Why Over-the-Counter Medications Pose Unique Risks to Older Adults
While often perceived as harmless, over-the-counter (OTC) medications and supplements can pose significant risks to elderly patients. Factors such as age-related changes in metabolism and body composition, an increased number of chronic health conditions, and the use of multiple prescribers heighten the risk of adverse drug events (ADEs). It is a common misconception that because a medication is available without a prescription, it is inherently safe, yet many OTC products, including common pain relievers and sleep aids, have potent effects that can be dangerous in an older population.
Polypharmacy, defined by some as taking five or more medications, is prevalent among older adults and is a key risk factor. The addition of OTC drugs and supplements can further complicate a patient's regimen, creating a cascade of potential issues, including increased risk of falls, impaired cognitive function, and organ toxicity. Pharmacists and other healthcare professionals play a critical role in mitigating these risks by performing a thorough medication reconciliation.
The Systematic Approach to Medication Review
When an elderly patient presents with a 'brown bag' of medications, the healthcare provider must follow a systematic process to ensure patient safety. This process, known as medication reconciliation, is designed to create the most accurate list possible of all medications the patient is taking.
- Gathering a complete list: Beyond prescribed medications, it is essential to ask about all OTC products, vitamins, herbal supplements, and even topical creams and ointments. Patients may not view these as 'real medicine' and may not volunteer the information otherwise. Be specific in your questioning.
- Assessing appropriateness and indication: Review each medication, asking the patient or caregiver why they are taking it. An OTC pain reliever, for instance, may have been started months ago for a temporary issue but is now taken daily, leading to unnecessary long-term risk.
- Checking for duplication: The active ingredients in different OTC products can easily be duplicated. For example, a patient might take a cold medicine containing acetaminophen while also taking a separate acetaminophen product for pain, leading to a dangerous overdose.
- Identifying drug interactions: Cross-reference all medications, including prescriptions, OTCs, and supplements, for potential interactions. This is especially important for high-risk medications like blood thinners.
- Screening for inappropriate medications: Use evidence-based criteria, such as the American Geriatrics Society (AGS) Beers Criteria®, to identify medications that may be inappropriate or carry a high risk for older adults. These criteria list specific drugs to avoid or use with caution due to risks of cognitive impairment, falls, or other adverse effects.
Potential Issues and Interventions in Geriatric Polypharmacy
| Potential Issue | Example | Clinical Consequence | Recommended Intervention |
|---|---|---|---|
| Drug Duplication | Patient takes acetaminophen for headache and another cold remedy containing acetaminophen. | Unintentional overdose, potential liver toxicity. | Counsel patient to read all labels, check for active ingredients, and select a single product. |
| Drug-Drug Interaction | Patient on a blood thinner (warfarin) takes an OTC NSAID (ibuprofen). | Increased risk of serious gastrointestinal bleeding. | Discontinue NSAID. Recommend safer alternatives like acetaminophen (within safe limits) after verifying liver function. |
| Drug-Disease Interaction | Patient with hypertension uses a decongestant (pseudoephedrine) to treat a cold. | Elevation of blood pressure, compromising cardiovascular health. | Recommend a decongestant specifically formulated for patients with high blood pressure, or discuss non-pharmacological options. |
| Anticholinergic Burden | Patient takes an antihistamine (diphenhydramine) as a sleep aid. | Increased risk of confusion, falls, constipation, and memory issues. | Recommend non-pharmacological sleep interventions or alternatives. Deprescribe the medication and educate the patient on risks. |
| Long-Term Unnecessary Use | Patient continues taking a proton pump inhibitor (PPI) for heartburn for years after the original indication. | Increased risk of fractures, vitamin deficiencies, and C. difficile infection. | Discuss deprescribing the PPI with a gradual taper, as per evidence-based guidelines. |
The Importance of Patient Education and Collaborative Care
Effective management of polypharmacy is a collaborative effort involving the patient, their family, and the healthcare team. Patient education is paramount, as older adults may not recognize the potential for harm from OTC products. Clear, concise, and understandable communication about proper dosage, potential side effects, and warning signs is essential. Using a single pharmacy can centralize information and help pharmacists identify potential conflicts. Additionally, utilizing a standardized format, such as keeping a written list or a 'brown bag' of all medications, ensures consistency during every healthcare visit. For high-risk cases, a senior care pharmacist, with expertise in geriatric medication needs, may provide further support. A multi-disciplinary team approach, including primary care providers, specialists, and pharmacists, ensures all aspects of a patient's health are considered when managing their complex medication regimen.
Conclusion: Prioritizing Safety Through Comprehensive Review
When an elderly patient presents with a myriad of over-the-counter medications, the most critical and foundational step for any healthcare provider is to conduct a thorough and comprehensive medication review. Ignoring OTC drugs in the medication reconciliation process is a significant patient safety gap, as these products carry the same—and sometimes greater—potential for adverse events as prescribed drugs. By systematically gathering a complete list of all substances, checking for duplication and interactions, and educating the patient on risks, healthcare professionals can drastically reduce the chances of harm from polypharmacy. This proactive, patient-centered approach not only ensures safer medication use but also promotes better health outcomes and a higher quality of life for the aging population.
Medication Safety for Older Adults - This article from Verywell Health provides further insights into the risks of specific OTC medications and how older adults can stay safe.
