out there who is struggling with their care giving role.