Preparing Family Caregivers to Manage Medications

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Medications can relieve symptoms and improve a patient’s quality of life. Some are literally life-saving. But those benefits depend on careful and constant watchfulness. Family caregivers are essential allies in achieving the best results. Many patients today depend on someone else to help them manage their medications. This is especially true if the patient is elderly, chronically ill, or has trouble understanding complicated instructions.

The person responsible for seeing that the patient obtains the right medications, takes them as prescribed, and monitors side effects is usually a family caregiver. A family caregiver can be anyone who has responsibility for providing or managing the patient’s care; it need not be a relative or kin. If you have any doubt about who is a patient’s family caregiver, you can ask, “Who helps you the most at home?” or “Who makes the arrangements for your doctor visits?”

Both the patient and the family caregiver should be involved in discussions about medications, but if the patient is forgetful, too sick, or needs help in medication management, the family caregiver is even more essential. An informed and observant family caregiver can help prevent medication errors and can alert medical staff to side effects. This guide is intended to help health care providers prepare family caregivers for this complicated but important responsibility. It is intended for all providers who are involved with prescribing, explaining, or monitoring medications—primarily physicians, nurses, and therapists.

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Getting a complete and accurate medication history may take some time, but it will also prevent some problems in the future. A form that the family caregiver can fill out at home, listing all the bottles and tubes in the patient’s medicine cabinet or night table, may provide a more comprehensive picture
than a discussion in the hospital or office where the caregiver has to rely on memory.

In addition to prescription medications, many patients take a number of over-the-counter medications and herbal or other supplements. They may not volunteer this information; you may need to probe by asking the family caregiver and the patient specifically about things like laxatives, aspirin, cold medications, heartburn medications, and all the other items that are on sale in pharmacies. Patients and family caregivers may not even consider preparations such as vitamins and herbal supplements as medications. Perhaps they are reluctant to talk about them for fear that they will be criticized or shamed.

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As you know, the trend in prescribing is to write prescriptions in plain English, giving up the arcane Latin abbreviations whose meaning is known only to the physician, nurse, and pharmacist. The reason is simple: too many errors result from abbreviations that are confused with look-alikes or numbers misinterpreted. A misplaced period or a missing zero can spell danger. There are extensive lists of error-prone abbreviations, symbols, and dose designations. One example is from the Institute for Safe Medication Practices at www.ismp.org/Tools/errorproneabbreviations.pdf. The Joint Commission has a “do-not-use” list of abbreviations (identified with double asterisks at the same ISMP site noted above).

Avoiding error is certainly the primary reason to write out “daily,” “every other day,” “by mouth,” and other instructions. Another important reason is that this practice makes it is easier for the patient and family caregiver to remember and follow the instructions.

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Patients with chronic or serious diseases usually take many prescribed medications, in addition to the array of nonprescription items they buy on their own. Medication reconciliation is the process of comparing a previous list of medications with an updated one. It simply means making sure that
everything that is on the list should be there, that nothing is missing, and that no contraindications have been overlooked. Medication reconciliation should occur whenever there is a change in medications, care settings, or diagnosis. For example, when a patient comes to an emergency room or
is admitted to the hospital, some medications are not included in the initial history. If the patient is in an ICU, some medications may be discontinued as part of acute care. Medication reconciliation is particularly important when a patient is discharged is moved from one level of care to another or discharged from the hospital.

The family caregiver is often the most knowledgeable source of information about what the patient was taking at home, and why. You should encourage family caregivers to help with this process by:

1. Keeping an up-to-date medication record. An example is the Medication Management Form at www.nextstepincare.org/Caregiver_Home/Medication_Management_Form.
2. Taking the medication record to doctor’s appointments, hospital stays, admission to a medical facility or nursing home.
3. Keeping the list in an easily accessible place at all times, in case of a change or an emergency.
4. Updating the record any time a medication is added to or taken off the list.
5. Telling each of the different doctors involved in the patient’s care all the medications that the patient is taking.
6. Reminding the doctor or nurse about any known allergies or side-effects the patient has experienced in the past.

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Medication reconciliation happens at hospital discharge and other points of transition. But medication management goes on all the time. Some of the family caregiver’s tasks are:

• Reading the label and following the instructions for each medication
• Reminding the patient to take the medications at the right time and in the right dose
• Watching for side-effects, such as confusion or dizziness, and calling the doctor or home care nurse with any changes in the patient’s condition
• Storing the medications safely (some may need to be kept in the refrigerator and all should be kept away from children)
• Checking the container of each medication to learn the expiration date
• Obtaining prescription refills as needed.
• Making sure that the medications are not shared with anyone else.
• Disposing of unused and expired medications prescriptions.

Here are some common questions that patients and caregivers may want to ask as part of good medication management. A health care provider should be able to provide the answers.

• What is this medication called?
• Why does the patient have to take it?
• How many times a day should the medication be taken?
• At what time should it be taken?
• Should this medication be taken with food or a certain amount of time or after meals (on an empty stomach)?
• Are there any foods or drinks to avoid with the medication?
• If the medication is prescribed “as needed,” how will I know when to give it?
• What side effects are common? What should I do if they occur?
• What if my family member forgets to take the medication? Should the next dose be doubled or just skipped?
• What if my family member takes too much or too little?
• When should my family member stop taking the medication?
• How much does this medication cost? Will my pharmacy stock it? Does insurance cover it? If not, are there other ways to obtain it?
• How should I dispose of unused medications?

(Adapted from NIA Website)

Although answering all these questions may be time-consuming, such a discussion will also let you know if the family caregiver understands the instructions for medication management and may identify areas of concern for both patient and caregiver.

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Obtaining the prescriptions

Some patients and caregivers do not get all their prescriptions filled, typically because their insurance does not cover the medications and they cannot pay out of pocket. Sometimes patients and caregivers do not understand why the medications are needed. While it is best for patients to get all their medications from one pharmacy, where potential drug interactions can be monitored, this is not always possible. Some patients use their health plan’s mail order prescription benefit. A frank discussion of these factors is important to finding solutions.

Difficulty remembering to take medications

If patients are taking more than one medication at a time, it can be difficult to keep track of them. At the drug store family caregivers can buy special pill boxes or other aids designed to help remind the patient and the caregiver about the times to take medications. Such aids include simple containers with compartments labeled for meals and bedtime, containers that beep when it’s time for a dose, or a special bottle cap that counts openings of the prescription bottle to keep track of the doses that have
been taken. If the patient has memory problems, it is essential that the family caregiver be in charge of all medicines.

Difficulty reading labels

Remind the family caregiver that it is important to read prescription labels for instructions on when and how to take the medication. Pharmacists may be able to provide prescription labels in large print. Glasses or magnifying glasses may also be helpful. Family caregivers should be encouraged to ask
questions if they don’t understand something on the label.

Difficulty hearing instructions from health care professionals

Although it is often difficult, try to give medication instructions in a quiet place, undisturbed by interruptions and phones. Don’t leave it until the end of the visit when everything is likely to be rushed. Write down important information about the safe use of medications so it can be used for
later reference.

Difficulty opening bottles and handling medicines

Large, easy-open bottle tops are available for prescription medicines. If a prescription dose is one-half tablet, pharmacists can split the tablets. If family caregivers have to administer administration of eye drops, inhaled medications, injections, and other dosage forms that require fine motor skills, they need to be shown how to do it. Once may not be enough. Try to allow some time to go over the procedure a few times.

Difficulty swallowing tablets or capsules

Some patients find it difficult to swallow medications. Many medicines are available in other forms like a liquid, skin patch, or suppository, which may be easier than swallowing. If there are alternative dosage forms, the pharmacist can help.

Scheduling different medications throughout the day

It can be challenging to work medications into daily routines. Special pill boxes and other aids can help. Taking medications at a fixed time, like after a meal, or at bedtime, can also help. Encourage the family caregiver to develop a plan to best suit his or her schedule.

(Excerpted from the FCA Fact Sheet “Caregivers’ Guide to Medications and Aging” written by Kathleen A. Cameron, R.Ph., M.P.H.)

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© 2013 United Hospital Fund