This is the thirty-third in a series of articles intended to demystify retirement living options.

Suppose that you have helped an elderly relative move into an assisted living apartment or into a room in a nursing or skilled nursing facility. Now you can breathe a big sigh of relief, knowing that they will be well taken care of, right?

Not so fast.

It is true that the employees in many well-run assisted living and nursing/skilled nursing facilities are well-trained, well-intentioned, skilled, caring, compassionate individuals. You may discover that they even have more patience with your elderly relative than you do.

It is still possible for major errors and gaps in care to arise – and you, who may not even have any training in health care, may be the first one to notice.

This article and several more will discuss this issue.

Lisa observed that her father, who had recently moved into a high-quality assisted living facility, had become very lethargic. She wondered if he was getting too high a dose of a newly-prescribed anti-anxiety medicine.

She discovered that the American Geriatrics Society provides useful reference guides at under the heading, “AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2012).” Clicking on the link calls up a whole list of available downloads.

Under the heading “Public Education Resources,” some of the titles are: “AGS Beers Criteria Summary – For Patients & Caregivers,” “10 Medications Older Adults Should Avoid,” and “What to Do and What to Ask Your Healthcare Provider if a Medication You Take is Listed in the Beers Criteria.”

Lisa found these all useful. The first and second both revealed that the drug her father was taking is known to cause problems in the elderly. She also consulted the “Beers Criteria Pocket Card” listed under “Clinical Tools.” While intended for doctors and other health care professionals, it was also helpful to her.

She met with her father’s doctor. She used the information she had learned – including the fact that it’s more useful to ask questions, rather than assuming that the doctor has done something wrong. Queries include, “What is this drug being prescribed for?” “Are new symptoms that have recently surfaced possible side effects of this drug?” “Is there a safer alternative that might be tried?”

She also asked if the dose could be reduced, and if a plan could be created to wean her father off the drug. The doctor agreed to reduce the dosage immediately by one-third. Lisa discussed this change with the staff at the assisted living facility so that they would know that the prescription was changing and not be surprised by it.

Lisa did not see any improvement in her father’s condition. In fact, he seemed more lethargic than before. About a month later, she received the usual monthly bill from the assisted living center. She found multiple charges for the drug, and discovered that one pharmacy had filled a prescription for the original dose on January 31, and a second pharmacy had filled a prescription for the reduced dose on February 01. Because two pharmacies were used, neither pharmacist – nor their computer systems – saw both prescriptions.

Lisa discovered that her father had been given both doses every day in February – meaning that he got two-and-a-half times the amount he was intended to get at that point.

It is not clear exactly what went wrong. Perhaps the first prescription was set up to refill automatically, which is a common arrangement, with drugs being sent and billed to the assisted living center. Perhaps it simply didn’t occur to the doctor that he needed to cancel that original order.

Had Lisa’s father been living independently, that minor oversight might not have caused any problems, because most people would not pick up and pay for two prescriptions for the same drug just a day apart. However, in assisted living or nursing facilities, staff may not question the doctor’s orders, and elderly patients never even see pill bottles. Instead they are simply handed a little cup with some pills in it and told, “Swallow these!”

Lisa’s experience highlights this reality: it is necessary to follow up to ensure that expected changes happen as intended.

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