Geriatric Nursing
Volume 28, Issue 2 , Pages 83-89, March 2007

Assisted Living Nursing Practice: Medication Management: Part 1 Assessing the Resident for Self-Medication Ability

Article Outline

Self-administration of medication suggests that individuals are functionally and cognitively competent to manage their health care. Older adults take a significant number of medications (borderline polypharmacy) as well as an unaccounted for number of over-the-counter, as necessary, and herbal remedies. Assisted living residences, moving from a social to a more medical model, are responsible for the safety and well-being of their residents. In addition, the prospect of aging-in-place in the residence is increasingly associated with appropriate medical and medication management. Assisted living services in most states include assistance with medication, but the nature of the assistance varies widely, at times approaching what even a nonclinical observer would regard as medication administration. Although state assisted living regulations can be quite specific regarding medication storage, there are scant guidelines about the components of a thorough assessment as to whether a resident can safely self-administer his or her medications. This article discusses assessment criteria of self-medication ability, drawn from a variety of instruments. In keeping with assisted living nursing standards of practice, the assisted living nurse has a critical responsibility in assessment of this self-care ability.

 

This article is the first of a 2-part series on medication management. Part I focuses on assessment of the resident to self-administer medications. Part II (in the May-June issue) will address competencies and performance evaluation criteria of medication administration by nonlicensed assisted living staff. Both topics are significant with regard to the scope and standards of assisted living (AL) nursing practice (including delegation and supervision of staff), resident rights, and the tension between autonomy and safety needs of residents who are cognitively impaired. There is no “gold standard” instrument or method of resident assessment for self-administration of medications. Hence, the article describes criteria for self-medication ability assessment which better positions the AL nurse to make an informed judgment about a resident’s ability to self-medicate.

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Background Issues in Medication Assessment 

As AL shifts from a social model to one that is more medically oriented—by necessity, given the age and frailty of residents—medication administration assumes a greater presence than heretofore among an array of services. Assistance with medication management is among the most frequent reasons for choosing to live in an AL setting.1 Not simply a therapeutic intervention to manage chronic illness and maintain function, medication management services are increasingly linked to being able to age in place. The depth and range of residents’ knowledge about the medications they take—rationale, precautions, side effects, dose manipulation, storage—is as important in medication self-administration as is the mechanical task of accessing and ingesting the drug.

AL residents take more medications than nursing home residents; one-fourth of AL residents take 9 or more medications.2 In addition, AL residents are prescribed more antidepressants and hypnotics than the average nursing home resident. Given that many older adults are prescribed potentially inappropriate medications (as per the Beers Criteria) the likelihood of adverse drug events is significantly increased for this population.3, 4 Medication safety is further compromised by ingestion of over-the-counter (OTC), as needed (i.e., PRN), and herbal products. The extent of usage is virtually unknown inasmuch as providers (i.e., prescribers) often fail to ask about these self-prescribing and medicating practices. It can be argued (as it has been in nursing homes) that searching and seizing this “stash” of OTC and herbal remedies is an invasion of privacy and resident self-determination. Some states (e.g., Idaho) require review of residents’ use of OTCs with regard to side effects and interactions.5 Studies indicate that residents ingesting 10 or more medications are more than twice as likely to have medication-related problems than residents taking fewer medications.1 In addition, self-medicating older adults commonly manipulate the dose and time they take certain drugs, such as diuretics, in furtherance of their quality of life.6 For example, people might skip a diuretic dose if they are going to be away from home and are not sure where they might find a bathroom; they might double the dose if they are going to eat a salt-loaded food they crave. Given the dangers of polypharmacy, it is a necessary part of nursing practice to assess residents’ understanding of the medications they are taking, their compliance and adherence practices, and their use of OTCs and herbal medicaments.

State Regulations, Autonomy, Safety Needs, and the AL Residence 

Some states require assessment by a health professional (i.e., physician, nurse practitioner, registered nurse, pharmacist) of a resident’s ability to self-administer medications. In some states (e.g., Colorado), a physician must document that the resident is able to self-administer his or her medications.7 This does not preclude “assisting” the resident with medication administration, however. Therein lies the dilemma: there are at least 17 regulatory definitions of assistance, including retrieving the drug, opening the container, verifying that the correct pill is being taken, and placing the medication in the resident’s mouth.8 Self-medication ability, in some states, is not an issue of functional ability but, rather, of “awareness,” being in control and directing the medication assistance, understanding the drug instructions (including the unit-dose packaging), and safe storage. These seemingly hairsplitting definitions and variances can mean the difference in whether a resident will be permitted to self-administer; such issues need to be considered in developing an instrument or test to assess capability. Another example is instructive. In some states (e.g., Alabama), unlicensed staff are not permitted to assist with self-administration of injections of any kind or with nose, ear, or eye drops; inhalers; suppositories; or enemas unless the resident has limited mobility or dexterity that interferes with self-administration of these drugs, in which case, unlicensed staff may assist, but the resident remains in control and directs the process.9 These between-state variations speak to the need to have an assessment tool that reflects local conditions. It is pointless to look for a self-administration ability or function that is not permitted by regulation. If awareness is a key criterion of self-medication ability, then behavioral descriptors and measures of awareness must be part of the assessment tool.

Risk is defined, in some states, as an “insecure location” such that access to medications by cognitively impaired residents can occur. In some states, the facility must document whether the resident or the facility will be responsible for drug storage. Failure to identify a resident at risk of harm from an unsecured drug location can incur a deficiency citation (e.g., Arizona).10 Prefilled medication boxes are permitted in most states, some of which require evaluation of a resident’s ability to recognize the drug label and accurately remove the drug.11 Medication reminding in some states includes handing the appropriate prefilled medication reminder box to the resident and opening the box if the resident is unable to do so. However, some states prohibit staff from taking the drug itself out of the box. Other states permit this if the resident is aware of the reason for the particular medication. Nebraska construes self-medication ability as having the “cognitive capacity to make an informed decision about taking the medication” and the ability to recognize and take appropriate action regarding desired as well as side effects, interactions, and contraindications.12 This level of detail can be built into an assessment instrument that contains generic questions about medication use and effect but is modified for the particular resident’s medication regimen.

Self-administration of PRN medications can be subject to complex regulations and directions. In California, for example, the physician must state in writing that the resident is able to determine and communicate the need for a prescription or nonprescription PRN medication.13 Unlicensed staff may assist this resident with self-administration of the PRN medication. Assistance with self-administration is also available to the resident who, although unable to determine the need for a PRN medication, can communicate his or her symptoms. However, in those cases in which the resident is unable to determine or communicate need for a PRN medication but the need exists in staff members’ judgment, the physician must be contacted before the PRN drug can be administered. Even in the absence of a specific state regulation regarding assistance with PRN medications, inclusion of only 2 items in an assessment tool regarding a resident’s ability to describe his or her need for a PRN medication and to know what and how much to take can be a critical element in medication self-administration safety and avoidance of an adverse drug event.

The continuum of self-administration ranges from complete independence—no reminders or assistance—to reminders with or without physical assistance. Under the rubric of informed consent, some states (e.g., Florida) must advise the resident and/or responsible party that the AL residence is not required to have a licensed nurse on staff and that the resident may be receiving assistance with self-administration from unlicensed assistive staff.14 Given the varied definitions of assistance and the lack of a standardized measure of capacity to self-administer, estimates that 50%–75%15 to as many as 86% of AL residents16 need assistance with medication management is hardly surprising. (In dementia care AL facilities, 99% of residents need assistance with medication administration.16) Because of the potential for facility liability if a resident self-administers and suffers injury or death, a resident assessed as unable to self-administer medications is at risk for discharge (in 4 states11) or for added personal costs to pay for staff assistance with medication administration. Twenty-seven states require, as of 2006, some kind of medication regimen review1 but not necessarily a focused assessment of capacity to self-medicate.

The Assisted Living Workgroup (ALW), convened in Washington, DC, in 2001 by the Senate Special Committee on Aging, was a coalition of approximately 50 national organizations representing a broad spectrum of AL stakeholders. Among 6 topics groups formed to discuss and develop recommendations and guidelines for assisted living, the Medication Management workgroup consisted of experienced clinicians. Over 18 months, this workgroup created and ultimately presented 22 recommendations to the full ALW, not all of which were agreed to by all workgroup members. For example, some members emphasized facility responsibility for a safe environment, whereas other members advocated for resident rights and choices, even if the choice had elements of risk. Although there was consensus that residents had the right to control their lives, there was acceptance of the fact that the complex medication regimens of many older adults might exceed their ability to safely manage their drugs. All members agreed that residents should be assessed by a qualified health professional for capacity to safely self-administer medications but no assessment criteria were elucidated nor was any instrument or method endorsed.

The moral distress expressed by AL nurses responsible for self-medication assessment speaks to the ethical principles of truth telling, beneficence (to do good), and nonmaleficence (to prevent harm or distress). The nurse is required by nursing’s professional code of ethics to communicate that the assessment indicated that the resident is unsafe to self-administer or that staff assisting with the medications are inadequately trained or supervised to do so. However, the nurse might feel equally compelled to prevent financial harm that is likely associated with an added service fee for medication assistance or emotional harm if the resident can no longer remain in the facility because medication assistance is not available. There is no easy answer to this dilemma. In some instances, it might be possible for the resident to retain some aspects of self-administration, perhaps by using a high-tech medication reminder system, such as the Medication Event Monitoring System, which electronically tracks and records when a medication container is opened.

Resident Characteristics 

Two additional factors impinge on assessment of self-medication ability: health literacy and task experience. Studies indicate that almost half of all American adults find it difficult to read medication labels and understand the instructions17; more than 65% of these individuals are aged 65 and older. Among the oldest-old (over age 85), even if visual acuity is adequate, cognitive changes and glare and contrast factors in print material are associated with reduced functional health literacy. Residents with lower education levels and reduced literacy are at risk for self-medication safety. Given the growing cultural diversity of the United States, assessment criteria must address ability to read medication instructions on the label and on the drug information pamphlet that comes with the medication. There is nothing in regulation that prohibits a medication label and instructions being printed in a language other than English. Therefore, the fact that an AL resident is unable to read or decipher medication instructions written in English is not a legitimate criterion to prohibit self-administration of medications until and unless it is demonstrated that the older adult is not literate in his or her native language.

Medication administration is a task; one does it for oneself or one person does it for another. It can be argued that medication management is not an “instrumental” activity of daily living, but rather an essential activity of daily living. A task can be obligatory or discretionary. Things that have to be attended to, such as cooking, cleaning, or writing checks, are obligatory; things that are done because they advance a person’s interests are discretionary. A person’s medication requirements straddle both domains. With couples, some obligatory tasks are assumed by 1 party and some by the other. It can be argued that a lifetime of having certain things attended to by the other party will leave an individual somewhat inexperienced and unskilled in a specific task performance, such as cooking or medication management. Having little experience with aspects of the medication task (e.g., drug retrieval, ensuring an adequate supply, safe storage) could appear on an AL resident’s assessment as lack of ability to self-administer. Yet in this person’s lifetime, there has been no need to learn the skills of medication administration. Nevertheless, lacking this demonstrable ability places the resident at risk of being denied the right to self-administer his or her medications. The issue is not cognitive or functional; it is experiential and needs to be addressed on the assessment in the context of history taking.

Nursing Competencies Associated With Self-Medication Assessment 

The AL nurse conducting an assessment of a resident’s ability to safely self-administer medications recognizes that sensation and perception in older adults is mediated by functional, physical, cognitive, psychological, and social changes. Not only is there a high degree of possibility of altered presentation of illness in the older adult, this is just as likely with regard to altered presentation of an adverse drug event.

Managing one’s medication speaks to personal competence. Rendering control of one’s medication management to another person (like giving up a driver’s license) can be emotionally upsetting. The skill needed here is to help the resident (and family) understand the delicate balance between the resident’s need to be a self-determining adult and concern for his or her safety.

The Scope of Practice of AL nursing (available at www.alnursing.org) addresses medication management and specifically includes assessing self-administration ability as well as storage and administration issues. Accountability for practice notes that “best interest” for a resident is “prevention of complications … and highest possible function.” One of the principles of AL nursing speaks to “collaborating with the older adult in planning, guiding and managing their care” and “promoting and assisting the older adult to maintain … maximum … functioning.” Assessment of the resident’s ability to safely self-administer his or her medications has to look for ways to make “managing” and “promoting” happen, while guiding and assisting. Holistic assessment of medication self-administration and sensitive counseling are hallmarks of AL nursing.

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Assessment Criteria for Self-Administration of Medication 

This section describes several assessment instruments. No particular instrument is endorsed. Research is clearly needed. The AL nurse should select assessment criteria (i.e., items) that are relevant to the resident population in the AL residence (i.e., “community”) and are in keeping with state regulations to create a useful resident-specific assessment instrument. Data should be aggregated and analyzed so that a profile of medication management activities in the residence can be described. These data will be useful in identifying needs regarding resident and staff education and resources for safe medication management.

Cognitive impairment in combination with medication regimen complexity are predictors of medication management capacity and safety.18 The Mini-Mental Status Examination can be used to exclude residents with scores below 23 from self-administration of medications. However, there are no published studies that predict safety of medication management among individuals with MMSE scores in the “normal/no cognitive deficit” range (i.e., 23-30).

Items in the Medication Self-Administration Assessment Form suggested by the American Society of Consultant Pharmacists assess a resident’s ability to read out loud the instructions on the medication container; state what each drug is for, its common side effects, and the correct time and dose (i.e., number of tablets); open and remove the correct amount of medication from the container; place the container in a secure place; and document self-administration. This instrument was interesting in that it also addressed administration of PRN medications, that is, residents’ awareness of indications or need for a PRN medication and documentation of its self-administration. Other items in this tool assessed correct demonstration of self-administration of drops, patches, inhalants, suppositories, inhalants, and subcutaneous drugs.

The Medication Self Administration Test (authors unknown) asks the resident to perform several acts—for example, identify the smallest pill or a particular color of pill; remove a medication from a box labeled “Monday night” or “Thursday evening.” A resident unable to follow instructions to remove or select a particular pill is likely assessed as unable to self-administer medications. The Medication Management Test (MMT) has significant methodological rigor and statistical analysis.19 The MMT requires recalling the number of pills in a medication bottle, removing a specific number of pills, calculating how long the pill supply will last on a given regimen, working out the schedule for taking pills over a 2-week period, identifying the pill container, and removal and replacement of pills from the key medication container. The MMT does not test medication knowledge.

Another medication management assessment method asks the resident about each drug that he or she is taking.20 The resident must identify the prescribed medication, state the dosage and when the medication is taken, state the reason for the medication, and explain how it is stored. As part of an overall approach to medication management and wellness care, “trigger questions” are addressed to the caregiver or the resident with regard to significant weight loss, skin breakdown, onset of incontinence, vertigo or loss of balance, extreme sedation, recent medication-related problems, and recent changes in mental status or behavior. Additional probes ask about depression, pain, sleep disturbances, vision changes, and alterations in mobility or range of motion. The intent of this instrument is to identify the resident’s ability to detect and report changes that might be associated with the medications that the resident is taking. If staff members are noticing changes that the resident does not, this might be an indicator that the resident is less or no longer able to self-administer safely his or her medications.

The Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) is a screening instrument that examines 3 areas associated with medication management: 1) knowledge (about the medication being taken), 2) administration (how to take the drug), 3) procurement (how to get the drug from a physician or pharmacy).21 Assessment is via resident interview and observation. Eight knowledge items include reason for the drug, its dosage, time-of-day instructions, and side effects. Administration items are observations of the resident’s physical ability to manipulate the medication container and ingest the medication. Procurement items focus on the resident’s knowledge and understanding of how to get a refill and being able to check that the correct medication was refilled. The MedMaIDE can be completed in 30 minutes. It reportedly has good reliability, validity, consistency, and sensitivity in identifying deficiencies in medication management.

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Conclusion 

In constructing a resident assessment tool, additional items may be needed with regard to negotiating Medicare Plan D options, particularly after hospitalization when a resident’s medications might have been changed or dosages adjusted. Given that many AL corporations have their own assessment instrument, the tools mentioned in this article might be a source of additional criteria or adjunctive assessment.

When assessing the resident’s ability to self-manage medications, there is no ignoring the clinical mandate that formal assessment is necessary. Often, residents are unaware of their deficits in relation to timing, pouring/retrieving, and self-administering their own medications. It is not uncommon for family members to discourage the AL community from assisting with medications because, unaware of the potential negative consequences of unsafe medication self-administration, they feel the (likely) additional cost is unnecessary. This decision might be a reflection of denial of their loved one’s cognitive decline. A formal tool makes the decision for medication assistance less subjective and less likely to be a source of dispute and contention between the AL community and family. Sitting together to view the results of an assessment arrived at by use of a valid tool can help the family and resident accept the necessity of assistance and oversight.

A new or significantly revised assessment instrument must meet the standards of validity and reliability. Validity means that the tool actually measures what it purports to measure, that is, self-medication capability. Reliability means that the same score is elicited by 2 examiners administering the instrument at the same time (i.e., interrater reliability) or that the same score is elicited when the test is administered to the resident a second time within a short time period (i.e., test-retest reliability). These 2 statistical measures require rigorous design, methods, and analysis—not impossible to achieve but requiring special skills. It bears noting that many schools and colleges of nursing seek AL communities as clinical campus sites for undergraduate and graduate student nurses. Nursing faculty prepared in gerontological nursing may be interested in developing and testing assessment protocols. Sharing best practices related to medication management among AL nurses helps remain abreast of changes and solutions within the AL industry. Local, state, and national meetings of provider organizations, such as the National Center for Assisted Living (ncal.org), the Assisted Living Federation of America (alfa.org), and the AL nursing specialty organization the American Assisted Living Nurses Association (alnursing.org) are venues for collaboration on instruments to better assess resident needs. Research dissemination, for example, on the validity and reliability of a medication self-administration tool, is supported by these organizations, and speaks directly to dissemination of evidence-based practice for nursing.

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Resources 

John A. Hartford Institute for Geriatric Nursing. Try This series. Beers criteria for potentially inappropriate medication usage in the elderly. Issue No. 16. Available at www.hartfordign.org.

Assisted Living Workgroup: full report. Available at: www.theceal.org.

American Society of Consultant Pharmacists. Available at: www.ascp.com

MedMaIDE. contact D. Orwig (dorwig@epi.umaryland.edu) or N. Brandt (nbrandt@rx.umaryland.edu).

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References 

  1. Wizwer P, Simonson W. Complex medication regimens call for help with medication management. Assisted Living Consult. 2006;26–30Nov/Dec
  2. McAllister D, Schommer JC, McAuley JW, et al. Comparison of skilled nursing and assisted living residents to determine potential benefits of pharmacist interventions. Consult Pharm. 2000;15:1110–1116
  3. Beers MH. Explicit criteria for determining potentially inappropriate medication usage by the elderly. Arch Int Med. 1997;157:1531–1536
  4. Fick M, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Int Med. 2003;163:2716–2724
  5. Idaho Administrative Code. IDAPA 16.03.22. Medication Standards and Requirements 428. Nursing Services 430.07.
  6. Glassman K. Older person’s experience of managing medication: the myth of compliance. 2006;Unpublished doctoral dissertation, College of Nursing, New York University
  7. Colorado Standards for Hospitals and Health Facilities. 6 CCR 1011-1. Chapter VII: Assisted living residences. Administration of medications and treatments 1.107(5)(c)(ii).
  8. Mitty E, Clark T. Assisted living: safety vs. autonomy. In:  Kapp Marshall B editors. Ethics, law, and aging review. Vol. 9:New York: Springer Publishing Co; 2003;p. 61–76
  9. Alabama Department of Public Health. Chapter 420-5-4. Assisted living facilities. Care of residents 420-5-4-.06. Medications (4).
  10. Arizona Administrative Code. Title 9. Chapter 10. Article 7: Assisted living facilities. 702.1.2.2.c.
  11. American Society of Consultant Pharmacists. Consultant pharmacist requirements for assisted living facilities. Alexandria VA: Author; 2006;
  12. Nebraska. Title 175 Health care facilities and Service Licensure. Chapter 4. Assisted-Living Facilities. 4-006.09A. Self-administration of medications.
  13. California. Residential Care Facilities for the Elderly. Article 6. 87575. Incidental medical and dental care. 7(b)(c).
  14. Florida. Nursing homes and related health care facilities. Part III. Assisted living facilities. Assistance with self-administration of medication. 400.4256 (1)(a).
  15. Hawes C, Phillips CD, Rose M. High service or high privacy. Assisted living facilities, their residents and staff: results from a national survey. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services 2000; 2001;Available at http://aspe.hhs.gov/daltcp/reports/hshp.html. Cited Nov. 5
  16. National Center for Assisted Living. Overview of assisted living. Washington DC: Author; 2006;
  17. Davis TC, Michielutte R, Askov EN. Practical assessment of adult literacy in health care. Health Edu Behav. 1998;25:613–624
  18. Maddigan SL, Farris KB, Keating N, et al. Predictors of older adults’ capacity for medication management in a self-medication program. J Aging Health. 2003;15:332–352
  19. Gurland BJ, Cross P, Chen J, et al. A new performance test of adaptive cognitive functioning: The Medication Management (MM) Test. Int J Geriatr Psychiatry. 1994;9:875–885
  20. Meade V. A new comprehensive model for assisted living medication management and wellness care. Consult Pharm. 2001;16:9–18
  21. Brandt N, Orwig D, Spellbring AM. Evaluation of the MedMaIDE to assess medication management deficiencies in the elderly living in the community. 2002;Poster presented at the Annual Meeting of the American Society of Consultant Pharmacists, November

ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, John A. Hartford Institute for Geriatric Nursing, New York University; SANDI FLORES, RN, C, is executive director, American Assisted Living Nurses Association, and education director of Community Education LLC (www.communityed.com).

PII: S0197-4572(07)00036-5

doi:10.1016/j.gerinurse.2007.01.008

Geriatric Nursing
Volume 28, Issue 2 , Pages 83-89, March 2007

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