Ida Canapp insists she would take her five medications and two vitamin pills every day, whether or not a nurse's aide came to her Parkville home to monitor her.
But her niece, Renee Gowland of Monkton, knows this is the dementia talking. "She wouldn't take them. Or she wouldn't know if she was taking the a.m. or the p.m. [doses]."
At 82, Canapp is energetic, hospitable and fiercely independent - with the help of Aricept, a drug that tempers the effects of mild to moderate Alzheimer's disease. But Canapp, who also has diabetes, high cholesterol and high blood pressure, and who takes a daily antidepressant, is like many older people with chronic health problems: She has difficulty keeping up with her many medications.
Medication mismanagement among seniors is a growing problem in the United States. Some experts estimate that half of all seniors mismanage one or more of their medications, and seniors are twice as likely to end up in emergency rooms because of drug safety issues.
As the baby boom generation ages - and older Americans take more medications to deal with chronic illnesses - medical professionals have become increasingly concerned about the issue.
"Not only is it getting worse, it has become one of the major sources of hospitalizations in the country and one of the greatest preventable causes of illnesses - and costs associated with illnesses - in this country," said George Lowe, director of medical services at the Overlea Physicians medical clinic in Northeast Baltimore. About 60 percent of his patients are seniors.
Not all seniors have memory problems as severe as Canapp's. But many have trouble keeping up with prescriptions because they can't see as well as they used to. Or they're confused by taking so many prescriptions, or from following different doctors' various treatment plans, or by multiple instructions on the pill bottles: Take this medicine with food. Take that one on an empty stomach. Take this one three times a day. Take that one twice.
Consequently, many seniors don't take enough medicine or take too much, experts said. Sometimes they skip doses, or stop taking a medication altogether because they just can't figure out when or how to take it. Doctors call this "noncompliance," and say it can lead to additional or more severe health problems in seniors, a loss of independence, sometimes even death.
"It's an ongoing concern," said Todd Semla, president of the American Geriatrics Society. "There are estimates that 50 percent of older people are noncompliant with one or more of their medications."
Medical experts say there are noncompliance problems in all age groups. But seniors seem to suffer from the problem more than others.
"What we have found is that older adults are at a greater risk for having problems," said Dr. Daniel Budnitz of the Centers for Disease Control and Prevention. "They are about twice as likely to end up in emergency rooms with drug safety problems than younger folks. And once they're [in the hospital], they're more likely to have to stay there."
Some problems have to do with the fact that older bodies don't process medications the same way as young ones, experts say.
"As we get older, there are changes in how drugs are metabolized and how drugs are distributed in the body and how we react to those medications," said Ilene Zuckerman, a professor in the pharmaceutical health services research department at the University of Maryland School of Pharmacy. "And older people use more medication; older people have more diseases. So we know that older people do have more adverse drug events."
People over age 65 represent about 13 percent of the population, experts said, but they consume about one-third of all the medication prescribed in the United States. As the elderly population grows - 25 percent will be 65 or older by the year 2040, experts say - so does their medication consumption: In about 30 years, seniors will be taking half of the nation's prescribed medication.
At the same time, according to a 2006 analysis by Medco Health Solutions Inc., a New Jersey-based pharmacy benefits manager company, patients over age 65 have a drug error rate about seven times greater than that of patients younger than 65.
The analysis also reported that one in four seniors received prescriptions from five or more doctors, while one in 20 received prescriptions from eight or more.
"Many of these drugs do have to be given more than once a day," said Christopher Kearney, director of the geriatric care unit at Union Memorial Hospital. "Or they're drugs that can't be given together or that can't be given on an empty stomach or can't be given on a full stomach. It's pretty complex."
Older patients who mismanage their medications many times end up in the hospital because they feel sick or dehydrated, or they become dizzy and fall.
Once a senior is in the hospital, Kearney said, physicians there sometimes change the patient's prescription plan - making medication management even more befuddling.
"Patients are in and out of the hospital setting, and every time they're in, their medications are revised, things are dropped, things are added. Prescriptions are substituted even in the outpatient setting," Kearney said. "So patients are pretty constantly having their drug lists altered. Even if they are equivalent drugs [that are being substituted], it's still very confusing."
As one solution, many doctors have begun asking patients to bring all their prescriptions and over-the-counter drugs, vitamins and herbal supplements to every office visit - a method they call "brown-bagging."
But this method puts too much responsibility on the patient, some experts say.
"It seems rather primitive in the 21st century that you have to have patients bring in their pill bottles in a brown paper bag," said Lowe. "I think the onus has to be on the physicians who are prescribing the medications to make sure that the medications they are prescribing will not and do not interact with what the patient is already taking."
To that end, Lowe said, there has been a push for doctors to move to electronic medical records, which follow a patient from specialist to specialist.
"The government is pushing us very hard, and rightly so, to go to the electronic medical record," said Lowe, whose offices moved to such a practice two years ago and who says he has seen "immense" improvements.
"It has the great potential to reduce this prescribing in a vacuum."
Health concerns are the most obvious ramification of mismanaging medications. But incorrectly taking prescription drugs also can lead to a senior's loss of independence.
"About 23 percent of nursing home admissions is due to mismanagement of medications," said Joan Chang, medical director at Good Samaritan Nursing Center. "What we're seeing is that because people don't have that social support, they don't have the means or ways of getting their medication taken appropriately, so they have to go to some kind of assisted living, where someone is there to help."
Without assistance from a Towson-based elder care group called Senior Helpers, Ida Canapp would most likely be forced to give up her home, where she has lived for more than 50 years, and be admitted to an assisted-living center or nursing home, Gowland, her niece, said.
About a month ago, Gowland signed her aunt up for Senior Helpers' MedServ program - which provides a registered nurse to manage medications for seniors who can't do it for themselves.
Susan Oberley, a MedServ nurse, fills marked pill boxes every two weeks with Canapp's morning and evening medications. She monitors the prescriptions and communicates with Canapp's pharmacy and physicians. An aide comes daily to fix meals and run errands with Canapp, and she reminds the elderly woman after breakfast and dinner to take her pills.
"I watch her to make sure she takes it," said Rose Davis, the aide.
With so many people checking on her well-being, Canapp said, "I feel like a movie star."
Save the dementia, Canapp is in relatively good health for her age, Gowland said. While living briefly with Gowland, her aunt yearned to be at her own house, where she could work in her yard, a favorite pastime.
"This helps her because she can stay here, she can go where she wants to go, she can do what she wants to do," Gowland said.
And it also has been good for Gowland.
"It's peace of mind," she said, "because I know she's getting everything she needs. She couldn't be on her own without it."
By the numbers
25 Percentage of seniors who receive prescriptions from five or more doctors
50 Approximate percentage of older Americans who improperly manage medication
23 Percentage of nursing home admissions due to patients failing to take prescription medications properly
2 Approximate factor by which people age 65 and older were more likely to require an emergency room visit because of an adverse drug incident
[Sources: American Geriatrics Society, Good Samaritan Nursing Center, Journal of the American Medical Association, Medco Health Solutions]