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A Caregiver’s Guide to Inhalers
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A Caregiver’s Guide to Inhalers
Author: Mark Parkinson BsPharm: President AFC-CE
Credit Hours 4 - Approximate time required: 240 min.
Educational Goal
Enable caregiver to properly facilitate inhaler device therapy.
Educational Objectives
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
A Caregiver’s Guide to Inhalers
Quickly, take a breath. Taking a deep, cleansing breath always feels so good. Can you imagine trying to take a deep breath and that big inrush of air doesn’t happen? Instead, only a small wheezing trickle of air comes into your lungs. How terrible would that be if it happened over and over again? This is the health concern that is faced by many of your residents. Foster care providers are in a good position to help—but only if they understand how to help. Let us get started with a brief discussion about the respiratory system, its disorders, and how they are treated.
The Respiratory Tract
The respiratory system consists of the organs and structures used to exchange the gases we utilize to live and function. It is divided into two parts. The upper respiratory tract is the mouth, nose, sinuses, and throat. The lower respiratory tract is the throat below the vocal cords, lungs, and diaphragm. The lungs are subdivided into the trachea, bronchi, bronchioles, and alveola.
Lining the respiratory system are several concentric layers of specialized tissue. Throughout the layers, you will find, to varying degrees, cartilage, muscle, nerves, blood vessels, mucosal cells, epithelium cells, and immunity cells, all of which have their part to play in taking in the oxygen we need to function. Once in the lungs, the oxygen can diffuse into the bloodstream and be transported around the body. In a reverse process, the carbon dioxide waste gas we produce diffuses out of the bloodstream and into the lungs, where it is exhaled. If all the parts work properly, respiration occurs. If something goes wrong, the whole body suffers.
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Diseases and Disorders
I’m not going to have a long, drawn-out discussion about everything that can go wrong in the lungs. For brevity, I am going to lump them into two broad categories and name them “asthma type” and “COPD type.” I know that I am taking quite a large medical literary liberty by doing so. Please don’t sweat the details, and instead, look at the broader picture I’m painting.
Asthma Type
Asthma is an inflammatory condition in the lungs. The layers lining the lungs become inflamed and swollen to the point that the airway paths are severely reduced. Along with the inflammation, extra mucus is produced. Together, these conditions block the capacity to breathe normally. Asthma symptoms can be triggered by environmental factors like allergies or pollutants, or they can be triggered by internal events like a sudden increase in exercise or strong emotions. The likelihood of an asthmatic condition manifesting itself can be increased by disease or genetic factors. The signs and symptoms of asthma are difficulty breathing, chest pain, cough, and wheezing. The symptoms can be seen as part of a chronic condition or a sudden flare-up called an asthma attack.
COPD Type
COPD, or chronic obstructive pulmonary disease, refers to a group of diseases that cause airflow blockage and a reduced capacity to exchange gases normally in the alveola. Exposure to toxins (like those in tobacco) and disease progression cause permanent damage to the lung tissues. The loss of lung tissue reduces the ability to breathe properly. Emphysema and chronic bronchitis are the two most common conditions that contribute to COPD. In emphysema, the alveoli have been damaged or destroyed. In bronchitis, the lining of the bronchial tubes is inflamed, and becomes mucus-filled. The signs and symptoms of COPD are shortness of breath, wheezing, chronic cough, and extra mucus production.
Asthma and COPD are both common respiratory disorders. Asthma can be seen in all ages, including the very young. COPD is usually seen in adults, with its prevalence increasing with age. Worldwide, approximately 300 million have asthma, and 10 percent of the adult population over the age of 40 years may have COPD. These conditions are common enough that, sooner or later, every foster caregiver will have to care for a resident with breathing difficulties.
Caregiving and Breathing Problems
Asthma and COPD are incurable diseases. The breathing problems—or the potential for breathing problems—will plague the resident for the rest of their life. Both conditions can be managed with the help of the right equipment, medication, and an understanding of how to use them. Medical oxygen can compensate for the reduced airflow, and medications can open airways by controlling the inflammation and reducing mucous production. Properly applied, these treatments can enable your resident to have a fairly normal life.
The majority of medications used for your residents with breathing problems are delivered via inhaler devices. They are the gold standard in respiratory care. Doctors prefer inhalers because they have several advantages over other treatment options.
But (and this is a Big But) the patient has to be taught how to use them. Inhalers requires practice to properly deliver the medication where it is supposed to go. If inhalers are used incorrectly, the outcome is less than desirable.
The Problem
Even though effective inhaler-based treatment options are readily available, asthma and COPD patients continue to suffer from their diseases. Far too many deaths from these controllable conditions are still being reported. It is a tragedy that so much suffering still occurs from these largely preventable adverse conditions.
The Stats
In medical studies, it has been shown that if patients use their inhalers correctly just 80 percent of the time, respiratory disorders can be controlled. But during recent research, it was observed that adherence to inhaler therapy rates are much lower, ranging from 73 percent to as low as 8 percent. It was also observed that when patients do use their inhalers, the majority of patients made errors in inhaler use. Non-adherence to therapy and improper inhaler use has resulted in a major health problem in the United States.
The impact of COPD:
The impact of asthma:
Source: https://www.aafa.org/asthma-facts
The Solution
How could this all have happened, and can it be prevented? That is where you, the in-home care provider, can step in and have a huge impact on those in your care. You can do what foster caregivers do better than anyone else, including family, doctors, nurses, therapists, and pharmacists. You are THE 24-7 therapy facilitator specialist. You can ensure that therapy is followed and done correctly. But you can’t facilitate anything until after you have the knowledge and skills required. So, let’s get to it and start learning what you need to know.
The Causes of Non-Compliance
The reasons for non-compliance in respiratory therapy are as complex and varied as humans are themselves. It can be a bit intimidating to caregivers to try to tackle such a huge subject. That is, until you simplify things by placing all various reasons for non-compliance into two categories: intentional non-compliance and unintentional non-compliance.
Intentional Non-Compliance
Intentional non-compliance is all the reasons a patient gives for not wanting to cooperate. Those who have been in the caregiving profession long enough will recognize the following list.
Intentional non-compliance is the easier category to understand and to manage … at least for foster care providers. Just perform your daily routine of good care practices, and eventually, even the grouchiest, most non-compliant resident will come around. New habits will be established, and greater understanding and acceptance will occur, but only if you maintain your good practices and persevere in your efforts. By the way, only foster care providers can apply this kind of behavior-altering pressure on the patient. Every other medical professional sees the client too infrequently to have as much of an impact on patient compliance as your caregiving efforts do.
Here are a few ideas for your caregiver’s mental toolbox.
Unintentional Non-Compliance
Unintentional non-compliance is where the resident wants to cooperate but still falls short in their therapy. This type of non-compliance falls into three categories: forgetfulness, misunderstanding of the instructions, or poor inhaler technique.
In my opinion, this is where most of the problems with non-compliance occur. That may surprise you, considering these are the patients who want to cooperate. They think they are using the medication the way it was prescribed but, for one reason or another, they are falling short of full adherence to therapy. This leads to sub-optimal outcomes and the patient still suffers. Often, the patient gets frustrated with their therapy, wondering why it’s not working for them. If the frustration continues, they lose confidence in the treatment or the prescriber and become less willing to comply with instructions.
In one study of inner-city children with asthma, 87 percent showed they had poorly controlled symptoms. It is small wonder that the same study showed that only 1 percent of the children’s caregivers were able to demonstrate proper inhaler technique.
Stating again what is now more obvious, this is where foster care providers can have the greatest impact. You are in the unique position of being with the patient the most. You can remember for the client when to use the inhaler. You can objectively evaluate inhaler technique and catch errors in inhaler use. You can identify and report any handicaps and barriers that prevent optimal drug therapy. You can follow up with concerns, help overcome handicaps, and continually ensure that therapy is followed. With a little effort on your part, things will only get better for your residents. Let’s go over a few caregiving suggestions I have for you.
Ways to Manage Forgetfulness
Life events and activities of daily living tend to compete for the attention of every person, including residents and their caregivers. It’s only human to forget even the most important of action items. Here are a few ways to help you and your resident remember their inhaler medication in a foster care setting. These are by no means the only methods of remembering dosage times. The following ideas are meant to augment what you are currently doing.
The Caregiver
A caregiver tool to help you remember medication administration times is good recordkeeping techniques. That’s right, the MARS. You know, that annoying chore that every caregiver wants to avoid and is tempted to put off until the very last day before inspection. But you got it all wrong. The MARS is not a chore; rather, it is the most powerful memory tool you’ve got. If utilized properly, it’s the ultimate “to-do” list for medication administration.
I suggest making filling out the MARS a part of the drug-dispensing routine. Fill it out as you’re giving out the meds. Don’t hide away the MARS in a closet; pull it out and bring it with you when you grab the meds. Heck, use it as a tray to carry the meds. Put it right down in the middle of things where it can’t be overlooked. Tie a pen on a string and attach it to the MARS where it will be handy. As you dispense the drug, fill out the MARS, just like crossing off an item on a to-do list. Then, move on to the next medication to dispense. If you regularly use the MARS several times a day, you will never forget to dispense the resident’s medication. I promise you, if you avoid filling out the MARS in robot mode and use it instead as a to-do list, the resident will always be compliant with medication times. (And you will never again worry about being dinged during an inspection.)
Another powerful memory tool is timer alarms. You can buy medication delivery devices with sound reminders, but why spend the money? Just set up your smartphone with timer alerts apps. It’s not that much effort to download free versions to your cell phone.
The Resident
First things first: Get permission from the doctor to self-administer all inhaler medications. This is one of those details that can come back to bite you come inspection and relicense time. You will find it easier to obtain the necessary documentation if you do all the work for the doctor. Write out your own order and have a place for the doctor to sign.
It doesn’t have to be fancy, and you can certainly copy other self-admin orders you have seen. In fact, you can copy the format below:
__________________________________________________________________________________
Consent to Self-Administer Medication
_________________________
Resident’s name
_________________________________ __________
Medication Dosage
_________________________________
Time of administration
I have prescribed the specified medication to the patient listed above and authorize the patient to self-administer it as I have instructed.
________________________________
Signature of the prescriber
__________________________________________________________________________________
Please return to: Business name, address, email, fax, or include in patient’s return file.
A final note on self-admin forms: As a matter of courtesy and to avoid future problems, make a copy of yours and send it along with the resident if they participate in any event, work, or program where you are not present. That thought brings us to the next item.
There will always be times when you are not around to remind the resident to use their inhalers, such as recreational or work programs and family outings. During such events, your resident will experience extra distractions that will make them forget their medication. You will have to set things up so it is easy for the resident to remember their dose. Here are a few ideas that might help. 
Misunderstanding of the Instructions
As far as medications go, inhaler use is quite involved. It is a lot more complicated than just popping a pill every day and you’re done. In order to get the full benefit out of the medication, the patient has to know when to take it, how to use the device, and why they are taking it in the first place. The data in studies show that misunderstandings are occurring in far too many cases. Why is that? The doctor and/or the pharmacist are supposed to educate the patient in all these details to ensure the medication’s proper use. “Yeah, right. Like that happens 100 percent of the time.” At the very least, they are supposed to send home literature explaining everything. “Well, you know how often the patient reads those wonderful literary masterpieces.”
Now consider understanding inhaler medication from the perspective of your resident’s point of view. How much medical training have they had? Add to that the mental acuity of your typical foster care resident. They are handicapped by their age (too old or too young) or impaired by their condition (developmentally disabled or mental-health challenged). In addition to those factors, think about how often they have seen their prescriber or pharmacist. “Once a year if you’re lucky.” Finally, think how long ago they received their initial instructions on inhaler use. “Months or even years, maybe.” Given these facts, it is small wonder that so many patients misunderstand their inhaler instructions.
You would be totally justified in thinking that none of your residents totally understand their inhaler medication instructions. In my expert opinion, you should assume that the resident doesn’t understand their inhaler medication. Start from scratch on every single inhaler prescription that comes into your home, no matter how long the resident has been on it. Even if I am proven wrong and they do understand the instructions, it is always wise to have a review of the details every so often.
If you are starting to get apprehensive about helping the residents with their inhalers, don’t be. It may appear that inhaler use is very difficult and impossible to get right. Quite the opposite is true. Inhalers are designed to be simply understood and used by almost anyone. You just need to be instructed on some of the basics and you will be good to go. As you read the following details about inhalers, remember, you’re not the prescriber, you’re the facilitator of therapy. You don’t have to understand the ins and outs of a drug. You just have to know enough to see that it’s used correctly.
The Prescription
As you know, the prescription contains the prescriber’s instructions on how the patient is to use the medication. When you first receive the medication from the pharmacy, read the instructions to see if you understand it. If you don’t fully understand it, ask the pharmacist questions until you do. Don’t worry about bothering the pharmacist. Remember, it’s your license on the line if you don’t ensure the doctor’s orders are followed as he or she intended.
Look for the hidden details that are not spelled out. For example:
Patient Drug Information Insert
Every medication that comes from a pharmacy has to have an information sheet. Have you taken the time to read those papers from the perspective of a caregiver? It has listed almost everything you need to know to manage the resident’s medication use. It’s all spelled out in black and white in everyday language. How easy is that?
I went down to my local grocery store pharmacy and picked up an information sheet on an albuterol inhaler. Listen to how it is organized.
It’s practically a caregiver’s training guide on albuterol. The only thing that is missing is how to fill out the MARS.
The Patient
Once the details are clear to you, set some time aside to counsel with the resident. Normally, caregivers don’t have to have a discussion with their residents about their drugs. But since inhaler devices are essentially self-administered, they require a degree of understanding and cooperation that must be verified by the caregiver. When you counsel with the resident, remember to be non-judgmental and use plenty of caring empathy in your discussion.
I suggest you start out by asking the following questions.
As they answer your questions, you may start to notice misconceptions and misunderstandings the patient has collected over the course of their therapy. How you correct those misunderstandings will take some skill. I suggest that you do not try to make any corrections after each response. Wait until all the questions are done. If corrections need to be made, do not make the resident feel like they were wrong. You will get more cooperation if you do not make them feel bad about what they have done in the past. Tell them that there is a better way, better understanding, or better techniques that will help them get better outcomes from their therapy.
Another counseling technique is not addressing the error in understanding at all. Make the correction appear to be something brand new. Say something like, “Well, it looks like there was a change somewhere along the way because I was told the doctor wants you to take the medication like this (add the correct detail). The doctor must have thought that you would feel better if you did it this way.”
Empathy can also be used to gain cooperation when changes are needed. Say something like, “I totally understand why you think (or feel) that way. Given your circumstance, I think I would have thought (felt) that way too. But there is a better way (better understanding) that will help you even more.”
There are circumstances when the mental abilities of the resident are so low that any discussion would just confuse the resident. In these cases, it is better to present the correct information as an authority figure. Confidence in your demeanor will be key for better outcomes.
Be careful not to blame any misconceptions on the doctor or pharmacist or you will undermine the resident’s confidence in them. That will only lead to problems down the road.
The Family or Other Responsible Person
Finally, do not forget to counsel with family members or other responsible persons who have influence on the resident in any significant way. If you do not include them in the conversation, they may undermine all your efforts to change the situation.
Poor Inhaler Technique
The vast majority of patients make at least one error in inhaler technique. Your residents either picked up some bad habits along the way, forgot their initial instructions, or were never shown the proper technique in the first place. If it wasn’t for the fact that inhalers are designed to be easily used, I don’t think that anyone would be close in getting it right.
The reality is that most health-care professionals are not very good at teaching their patients proper inhaler technique. In one study of pulmonologists (they are supposed to be the inhaler therapy specialists), it was discovered that only 43 percent were knowledgeable in teaching patients how to use inhalers. The problem is lack of available training. I remember as a practicing pharmacist I was never given any instructions on how to educate a patient when a new inhaler hit the market. I was supposed to just know what to say. I assume the same happens with doctors and nurses. Even if the resident was shown the proper technique, one education session is rarely enough to ensure proper inhaler use over the course of the therapy.
Knowing these facts should give you, the caregiver, the proper perspective when you start working with your residents. You are in a great position to teach what has not been taught and help remember what has been forgotten. After all, you have more time with and better access to the patient than any other health professional. Why shouldn’t foster caregivers be the ones to support proper inhaler technique? “But where is my training?” I hear you say. This CE is the start. I will show you how to access more training as we continue. All you will need is a computer, your good communication methods, and your keen observational skills. You will be able to help your resident have better inhaler technique.
Let us start with the basics. There are three varieties of inhalers: metered-dose inhalers (MDIs), dry powder inhalers (DPIs), and slow mist inhalers (SMIs). Each type relies on a different mechanism to deliver the medication into the lungs. I will give a general description of each category, but don’t get too caught up in the narrative. Each brand of inhaler will have its own set of specific instructions. I will cover how to get those instructions later.
MDIs
Metered-dose inhalers deliver the medication via a propellant from a pressurized canister. It works in the same way as an aerosol can of hairspray. By depressing the canister into the plastic mouthpiece, a measured dose of the drug is pushed into the lungs. This is the type of inhaler that most people are familiar with and, unfortunately, it is the most difficult type to get right.
Patient Instructions
Caregiver Instructions
Spacer Instructions
DPI
Dry powder inhalers deliver the medication as a fine powder mixed into the air of the inhaled breath. They come in either a multidose inhaler or as individual capsules that are placed into the devices with each use. In either case, the drug-containing capsule needs to be punctured by the device before a breath is inhaled. Most often, it makes a clicking sound. The medication is released only when the user takes a deep, fast breath in through the inhaler.
Patient Instructions
Caregiver Instructions
SMI
Soft mist inhalers deliver the medication via a sprayed mist. It does not have a propellant but has a spray of fine vapor, which is breathed into the lung. They are also known as Respimat inhalers and are the newest device type on the market.
Patient Instructions
Caregiver Instructions
Foster Caregiver Considerations
You now have a basic understanding of the fundamental principles of inhaler therapy. You are by no means an expert, but you don’t have to be. You have enough info to get started. You certainly have more understanding than the resident has, and that is the whole point of foster care—taking better care of those who can’t take care of themselves. You may not be the authority on therapy and medication (that’s why you keep a doctor and pharmacist around) but you are the authority on “get ‘er done,”
Here are a few more ideas on “get ‘er done” and inhaler therapy.
Rescue vs. Regular
We have talked a lot about inhaler devices and technique. Now, let’s talk about the medication itself. I’ll spare you a long, drawn-out (and boring) discussion of the different classes of drugs and what they do. If you have a burning desire for that knowledge, ask the pharmacist for the package insert on the medication. What you do need to understand is rescue versus maintenance therapy.
Maintenance therapies are the drugs that prevent respiratory symptoms from occurring. Rescue medications are drugs that relieve breathing problems after they happen. Most likely that would be albuterol, but there are others. When you first receive the inhalers, ask which ones are the rescue inhalers. You can also tell which ones they are by the instructions on the prescription. They’re the ones that will be PRN (or as-needed).
There are two reasons why you ask about the rescue inhaler up front. First, you have to know what to reach for in breathing emergencies. Second, how often the PRN meds are being used is a great indicator of how the therapy is going. If the resident is having to be constantly “rescued,” you have to start thinking, “Why?” What is causing all the problems? Here are a few possibilities.
Evaluating Inhaler Technique
Pay close attention to how the resident uses their inhalers when they first move into your home. Keep observing inhaler technique from then on. You should know that their technique will suffer during respiratory distress. School them with empathy and caring, or you might add to their anxiety. They may not be able to hold their breath for the full count. To ensure proper breath-hold times, have them concentrate on counting to 10 with their fingers.
These are common errors made by the patient to watch for.
Spacer Use and Care
Spacers are made of plastic, and plastic can build up an electrical static charge. The charge will make the medication stick to its side. Before using a spacer for the first time, you should wash the spacer with warm dilute soapy water. The device should be air-dried. Some brands are manufactured electrostatic-free, and no preparation is needed. Read the package instructions. When in doubt, wash them out. Cleaning the spacer with just warm water will cause the electrostatic charge to develop, reducing the effectiveness of the spacer. If you are using the pediatric version that comes with a mask, the same cleaning techniques apply. Also, when you use a mask, make sure there is a good seal around the entire mask. If you are careless, extra air will leak in and the entire dose of the med will not be inhaled.
When the Resident First Moves into Your Home
Inspect the inhalers and spacers. Determine which are the maintenance inhalers and which ones are the rescue inhalers. Do the inhalers need to be cleaned? Which ones are empty or close to being empty, expired, or broken and need to be replaced? When in doubt, replace them.
Determining How Full the Canister Is
Using the MARS to keep track of how many doses are left is the best way to determine when prescriptions should be renewed. But that’s not the only way. It is also not as useful when you cannot account for every dose used, for example, when they first move in or when the inhaler is used outside of the home. Two methods of estimating what remains in the MDI inhaler are:
Rescue Inhaler Prescription Refill
For rescue inhalers, I recommend that you try to keep spares around just in case of emergencies. You can get around insurance refill issues by calling the pharmacy and finding out how many days’ supply they assigned the prescription. Most insurances will allow you to fill the prescription when 80 percent of the days assigned to the prescription fill have transpired. Keep ordering the rescue med early even if you don’t need it until you have a full extra prescription in reserve. Another method is to have the prescriber order two inhalers for a same-day’s supply. The insurance may not cooperate with that, though.
A Demonstration Is Worth a Thousand Words
Every brand of inhaler will come with its own specific set of instructions. You will find them tucked inside of the box that the inhaler comes in, written on a small paper insert. Take it out and become familiar with the device’s requirements. In my opinion, though, that is not good enough. The patient needs a demonstration. That is where you and your computer come into play.
There are thousands of demonstration videos on inhalers published by the drug manufacturers and knowledgeable health-care providers. The ways to find the good ones are:
After watching the video, have the resident use their inhaler. This show-and-tell session will be critical for you in evaluating their understanding of the instructions. Work with the resident until they get it right. It may take several sessions. Some habits are just hard to break.
Remember to be humble and helpful. After all, you are no therapy expert. You are just someone who is supporting the resident’s efforts to get it right. If there are difficulties, first evaluate your own understanding and communication techniques. Are you getting it right? If there are still difficulties that are too hard to overcome, report them to the doctor. When you talk to the doctor, be specific in reporting your observations.
I recommend that you repeat the video or demonstrate sessions periodically. Once or twice is never enough to ensure continued proper inhaler technique.
Conclusion
Asthma and COPD are significant health concerns in many residents of foster care homes. Inhaled medications are the gold standard for treating these conditions, but these devices require a greater effort from the patient to comply with therapy requirements. Studies have shown that the majority of patients are not compliant with their therapy, thus leading to increased mortality and morbidity issues.
The reasons for non-compliance are complex and are either intentional or unintentional. There is a great need to assist the patient in becoming compliant with therapy that is just not being met. Foster care providers are uniquely situated to effectively take care of this need. They can observe and evaluate the resident’s understanding and compliance with therapy. Facilitate the resident’s effort to become compliant and report back to the prescriber any significant difficulties the resident is having.
Caregivers are also best suited to ensure continued compliance over the course of the therapy. I hope that this CE has helped the caregiver along with internet resources to become THE expert on “getting it done.”
As always, good luck in your caregiving efforts.
Mark Parkinson, BS Pharm.
References:
Stephanie Watson. Inhalers for COPD. Healthline, Aug 14, 2018. https://www.healthline.com/health/copd/inhaler-nebulizer
Laura Koppen PharmD, BCPS. Advances in Inhaler Technology: Helping Patients Increase Adherence. Power-Pak CE. UAN: 0430-0000-19-138-H01-P. Dec 20, 2019 https://www.powerpak.com/course/preamble/119037
Aimee Simone. Many Caregivers Unable to Demonstrate Proper Use of Kids' Asthma Inhalers. Pharmacy Times. 2013-11-11 03:06:17.
How to Use a Metered Dose Inhaler. Family Doctor.org. American Academy of Family Physicians. 2020. https://familydoctor.org/how-to-use-a-metered-dose-inhaler/
Jane Scullion. The Nurse Practitioners’ Perspective on Inhaler Education in Asthma and Chronic Obstructive Pulmonary Disease. Hindawi. Canadian Respiratory Journal. Volume 2018 |Article ID 2525319. https://www.hindawi.com/journals/crj/2018/2525319/
Toby GD Capstick & Ian J Clifton. Inhaler technique and training in people with chronic obstructive pulmonary disease and asthma. Expert Review of Respiratory. Medicine, 6:1, 91-103, DOI: 10.1586/ers.11.89. https://www.tandfonline.com/doi/pdf/10.1586/ers.11.89
Lynn B Gerald, PhD, MSPHRajiv Dhand, MD. Patient education: Inhaler techniques in adults (Beyond the Basics). Up To Date, Sep 29, 2020.https://www.uptodate.com/contents/inhaler-techniques-in-adults-beyond-the-basics
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Medication Overload
Author: Mark Parkinson BsPharm: President AFC-CE
Credit Hours 2- Approximate time required: 120 min.
Educational Goal
Explain what Medication Overload is and ways that caregivers and reduce it’s negative effects on the residents.
Educational Objectives
Procedure:
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Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Medication Overload
Three times in one year, a normally clear-thinking elderly woman was found wandering the neighborhood with her dog, unable to find her way back home. Upon review of her medication use, it was discovered that she had three different PRN (or, as-needed) medications for pain and anxiety. When all three were taken together, her ability to think clearly was so impaired that she would attempt to get into other people’s homes, thinking they were her own.
The adverse effects that arise from polypharmacy has been described as “America’s other drug problem.” Polypharmacy is loosely defined as the taking of at least five different medications together. As more and more drugs are prescribed to manage medical complaints, the chances of unforeseen side effects increase.
Iatrogenesis, or doctor-caused harm, is a perplexing problem that has always been associated with the prescribing of multiple medications together. Doctors find it hard to predict what side effects will arise when normally beneficial medications are taken together. Ironically, many doctors will prescribe even more medications to manage this “drug-caused” problem. What has been described as the “drug cascade” is an old problem of polypharmacy that is receiving new efforts to manage.
Not all polypharmacy is bad. There are certain disease states, like diabetes and mental health issues, where a multi-drug regime is required to manage the medical condition. To differentiate from those situations, a new term has been developed: medication overload. Medication overload is defined as the use of multiple medications for which the harm to the patient outweighs the benefit.
Harm to the patient can be more than just a biological side effect. Taking multiple medications can create a significant financial, emotional, and time burden for the patient to manage. Taken together, all these problems are known, in many medical publications, as the pill burden. A significant pill burden can greatly reduce the overall quality of life for a patient. As a practicing pharmacist, I witnessed firsthand the pill burden that many of my customers faced. It was heartbreaking to watch them struggle to decide whether to buy food or fill their prescriptions.
Major health institutions and medical associations are starting to recognize the problems of medication overload. They are beginning to take steps to try to understand the causes of iatrogenesis and reduce the pill burden their patients are experiencing. As with any scientific endeavor, the first step these organizations are taking is the gathering of data.
The Lown Institute of Canada reports that “Every day, 750 older people living in the United States (age 65 and older) are hospitalized due to serious side effects from one or more medications. Over the last decade, older people sought medical treatment more than 35 million times for adverse drug events, and there were more than 2 million hospital admissions.” Source: Medication Overload and Older Americans,” Lown Institute.
In the same article, it was also reported that polypharmacy “has reached epidemic proportions. More than four in ten older adults take five or more prescription medications a day, tripling over the past two decades. Nearly 20 percent take ten drugs or more.” Similar data has also been reported in mental health and developmentally disabled patients who have multiple heath problems.
Why has this occurred?
No one in the medical field wants to cause the patient harm. Yet, for multiple reasons, harm is being experienced. To better manage the problem, a greater understanding of the causes must be considered. The many contributing factors can be more fully comprehended by placing them in three broad categories.
The Culture of Prescribing
The “a pill for every ill” culture of our modern society has it roots in several factors:
The perception of treatment is often linked to taking a drug.
Information & Knowledge Gaps
The more medications that are consumed, the more information and knowledge is required by the prescriber and the patient. Yet when harm is caused, it is a clear indication that information was lacking.
Fragmentation of Care
The more advanced our medical knowledge becomes, the more specialized its practitioners become. You have cancer specialists, gerontologists, urologists, nurse practitioners, physician assistants, psychiatrists, and all the other “–ists” who have the ability to write prescriptions. Each has the same pressure to “do something.” Yet who is being held responsible to coordinate all these efforts? The primary care doctor (if there is one), the patient (who has no medical background), or the caregiver (who has no authority)? The coordination of American-style medicine and communication between its practitioners is lacking in many ways. Often, a “prescription cascade” occurs when one doctor will prescribe a medication that causes a side effect. Another doctor will prescribe an additional drug to manage the side effect, and around and around it goes until there is a significant medication overload.
Case in point, as reported by the Lown Institute:
“Killed by a Prescription Cascade
How did Joe Esposito go from a man in remarkable health, effortlessly running half marathons in his 50s, to being debilitated and incapacitated, struggling at death’s door, in just a few years? When Joe sought treatment for his mild to moderate Crohn’s disease, his list of medications cascaded from one to six to twenty, as each new medication brought on a new side effect. The steroids he was prescribed to treat Crohn’s led to bone loss and anal fistulas. He was given antibiotics for the fistulas, which caused peripheral neuropathy in his feet. He couldn’t sleep from the pain so he was prescribed benzodiazepines and Ambien for sleep, Lyrica for the nerve damage, and Tramadol for the pain. Several of the drugs gave him severe diarrhea. To treat his diarrhea, he was given opium drops, and other medications. Additional drugs weakened his kidneys, which in turn raised his blood pressure, so he was put on four blood pressure medications. And an experimental anti-inflammatory drug led to Joe contracting pericardial tuberculosis, which almost killed him.
At the end of his life, Joe was taking over 20 medications and 31 pills a day, but not one physician saw this as a problem worth addressing or even considered that his symptoms were caused by the drugs and not the Crohn’s disease.”
What can be done?
No one doctor can solve this problem. The training and tools are lacking. Medical societies and organizations are trying to step up to the plate and help manage medication overload. They are promoting new medical paradigms to counter the “pill for every ill” culture we live in.
Integrated Medical Records
In the past, prescribers kept their own records that other prescribers did not have easy access to. Larger health systems like Kaiser Permanente and the University of Utah now have medical record systems that are available via a shared computer system to everyone who has a need to know. Any prescriber, nurse, therapist, or pharmacist can see what the other clinicians are doing. In addition, since patient histories and lab values are readily available to other medical personnel, some of the more mundane doctor tasks are being done by other staff. This frees up prescribers to have more time with their patients.
Medication Management Services
Medical specialists are providing services that assist the doctor and patient in managing their medications. For example, diabetic educators and pharmacists actively work with patients to review all their medications, monitor outcomes, and report to the doctor any significant events and recommendations.
MTM – Medication Therapy Management is a program of several services provided to assist the doctor and patient and help them get the most out of drug therapy. Those services include:
Deprescribing
Deprescribing is the planned and supervised process of dose reduction or stoppage of medication that might be causing harm or is no longer of benefit. To encourage prescribers to incorporate deprescribing in their practice:
What can in-home caregivers do?
In-home caregivers are in a unique position. They are both part of the professional health-care team and can act as an advocate of the patient. This makes caregivers particularly suited to deal with medication overload problems. They can ensure drug therapy is followed and push for changing the therapy when it needs to be changed. Even if the patient is already part of an MTM program, there are still many things a caregiver can do to reduce the ill effects of medication overload.
Monitor and Report
Advocate and Action
Caregivers can act as the representative of the doctor and the resident, and can work to support the interests of both.
Caregivers representing the doctor:
Ensuring the resident understands and remembers their medication instructions is a very important part of drug therapy. The lack of understanding and the failure to remember are major causes of medication overload. A study done in Italy in 2014 demonstrated how big this problem is. It looked at 100 patients (65 years of age or older) discharged from an internal medicine ward throughout 2012. The patients were followed for three months after discharge. The study found:
When therapy is not followed, symptoms will continue. This leads to patients complaining to the doctor, demanding they “do something.” This leads to more medications being added, and the drug list grows and grows.
Caregivers representing the resident:
Consider the following case.
Mrs. A was a 71-year-old widow with congestive cardiac failure and osteoarthritis. She was put on digoxin to help her heart function normally. Later, furosemide (a water pill) was added to reduce the amount of fluid that was building up. The daughter noticed over a two- to three-month period that her mother was becoming confused, easily fatigued, and very irritable. She also noticed that her mother had become compulsive about washing her curtains. Mrs. A said they always looked yellow-green and possibly moldy. The daughter, not knowing what was going on, assumed her mother was getting dementia and contemplated putting her in a nursing home. Fortunately, someone started asking what effect adding the furosemide had on Mrs. A’s symptoms. It turned out furosemide can cause digoxin poisoning, The poisoning caused confusion, irregular pulse, nausea, and a fast heartbeat. Mrs. A felt miserable and became irritable more often. Tellingly, digoxin poisoning can create vision changes. Mrs. A always saw her curtains as yellow and green, no matter how often she cleaned them.
Too bad there wasn’t a foster caregiver there to start asking the right questions earlier.
Medication Overload Action Steps for Caregivers
Caregivers have been working to prevent medication overload for decades. We just didn’t know what our efforts were called. All of us have, to one extent or another, been trying to control medications, promote healthy lifestyles, and fight with doctors over what is best for our residents.
To help make your efforts more effective, I recommend the following action steps. I do not intend this to be a step-by-step system that has to be followed in order to be effective. Rather, I present these action steps as suggestions to augment what you are currently doing.
New resident’s drug and supplement evaluation
When a new resident moves into your home, gather all their drugs (prescription and OTC) and supplements. Compile a list for the primary care physician to review. Look for the following information and make notes on the drug list you’re going to give to the doctor. The information will be very important, and it may be the first time that the doctor has seen it.
Med list in resident’s file
After you get an “approved” drug list from the doctor, add the list to the resident’s file and make sure it goes with the resident to every medically related trip the resident takes. That includes therapy visits.
New order evaluation
Do not just accept a new prescription or therapy order. Find out the why’s and the what’s.
Report to the doctor what you have observed.
Old order evaluation
Do not be afraid to ask questions about any drug or therapy order. Doctors have had plenty of training on how to prescribe a drug but little to no training on how to deprescribe a drug. I find the prevailing course of action in medical practice is to add a drug and just leave it there until it is forced off the list by an adverse event. Often, I find that the only person willing to ask the challenging questions surrounding the need for a drug is the caregiver.
Keep an eye on these drugs
Pay close attention to the following drugs:
|
Drug/Drug Class |
Reason to pay attention |
|
Digoxin |
Digoxin poisoning can be caused by other drugs. |
|
Blood thinners – Warfarin, Heparin |
Interaction with drugs, supplements, and even food can cause excessive bleeding and bruising. |
|
Antidepressants – Fluoxetine, Amitriptyline, Doxepin, Trazodone, Citalopram, Sertraline |
Serotonin Syndrome: slurred speech, confusion, falls. Changes in behavior. Just not needed in the stable, supportive environment of a care home. |
|
Antianxiety/Sedatives – Lorazepam, Ativan, Diazepam, Zolpidem, Diphenhydramine, Haloperidol
|
Slurred speech, dizziness, falls, confusion. Changes in behavior. Just not needed in the stable supportive, environment of a care home. |
|
Painkillers – NSAIDS, Aspirin, Opioids, Narcotics |
Can cause drowsiness, confusion, falls, constipation, nausea. Can interfere with other meds. |
|
Protein-Pump Inhibitors (PPIs) – Omeprazole, Lansoprazole, Pantoprazole
|
Just not needed for long-term therapy. |
|
Nerve Pain/Antiseizure – Gabapentin, Lamotrigine Phenytoin, Carbamazepine, Phenobarbital |
Slurred speech, dizziness, falls, confusion, changes in behavior. |
Manage the drugs
Foster care providers are not idle followers of other medical professionals’ orders. They are active participants in drug therapy management. The doctors may be the generals who give the orders, but you are the soldiers who actually turn those orders into actions. When those orders don’t fit neatly into the reality of the situation, you can push for a modification of those orders.
Here are two more case studies that illustrate the need for active medication management by the caregiver.
CASE 1
A 39-year-old white woman with depression and panic attacks was being treated with fluoxetine, trazodone, clonazepam, and cimetidine. After fluoxetine and clonazepam were abruptly discontinued, venlafaxine and lorazepam were started. Within 24 hours, she developed diaphoresis, tremors, slurred speech, myoclonus, restlessness, impaired thinking, and diarrhea. These are all symptoms of drug-caused serotonin syndrome.
Case 2
An 83-year-old woman was taking 17 different medications. She started to show new signs of tremors, slurred speech, ataxia, and depression. Her symptoms started to manifest themselves after a recent stay in the hospital and the addition of several new medications.
Conclusion
When the pill burden and the side effects of medications outweigh their benefits, a medication overload condition exists. Foster caregivers are in a powerful position to start to manage and reduce this harmful effect of polypharmacy. For the good of the resident, caregivers need to actively monitor the drug effects, manage the drugs, and push for changes when needed.
As always, good luck in your caregiving.
Mark Parkinson, BS Pharm
References:
Medication overload and older Americans. Lown Institute, 2020
Angie Eaton, PharmD, Polypharmacy in the Elderly. https://media.bcm.edu/documents/2015/c9/igcesession021815.pdf
Alice Bonner. How to Address the Harm of Medication Overload. Institute for Health Care Improvement. Feb 20, 2020.
http://www.ihi.org/communities/blogs/how-to-address-the-harm-of-medication-overload
Maria G. Tanzi. Eliminating medication overload. Pharmacy Today, Volume 26, Issue 4, P20-21, Apr 01, 2020
https://www.pharmacytoday.org/article/S1042-0991(20)30297-8/fulltext
Tackling Medication Overload. Aging 2.0. Sep 24, 2019 https://www.aging2.com/events/details/aging-20-baltimore-presents-tackling-medication-overload/
What is Deprescribing?. Deprescribing.org. 2020 https://deprescribing.org/what-is-deprescribing/
Wade Thompson, HBSc, Barbara Farrell, BScPhm, PharmD, FCSHP, Deprescribing: What Is It and What Does the Evidence Tell Us?. Can J Hosp Pharm. 2013 May-Jun; 66(3): 201–202., doi: 10.4212/cjhp.v66i3.126. PMCID: PMC3694945. PMID: 23814291 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3694945/
Michael Steinman, MDEmily Reeve, BPharm(Hons) PhD. Deprescribing. Up To Date, Jan 21, 2020. https://www.uptodate.com/contents/deprescribing
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