Older patients are an opportunity for pharmacists to improve care with OTC medications by providing education and recommendations and by making referrals when indicated. The OTC section of a pharmacy can be a minefield for older patients unfamiliar with product details and the important safety issues associated with many ingredients. Thousands of product options are available, and the risk profile for this category has escalated over the last several years with the introduction of more prescription-to-OTC switches. The issue of prescription-to-OTC switches, as it relates to medication access and safety in older patients, continues to be a concern. Since 1975, more than 100 distinct ingredients and dosages have switched from prescription to OTC status, and a number of these are considered “higher risk” in the geriatric population.1,2,3
In 2014, the U.S. Census Bureau predicted the number of Americans older than 65 years will exceed 82 million by 2040 and more than 98 million by 2060, including 20 million older than 85 years.4
What does this mean? Pharmacists can and should be more active participants in assisting older patients with self-care. When patients act on their own, issues such as self-misdiagnosis, a delay in access to appropriate treatment, therapy duplication, overdose, and poor health literacy all can lead to poor outcomes in this population. An assessment of OTC medication use in nursing home residents found duplication with prescription products in the categories of analgesics, antacids/antiulcer medications, and cough/cold products, among others.5 Many OTC medications within these categories are considered high risk.
Determining whom you’re speaking to—whether he or she is the patient, a family member, or caregiver—is critical. Your approach to making a recommendation will vary considerably, depending on how much information you do or don’t have. One drawback is the lack of access to electronic health information in the community pharmacy setting. A recent Danish study found an increased risk of drug interactions because OTC medication use was not documented in the online prescription record.6 These data support the need for a focused conversation regarding the patient’s health before making a recommendation.
If you’re waiting for patients to initiate conversation with you about OTC options and to ask questions on a regular basis, that’s highly unlikely. A small study completed in older adults with arthritis found that just over 18% of patients reached out to any type of health care provider regarding their condition; nonphysicians were consulted by just 6.3% of patients. Interestingly, 71.7% of all patients reported using an OTC pain reliever; the majority used oral medications, and almost 30% also used a topical product. These data suggest many people self-select products with no apparent expert input.7
A 2013 report from a national summit of the Gerontological Society of America and the Consumer Healthcare Products Association provides some excellent information on OTC medication behaviors in older patients. These experts from myriad practice and business areas reviewed significant literature to describe how factors such as health literacy, technology, communication, and outcomes influence decisions on the older patient’s use of OTC medications and highlight research needs. This is excellent reading for anyone involved in OTC medication management and the geriatric population.8
A recent study looked at pharmacists’ thought processes when making a recommendation for an OTC sleep aid for an older patient. Findings suggested that most pharmacists use a patient assessment process to obtain background information, and that in this particular scenario, they were most likely to recommend behavioral changes and referral versus a specific product, primarily because of safety issues.9
Implementing a self-care medication reconciliation process—either during an OTC consult or any time when dispensing medications to an older patient—is a good place to start. This could be considered an element of the QuEST/SCHOLAR process for patient assessment.10 A common reason for discrepancies during a traditional medication reconciliation visit is lack of information on OTC products being used by the patient.11,12 The National Council on Patient Information and Education (NCPIE) has resources that can help educate older patients on medication use.13,14