Automatic Refills
Consider the following case vignette, a composite of the recent experience of two patients in my practice. A 79 year-old woman with severe depression and anxiety was hospitalized for pneumonia. The hospital doctors made a change in her psychiatric medication. Drug A was replaced with drug B. After she returned home, she had the prescription for Drug B filled. About a week later, the pharmacy called to tell her that her prescription for Drug A, which had been on automatic refill, was ready to be picked up. She picked up Drug A and took it, according to the directions on the bottle, along with Drug B, effectively causing an overdose. Within a few days she became toxic and ended up back in the hospital. Fortunately, there was no permanent harm. She later explained, “When the pharmacy called to tell me my prescription was ready I just assumed I was supposed to take it”.
This scenario illustrates the inadvertent trouble that can result when programs are conceived without consideration of the cognitive or behavioral disabilities of elderly consumers who utilize them. Such schemes are devised ostensibly to improve customer service. One pharmacy touts its automatic refill system as an aid for forgetful patients who might miss needed medication because they forgot to refill prescriptions. But the program fails to consider broader cognitive deficits that can lead to the type of mistake described in my scenario. Many older people with late-life psychiatric disorders are more than just a little forgetful. They sometimes also get confused or exhibit poor judgment.
Our society has many protections for people with various vulnerabilities. Child-proof bottles protect children from taking medications. Healthcare providers are required to provide translators for patients who do not speak English. The Americans with Disabilities Act safeguards access for those with disabilities.
It is time for Congress to amend the Older Americans Act to include provisions to ensure that healthcare programs that serve the elderly be required to ensure the safety of elderly people with cognitive disabilities who use their systems. As a practicing physician, I’m not sure automatic refill programs are a good idea. Some of my sharpest patients – retired judges, engineers, and teachers – complain about the reminder calls that they insist they never requested. Until the US healthcare system has a universal electronic health record that ensures that pharmacies have up-to-date knowledge of patients’ current medications, automatic refill programs seem ill advised to me.