Medication Management

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[0:15] Hi, everyone. I'm Emily. And this is Eva. And you're listening to Speech Talk. Where you research book clubs so you can do evidence-based practice in practice. So let's start talking. Okay, today we are going to be talking about medication management by our older adults with cognitive impairments. Emily, how often do you do med management activities? All the time. I feel like this is one of the things that I use in my practice as like a requirement. If you are going home, if you're going anywhere outside of this facility and you have to be managing your medications or hands-on for your medications at all, this is something I address. What about you, Eva? I am pretty recent to it. I think I did a lot more long-term care before.

[1:04] And I was like, I don't even know why it's important. The nurses are the ones who give the medication. They're never leaving. So I think this is something I had like given up on. And now that I work at a facility where there's a much higher turnover, people are going home. I have started to go, oh, oh man, I should really be checking in on this. Yeah. So we looked at the research article, Medication Self-Management Skills in Cognitive Impairment in Older Adults Hospitalized for Heart Failure by Gorodowski et al. And the researchers met with 55 participants, screened them for cognitive impairments with the mini-cog screener, and then asked them to complete a medication management task set, including grading a pill bottle label, opening a pill container, and allocating pretend pills into a pill box.

[1:57] Eva, what did they find?

[1:59] So of the 55 people that they met with, 22% were found to have cognitive impairments after they performed the mini-cog. And those people were found to have poorer abilities to complete all three of the assessment tasks. Again, that was reading the pill label, opening the pill container, and allocating the pretend pills. And in particular, our cognitively impaired patients struggled with reading and opening the pill bottles. Somewhat hilariously, about 65% of the participants had pill allocation errors regardless of cognitive impairment. So, like, everybody was just throwing pills around. Yeah.

[2:37] Nobody, it turns out, could use the pill box, cognitive impairment or no. But that being said, patients with cognitive impairments had more errors for not putting pills in the correct box slot and more errors for what the researchers called knowledge-based mistakes. And I really liked this description because it felt like it was just nail on the head for the types of cognitive errors that we, cognitive impairments we see, or at least how they present. These include failures in perception, judgment, inference, and interpretation, which are four really important abilities when you're trying to lay out your pills. This can, this like type of error often occurs when we're in a new situation that's outside of our usual problem-solving routine. So like outside of your kitchen, when that's like where you normally do it. Yeah, they said that these issues get worse when people are out of their home context in general. I feel like even outside this situation, we see people who have increased difficulties outside of their home context. And we always hear that. Well, I can do this really, really good when I'm at home. I don't have these issues when I'm at home. But it's good to at least address them outside of their home context so that they are learning these new inferences and expanding their mind a little bit.

[3:59] 100%. I struggle when I'm out of my home context. My home context is where like my blankets and coffee are.

[4:08] Yes, exactly. So patients who've experienced heart failure, they're hospitalized, they're not home, they're not in their usual habits and routines.

[4:16] And the researchers make some recommendations for how we should transition care for patients from the hospital back into the community. And they specify for patients with heart failure because that's the population they looked at. But I think these guidelines were really good for just in general, looking at our folks with cog impairments and helping manage their transition home. So in that transition, they said that they should be receiving cognitive screenings, a medication education. So yeah, I've recently been trying to do more medication education. And I think this is something that we you kind of have to like, figure out better. Emily, like jump in if you have a good way to do this. But whenever I print my patient's medication list, there's 100 medications on there. Enemas, option, PRN, milk of magnesia. Everyone's getting milk of magnesia PRN. And I'm like, okay, how do I know which of these they're going home with? Because there's sometimes not literally 100, but 20 things And there's no way they're going to be doing 20 medication-based activities when they go home. And they are certainly not doing their own enemas.

[5:35] That's so funny. No, I hope they're not trying to do their own enemas. I did recently have a patient who said he had to, quote, go up there and take care of the constipation himself. And I was like, oh, buddy, one, you didn't. Two, how was it? Wait, I have follow-up questions. I don't know if I want the answers, but I have a lot of questions. Yeah, a lot of questions. I mean, whenever I do this, I try to, and I always preface this, like this ends up being one of my longest sessions with people.

[6:10] It can separate into two, but I try and like go through the medications. A lot of people know their medications by their generic name and not the name that's listed on there. So we're trying to remember them. And then I'll try and talk with nursing. Like if it is the goal to go home, maybe they are going home with 18 pills. I've had people literally have 18 pills and then they have a weird one where they have to take six pills on a Monday. And that's their weekly pill is six pills on a Monday. So they know that one slot is going to be filled to the brim. They really just have like a Monday pill box. Just the one. It's six pills on a Monday every other day. And then like, uh, one with dinner, one before bedtime, they have the biggest pill box. It's a whole table.

[7:01] Yes. Um, and I think something that was kind of insightful on behalf of the researchers, they, they ask, like, we're not really sure how successful medication education will be with our cognitively impaired patients. Um, and yeah. Because they're cognitively impaired. And they have poor comprehension, poor retention.

[7:23] And so they did put in like an advocacy section for including family and social circle as an alternative for doing medication education. Obviously, do it with the patient. But if you can, bring people in for caregiver hours because they may need continued support once they leave the facility. Right. And make sure we're going through our handoff procedures, meaning like, how are these people getting home? Like, how are they getting this information? Like, what are all the things that we need to do to make sure these people are going to be safe in their next transition?

[8:02] Absolutely. And this article was written through a hospital facility and we are in the skilled nursing side. Cleveland. So another part of that handoff pipeline is from the hospital to us. And so I have not done this, but if anybody listening wants to try out, you know, talking with the DON or whoever is in charge with like relationships with hospitals, asking if a cog screen is something we can get or any notes they have on medication adherence. That would be great because that's something that needs to inform our practice. And obviously, we can help assess, evaluate, and design care for that. But it would be nice to know if they had a note at the hospital, like, this patient does not appear to be able to do this on their own.

[8:55] Please help sign to the hospital that also it might fall a little bit on us in general when they get to us like those are a heart failure diagnosis it doesn't scream speech therapy but we kind of know like if somebody has a heart failure it's they could have swallowing deficits because of that vagus nerve right like if they have um heart failure in this we see that they can have cognitive things. And even if, I don't know a lot of your policies, Eva, but it's in my job thing, my job thing, my description, I guess, the things that I've expected to do, but, I screen everybody who comes in. And I typically give a BCAT short form just because it shows pose dementia and I kind of use it to frame. Like if somebody is going to an AL 18, this is personal. I don't know if it's based on anything, but this is just how I kind of go off of it. But if they're around 18 and they're going to an assisted living, they're not really expected, I would pick them up for general safety in the home. If they are 16 or below, that's, or I think it might be 14 or below, double check. Don't quote me in this podcast.

[10:19] Then that would be an indicator of dementia. And I would be having conversations with the patient and the nursing on my concerns and seeing if they can get a neurological exam from a neurologist to make sure if they don't have a current dementia diagnosis that we are looking to get them more evaluated, yeah, for someone who's smarter than us, because if they can benefit from having some kind of additional pharmacological intervention for cognition, then let's hurry up and get on it before it gets worse. Yeah, definitely. And I think that when it comes to our screeners, ones that have recall for multiple sentences, I think are great because if I read you what it says on your pill bottle and you can't remember like more than five words at a time, that's certainly something we should be aware of because it's an important part in doing your medication management. You have to remember like give one tablet twice daily, Monday, Thursday, Friday, or you know, whatever it is. That's a dense piece of information. So here's to like implementing those cog screeners effectively.

[11:33] Okay. So why was this article so great?

[11:36] It was incredibly practical. The way they laid out the research method section was really helpful. They just took three steps. Can you read the pill label? Can you open the pill bottle? And can you allocate appropriately? Not to always bring up my mom, but she was telling me that even for the last one, uh can you not that last one the second one can you open the pill bottle she's like i can't i have arthritis i have to ask for like special children's pill bottles um so yes these are um interestingly like simple tasks but they show you a lot about the patient, i did this this week uh having read this article i was like i could do this I had so many people. I had one guy who could not open the pill bottle in under a minute. He was like just fiddling with it, like trying to push it, trying to spin it, trying to pop it off. He was not doing the push and spin to open it. I had another guy who was like, I've been doing this for 20 years. Of course I can do this. And then I was like, okay, great. It'll be so fast for you. And he's like looking at it being like, give one tablet. One twice daily. And then looking at the pill bottle, one tablet twice daily.

[13:02] So that's one tablet twice daily. And I was like, oh, okay. So when it comes to that knowledge base error, you are not able to register what this information is, hold it in your mind for long enough to then transfer it to the pill box. I love that you actually implemented it because I feel like I get that Joe all the time. He's always like, I could do it. I've been doing this for so long. You're coming in here with your games. I know, because we're just here to mess with people. That's like the point. You think you're so smart with your dots and your lines.

[13:43] Oh, God bless the mocha. But like when it comes down to it, like, yeah, they really can't do these things. And it's like that admittance of like, man, I don't know when it started happening, but this is hard. It's like such a huge hurdle for our geriatric population to kind of accept and go through. And to quickly go back to like choice of screener, again, the Minicog, great for severe cognitive impairments. But a lot of those patients who kind of like try to bluster their way out of cognitive tasks are higher level and they're doing a lot of masking.

[14:21] And so doing a cognitive impairment that is higher level is good for them. And two, even if you're just kind of getting that weird gut feeling of like.

[14:33] They actually did pretty well on the mocha, but there's just something weird. Having them do a practical task and just seeing how they do it, no assistance provided, I feel like it's just the ultimate unveiling. Like, ha ha, you couldn't read a pill bottle after all. I knew my gut was right. And they look at us like, you meddling kids. Yeah, exactly. You meddling kids. It was Mr. Jenkins. Back to the article they brought up some really practical points like research used colorful pills and most pills kind of look similar i don't know where i got this piece of paper the the medication error thing that i use but i photocopied it on our of course black and white printer and so all the pills kind of look a little bit similar and i would like draw like an a in one and an r in the other one. So they look similar. There's different letters on them, but to kind of give them that realistic feel. I love that you took a, our facility doesn't have enough resources and really spun it as like, this is way more naturalistic because it's hard to tell what is even printed here. And then people will come to me and they're like, I can't tell what this is. And I say, aha, Yeah. That's the point. We're not cheap. That is the point.

[15:58] Yes, 100%. And meds do look really similar. And the article also pointed out that apparently heart failure patients on average are prescribed seven medications. So similar looking pills, seven of them. You have to be able to pay attention to those details. Read the box, the jars, containers, I don't know what they're called appropriately, in order to not be taking the wrong quantities of the wrong meds. They also point out that just because someone doesn't have a cognitive impairment, doesn't mean they won't have medication management errors. That's like my mom. Yeah. I mean, in general, people make mistakes, right? This is just kind of covering those bases. Like if you're tired, like you might not notice something if you're going quickly, you might notice something, as Eva pointed out earlier. Yeah, you're not wearing your glasses. Maybe there's like, I don't know, something else going on. But everybody can have mistakes. It doesn't necessarily mean that they have a cognitive impairment or they necessarily need anything in particular. Just, I don't know, everybody can. Just being aware. People make errors. Yeah.

[17:11] So some other things that were interesting in this article. One was the error type. So if you remember way back, like 15 minutes ago in this conversation, we talked about knowledge-based errors. There were a couple more they mentioned that I thought were really good for... Just as ways to kind of categorize what we're seeing, one of them was rule-based mistakes. So misinterpretation of the task. Like if you're doing this activity and you consistently see the patient putting a Tuesday pill in the Monday slots, they're misinterpreting the task. Or going back to that one tablet twice daily, if they're only putting in one tablet or they're, you know, skipping a day or however they're misinterpreting it, but oh, there's an error in how they're processing the rules. The next one was a skill-based slip. And this is errors that happen when you're distracted. And I thought this was so great that they pointed out because it happens all the time with our patients.

[18:13] Their roommate says something to them. You're accidentally engaging them in conversation while they're trying to accomplish your task. The TV is loud. You know, all these are things that can affect how our patients are able to manage their own minutes. And then they talked about how the minicog in general is a good tool for screening severe cognitive impairments, right? Which makes sense that it's, you're recalling a few items and you're drawing a clock. But they weren't really good for teasing between mild and moderate cognitive impairments. Yeah. And I recently had a patient who, at face value, he obviously had cognitive impairments, but he carried on, say, like social interactions really well. Like, hey, how are you? How was your day? What did you do? Level of conversation. So well. And I only had time to the mini cog and his son kind of indicated that he'd been in decline. I was like, oh, that would be a good screen. Could not draw a clock. When I asked him to recall words, just stared at me and I was like, oh, okay. Like I see, I see where we're at now.

[19:26] You drew a spiral and you don't remember that I told you to remember any words. It was just night and day, the perception I had of his cognitive abilities from our conversation to after the mini cog. So great quick screen. I think that's so important too, because I feel like whenever I pick up someone that seems like they're a mild mod cog and they are, you know, fluent at masking, they're just good at having very naturalistic conversations and they have a back and forth and they can talk, tell you their stories from a long time ago. And I'm like, no, no, like there is something wrong. And then people are like, are you sure?

[20:11] Like, yes, yes, I can definitely tell, like, something's going on. Like, this is what's kind of happening. So I think it, the mini, it's a good, like, the mini cog is a good screening tool to show you those severe impairments and kind of do that quickly. But it is nice to. Just think like how many people end up falling through the cracks because they are so good at just that conversational masking and they get through on to the next step of things, going home, doing things independently. Yeah. Nobody did this training because they're like, oh, they're fine. We talk all the time and nobody flagged them for like high risk of not taking any of their meds when they go home. Moving right along, let's talk about clinical practice and how we can use what we read.

[20:59] One, just buy or make a med management kit. Like, they're amazing apps. I know Emily is the queen of the apps. But also try something physical to make sure you are checking that they can read and open the pill bottles.

[21:14] TPT Teachers Pay Teachers has tons of resources. Just, you know, type in med management kit and enjoy like everything that comes up. Yeah. Don't rewrite the wheel. Someone already did it. They have a bunch of pill labels already on there. So you can like purchase them and print them out and put them on, you know, containers. They have easel things. There's a lot of cool stuff on there. People are very creative. They are. And they got time and they're doing stuff. They're doing stuff. Pay them for their time because they did a good job. Yeah. You could also work with them to make medication schedule or calendar as a reference for their pillbox. You can teach the check recheck technique to count for errors. So that's basically you're going through your pillbox, you're filling everything in. Let's say you have, you know, four pills you take in the morning. You're going back after you finished all your pills and checking, okay, four pills for each day to make sure you're looking for errors. And then if you miscount, then you can go through and see which one is out.

[22:17] Yeah, definitely. And then we mentioned this a little bit earlier, but train family and community. Not all of our folks are going to go home fully independent. And that just because they're going home independent doesn't mean that they are 100% capable. A lot of people have community that supports them. So get them in the building, do your caregiver training hours. That is super valid use of clinical time. Yeah. And this isn't really applied to my facility so much, but there is a billable

[22:49] code for caregiver training. This would be a really good opportunity to provide a group caregiver training for medication management for people who are going home. So you could have a Friday meeting or something and invite all the caregivers, all the people, and they can... Invite all the people. Yeah, you can give like a one mini lesson and that's like a very specific billable code. I think it just introduced last year, 2024. I'll have to go look. I don't think I know about that code. But I actually have a patient right now. He is unhoused and he kind of bounces between friends' houses. And one of his friends, she's like in charge of his pharmacy stuff. Like he can pick up his meds. He definitely has that. But in terms of the check recheck ability, it's kind of shot. And every morning she does his meds with him.

[23:42] And he knows that and he knows to go to her for his morning meds. So, you know, on our list is to get her in the building and make sure she understands the change in his medication requirements following heart failure. He actually was an HF patient. If someone can't perform their meds and doesn't have a lot of support in the area, let your DOR know or their doctor, nursing, all the people, that this is a real concern for rehospitalization. Yeah, 100%. I think that when people start hearing, oh, they can't do this or that safely on their own, they're like, oh, my God, are they going to have to stay here indefinitely? No, they are not trapped in the building. It doesn't mean they can't go home. But it may inform what kind of services we need for home health. It may be a piece of input on meetings they're having for considering assisted care. They may have friends and family who are out of state, who are considering putting them in an ALF or something like that. You know, that's a real problem. Factor to be considering when you're wondering what your next stage in life is. Can you take care of your own medical needs?

[24:53] And then, of course, just making sure that their case has an alert for higher re-hospitalization risk due to poor medication adherence. It may not be that that information, quote-unquote, goes anywhere, but making sure that we as their healthcare community are aware that they have

[25:11] this concern is really valid. We should all be making sure we understand our patient's abilities. Yeah. And if like you're doing all of the things with them to train them on their medication and they're just not getting it, they're not remembering, they're not good at the check recheck, even doing extra strategies or telling them about like things that are available. Like some pharmacies preload a medication pill box for you. Some pharmacies or services will put your pills in prepackaged containers and then you just have to remember to take them at certain times. And maybe that's like an alarm on your phone or having Amazon Echo or Google Home or whatever you have to set like an alarm to take those pills, like, or even like a caregiver phone call, like, hey, did you take your pills yet today? Because even if it's all wrapped up nicely and pretty and above, doesn't necessarily mean you'll take it.

[26:13] Yeah. And, Emily, you're just like queen of resources. I had no idea pharmacies did that. That's so great. I'm definitely filing that away. But I did want to, before I forget, I had a hilarious story from this week when I was doing some med management stuff, which is that one of my patients had like set out all the pill bottles. And for the record, this was not my pill containers.

[26:37] And it was like from the last person who'd actually designed this kit. And it had like generic little vitamins in it. And yeah. I did not think about this when I went in the room, but I put them all out. I set everything up and I was like, okay, so you're going to just read the pill bottle, open it and put it in the pill box. And the patient takes it, reads it, opens it, takes a pill out, puts it in his mouth. And I was like, no, oh my God, like take that out. And I'm so ready to like do the whole thing where you just shove your hand in someone's mouth. And he goes, just kidding. I wanted to see what would happen. I was like, don't. Do that, man. Oh my God. Oh, it gave me a heart attack. I was like, I'm going to be the one sent in for heart failure. Don't be like that.

[27:26] Anyways, all that is to say is I'm exploring non-pharmaceutical alternatives because even though vitamin C is pretty harmless. I was like, I cannot be having patients because there will be a patient, mark my word too, if I don't change it out. We'll not comprehend the task and just wrote memorization, open a pill bottle and take a pill. Oh, God. So I got to get ahead of that. No, yes. Okay. Immediately, Eva, buy a box of beads, different shaped beads. My OT was like, here's an alternative. We just cut up crayons. So now we have pink pills and yellow pills that are just cut up crayons until I can find a better alternative.

[28:07] I love that. And I actually hate that for you because I bet I would have actually had a heart attack because that is it was horrible that is all we have for you today on medication management so tell us what you use tell us what you think about that episode use the strategies do they work do they not work do you hate them let us know we like to know things all right have a good one thanks guys.

[28:32] You've been listening to Speech Talk. Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research. If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world, because as podcasters, our love language is in positive affirmations. If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speech talk pod.com. If you want even more speech talk content, check out our website at speech talk pod.com where you can find all of our resources we made for you copies of articles covered and Eva's blog, following these topics and more. We're your hosts, Eva Johnson and Emily Brady. Our editor and engineer is Andrew Sims. Our music is by Omar Benzvi. Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke. To learn about Speech Talk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers. Speech Talk is a proud member of the Human Content Podcast Network.

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