Home alone and high risk: Supporting medication management in older adults living alone with cognitive impairment

Abstract

Older adults living with cognitive impairment are at increased risk of medication nonadherence and administration errors, which can result in an increased risk of hospitalization and death.¹ Currently, one quarter of older adults living with cognitive impairment reside at home alone.² These individuals are mostly women who often have no support or oversight for medication management, placing them at risk for adverse drug events. In this issue of the Journal of the American Geriatrics Society, Growdon et al.³ describe and compare high-risk medication use among older adults living with cognitive impairment who were either residing with others or living alone.³

The cross-sectional study used data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal cohort of Medicare beneficiaries, aged 65 years and older.⁴ Individuals were included if they had cognitive impairment identified by a validated algorithm, were aged 66 years or older, enrolled in Medicare part D for a year or more, had at least one prescription claim in the last 6 months, and resided in a community setting. Individuals self-reported whether they lived alone, if they received support with medication administration, and if they had any difficulty with medication use. The primary outcome was being on one or more high-risk medication, defined as (1) highly sedating and/or anticholinergic medications or medications on the 2023 American Geriatrics Society Beers Criteria,⁵ (2) anticoagulants, (3) sulfonylureas, (4) insulin, and/or (5) opioid medications.

Among 1569 older adults living with cognitive impairment, about a third resided alone. Individuals living alone were more likely to be older, be female, have a diagnosis of mild cognitive impairment as compared with dementia, and have fewer comorbidities. Seventy-nine percent of those living alone did not receive any help with medication administration, whereas 54% of those living with others received help. Eighteen percent of those living alone required total support with medications, and 14% had some difficulty with medication administration. The median number of prescribed medications was similar among those living alone versus with others. Forty-six percent of those living alone were on at least one high-risk medication, compared with 52% of those living with others (p = 0.06, unadjusted analyses). As such, although living alone was not associated with an increased risk of being prescribed one or more high-risk medication, living alone was associated with being prescribed one or more high-risk medication and not receiving help with medication management (34% of those living alone vs. 23% of those living with others, p = 0.003).

Limitations of the study included the inability to evaluate the use of over-the-counter medications and cognitive impairment severity. The study was further limited by the fact that the exposure (living alone) and important covariates (support with medication administration and difficulty with medication use) were self-reported, which may be prone to misclassification given that all study participants lived with cognitive impairment.

This study does highlight that one third of older adults who are living alone and with cognitive impairment are being prescribed high-risk medications with limited oversight for medication administration. Individuals who live alone are at an increased risk of social isolation.⁶ As such, the study further reconfirms that social isolation disproportionately affects older women, as they are both more likely to live alone and live with cognitive impairment.⁷ This study also expands on the known associations between social isolation and loneliness with polypharmacy and challenges with medication adherence.^8-11 As such, older adults who are living alone should be considered high-risk groups for adverse drug events and should be prioritized for support with medication administration.

Older adults who are living alone with cognitive impairment can be a challenge for health and social service providers.¹² These challenges may include the lack of an advocate to implement recommendations (e.g., medication administration, safety precautions), difficulty arranging appointments and supports, and limited healthcare resources to prevent health crises (e.g. falls and medication errors). Previous studies have examined different interventions to improve medication adherence and administration among all older adults.^{13, 14} These include regimen simplification and deprescribing, pill dispenser reminder devices and/or messages, telehealth home monitoring, and home-based pharmacist counseling.^14-16 Studies that were focused on individuals with cognitive impairment have shown some benefit for medication delivery units,¹⁷ telehealth monitoring,¹⁵ and reminder devices.¹⁸ Clinicians should carefully select individuals who are most likely to benefit from such assistive technologies. This includes assessing manual dexterity, the severity of cognitive impairment and the cognitive domains affected, and the presence of visual impairment.¹⁹ Innovative interventions and technologies should be further studied as a potential method to improve medication adherence in this population, including those with cognitive and sensory impairment as well as functional limitations.

This research has three important applications. First, when an older adult living with cognitive impairment is seen for a routine visit, inquire about their living situation and recognize that living alone may be a risk factor for limited oversight of medication administration. Use the clinical encounter as an opportunity for a medication review, and in appropriate cases, consider deprescribing high-risk medications. Second, if an older adult is on an optimal medication regimen which includes high-risk medications, clinicians could consider providing medication support or even suggest assistive technologies, recognizing their limitations.²⁰ Clinicians should also consider involving their local community home health agencies to support medication administration and monitoring. Third, when older individuals living with cognitive impairment present to the emergency department, clinicians should consider whether living alone has contributed to adverse drug events.

Overall, the study by Growdon et al.³ highlights that living alone is an important determinant of health for older adults living with cognitive impairment. Future research should not only characterize at-risk individuals, but also include adverse drug events and related clinical outcomes. With the majority of older adults, including those living with cognitive impairment, preferring to age in place, it is imperative that clinicians and health systems recognize the risks associated with social isolation, and prioritize interventions and policies to better support this at-risk population.²¹

Study concept: Paula A. Rochon. Drafting of the manuscript: Peter M. Hoang. Critical revision of the manuscript for important intellectual content: Nathan M. Stall and Paula A. Rochon.

Dr. Paula Rochon is the Deputy Editor for the Journal. The authors declare no other financial or personal conflicts of interest.

No specific funding was received for this work.