For Clinicians | Emergency Preparedness in Older Adults

For Clinicians | Emergency Preparedness in Older Adults

The Three Parts That Are Yours

By Dr. Jamie Wilkey, PharmD — Director of Clinical Strategy, Jase
Medically reviewed and edited by Kristen Carpenter, PA-C

Most of your patients over 55 are doing well. Pickleball four mornings a week, a cruise booked for October, a flight out to see the grandkids.

Then something changes the math. A first prescription for blood pressure or thyroid or a statin. A fall that took a lot longer to come back from than it would have at 40. A hospitalization nobody saw coming. Nothing catastrophic, but important enough to stay with them, and afterward a question shows up that never occurred to them at 30: what would I do if I couldn’t get to care?

At 30 nobody asks that. You take nothing, and you have never once considered slipping on your own front steps. By 60 it’s a pertinent question that is top of mind and being discussed at games on the court, on the deck of the ship, and with a whole peer group running the same arithmetic. “What if I can’t get this medication anymore? What if I get hurt again and am far from care?”

So they prepare, off the same checklist a 30-year-old would use. She isn’t going to bring that medical preparation to you as her clinician or pharmacist. Three parts of this prep are yours anyway: how long a fill she can get on the prescriptions she already takes, whether the medication reference list in her bag is sufficient, and what she decides to keep on hand for the illnesses that haven’t happened yet.

We’re a team of physicians, PAs, and pharmacists, and we field this question constantly from patients in exactly that age band. Today we’re covering what makes appropriate medical preparation different for this age group than for any other.

Your patients are already preparing, and it’s happening without us

This is not behavior we need to talk anyone into. In a 2019 national poll of adults 50 to 80, 82% said they had a week’s supply of their medications on hand, and 72% had a week of other health supplies.¹ Three-quarters had lived through at least one major emergency in their lifetime. Fewer than a third had actually assembled an emergency kit, and among the patients who depend on electrically powered medical equipment, only one in four had backup power.

So the intent is close to universal and the execution is uneven. The medication half is the part they’ve done best, which makes sense, because it’s the part they already think about every morning.

Then there’s the number that should get our attention. Only 40% had discussed their emergency plans with their own family. If six in ten haven’t raised it with the people they live with, the odds they raised it at their annual visit are worse. The planning is happening, the supplies are being bought, the medication list is being written, and no clinician or pharmacist has looked at any of it.

What makes their preparation different is that it’s mostly a medication problem

For most people under 40, preparation is a supply question. Water, food, a flashlight, a first aid kit, plus some way to hear what’s happening. Medication appears on those checklists, but it isn’t what they’re built around, and for a healthy 30-year-old that doesn’t take any chronic meds it is the right call.

It stops being the right call somewhere in the late fifties. Polypharmacy in adults 65 and older climbed from 23.6% in 1999 to 2000 up to 43.0% by 2017 through March 2020, and the average number of prescriptions per person went from 3.0 to 4.3.² In twenty years, taking five or more prescription medications went from about a quarter of this population to nearly half of it.

So her grandson’s version of this and her’s are not the same exercise. His is bandages, ibuprofen, and a flashlight. Hers is four or five prescriptions she can’t skip for a week, plus everything on his list.

And her four or five medications she does take are not equal, which is the part she may not be able to differentiate on her own. A week without a statin is a non-event. Levothyroxine has enough half-life to forgive a few missed days. A beta blocker stopped abruptly is much more time-sensitive. So are anticoagulants, antiepileptics, and insulin. It’s easy to treat all of them as one undifferentiated pile labeled ‘my medications.’ Sorting that pile into what tolerates a gap and what doesn’t only take 2 minutes and helps flag what is most important to have enough of hand on to prevent a disruption in care.

Part one: how long a fill she can get

Let’s take the easiest of the three first. When a patient asks whether she can get more of a medication she already takes, that’s a dispensing-interval question. Same drug, same dose, same indication, same prescriber. Only the interval changes, and nothing about her pharmacologic exposure does. That is, speaking for general chronic medications. This isn’t the same for controlled substances or acute cases like antibiotics.

So write it long. For a patient who’s worried, you can write a year of refills on a chronic medication up front and let her decide how much to have on hand at any one time. She can pick up a month, or three, or the whole year if her plan allows it. Some plans will cover a full year at once for travel, which is worth asking about rather than assuming.

If you do nothing else with this article, default your chronic prescriptions to 90 days. Your patients end up with a real amount on hand without anyone having to plan for it, and they stop driving to the pharmacy and standing in line twelve times a year for a medication that hasn’t changed in a decade.

Part two: the list in her bag

The AGS tip sheet says to carry a written medication list that contains all brand and generic names and doses a patient takes regularly.³ That’s the right instruction, and it’s the one she’s most likely to have done badly, because most people don’t have this written down and just cite it from memory. What comes out is “the little white one for blood pressure” and a dose she’s half sure about. And to make matters more complicated many patients pharmacy shop for the best price on medications so the Rx are spread across pharmacy chains and multiple prescribers with no central EMR hub all healthcare professionals can access.

A clearly printed, and accurately updated med list is usable by a pharmacist who has never met her. Drug, strength, and directions for each item, and the condition each one treats. Indication is important to remember and not leave off either. Add her allergies, adverse reactions to previous medications, and your office phone number while you’re at it.

This simple list costs almost nothing. Your MA can print the med list at check-out in a minute. Just make sure to add the medications prescribed by other HCPs she sees. Better than that, have her ask her pharmacy(ies) for a printed profile, because the dispensing record shows what she has actually been filling and when, which is often closer to the truth than what’s in the chart. Reconciling those two against each other is the whole exercise that is most helpful. If they disagree, you and she have learned something worth knowing whether or not a disaster ever shows up.

Part three: what she keeps on hand for what hasn’t happened yet

This is the part that earns the skepticism, and it’s also the part where the answer moves with the decade. A healthy 58-year-old on one antihypertensive is not a Beers patient⁴. A 78-year-old on four medications, with a creatinine clearance you’d want in front of you first, is a different conversation. The difference isn’t age by itself. It’s the list she’s already on.

A single new drug isn’t generally a big deal.  It’s when another is added to a polypharmacy list that there’s more for it to bump into for drug-drug interactions and drug-condition interactions. And the kidneys are slower, so the same dose hits harder. The 2023 Beers criteria are still current as of this summer if you want the reference.

And, since we are talking about appropriate medical preparation, if she’s in a situation where she can’t reach a healthcare professional she’s the one who decides whether to take it with nobody to ask. The bottle won’t tell her when not to. You will, ahead of time, while she’s feeling fine. Anything she keeps on hand is for an emergency, after she’s tried to reach a provider, and she only knows that because somebody told her. That’s the argument for having the conversation about how to prep well instead of saying no and sending her to figure it out herself with the internet chat rooms as guide.

The drug-by-drug version of what medications are appropriate for seniors in emergency kits is its own article and we’re writing it: what to look for in medical preparation after 70, and which contents actually matter at that age. 

The missing middle layer

Here’s the structural problem underneath all three parts. Care in this country is all or none. Either she reaches a clinician and gets a prescription, or she’s on her own with whatever happens to be in the house. Nothing sanctioned sits in between, which is how a reasonable 64-year-old asking a reasonable question ends up choosing between a no from her prescriber and whatever she finds on her own.

Appropriate medical preparation is the name for that middle layer. One bounded step, taken ahead of time, by a clinician, for the disruptions that actually happen to people her age: the week she can’t get to the pharmacy, the storm, the trip that puts her four hours from a clinic. Or international travel.

It isn’t a replacement for the clinician or the pharmacist she already has. It doesn’t manage her chronic conditions, it doesn’t follow her labs, and it makes no decision at the point of use. It’s what’s on the shelf for the times you aren’t reachable, used in an emergency, after she’s tried to reach someone.

If a patient in that age band asks and you’d rather not be the one to build an appropriate medication kit with her, you can send her to us at Jase.com. A licensed provider reviews every request and writes every prescription, so it’s a handoff rather than a workaround.

We’ll keep publishing where we draw the lines, including the lines that run through our own products. Right now that conversation is happening on the pickleball court with nobody clinical in it. That’s the part we’re trying to fix.

Sources

1. National Poll on Healthy Aging. Emergency Planning among Older Adults. University of Michigan Institute for Healthcare Policy and Innovation, with support from AARP and Michigan Medicine. Fielded May 2019, published September 4, 2019. n = 2,249 adults ages 50 to 80. https://www.healthyagingpoll.org/reports-more/report/emergency-planning-among-older-adults
2. Innes GK, Ogden CL, Crentsil V, Concato J, Fakhouri TH. Prescription Medication Use Among Older Adults in the US. JAMA Internal Medicine. 2024;184(9). NHANES, January 1999 through March 2020, 14,917 adults aged 65 and older. Polypharmacy, defined as 5 or more prescription medications, rose from 23.6% to 43.0%; mean medications per person rose from 3.0 to 4.3. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2820722
3. American Geriatrics Society. Tip Sheet: Emergency Preparedness for Older Adults. HealthInAging.org, September 2019. https://www.healthinaging.org/tools-and-tips/tip-sheet-emergency-preparedness-older-adults
4. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052-2081. doi:10.1111/jgs.18372. https://pubmed.ncbi.nlm.nih.gov/37139824/