Transcript Chapter 11 Promoting Healthy Aging

Chapter 11:
Polypharmacy
Learning Objectives
• Identify evidence and references in medical literature
that demonstrate polypharmacy’s impact on patient
outcomes.
• Recognize the symptoms of the syndrome of
polypharmacy in elderly patients, acknowledging that
the symptoms may be quite distant from the cause.
• Understand how goals of care influence
appropriateness of medication choice.
• Identify drugs that are being used to treat side effects
of other drugs.
Learning Objectives (cont’d)
• Develop a personal system of addressing
polypharmacy and medication-related problems
in the clinical setting.
• Discuss how increasing medication burden can
pose a hazard to the cognitively impaired elder.
• Describe why nurses have a unique perspective
and role in the healthcare team when it comes to
medication use and outcomes.
Polypharmacy Background
• Polypharmacy
– Concurrent use of multiple medications
• Geriatric syndrome
– Common health condition in older adults that is
not a discrete disease
• Pharmacokinetics
– How drugs are absorbed, metabolized, and
eliminated; How drugs move through the body.
• Pharmacodynamics
– How drugs work in the body; What drugs do in
the body.
Significance of the Polyp. Problem
• Morbidity, mortality, and costs
– Adverse drug reactions (ADRs): overlooked. The
reported statistics on ADRs are underestimated.
– Medication-related problems (MRPs): the 5th
highest cost of disease (if MRPs were considered
disease)
• Historical perspective
– Pharmacogenomics: people have a genetic, set-atbirth capacity to metabolize medications through
different pathways, each one working at a different
rate in different people.
Risk Factors of Polypharmacy
• Prescribing cascade: treating med side effects
with other medication
• Multiple prescribers and iatrogenic harm
(iatrogenesis): doctor or healthcare created harm
• Multiple pharmacies
• Older Age: Frailty, Chronic Disease, Cognitive
Impairment, and Altered Pharmacokinetics
• Transitions of care
• Isolation
Warning Signs
• Nonspecific complaints
– Symptoms caused by medication side effects
can seem unrelated to the actual medication
• Timeline
– Be aware of new problems that emerge after a
new medication is introduced
– Challenges
• Poor patient record keeping
• Hidden use of OTC drugs, herbal and other
supplements
Warning Signs
• Drugs usually associated with falls
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Benzodiazepines
Muscle relaxants
First generation antihistamines
Opioids
• Sudden change in ADLs or IADLs
– Global sign of a problem in the elderly
– Anticholinergic drugs
Assessment
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Brown bag assessment
Gait and frailty
Medication adherence rating scales and tests
Take-home medical administration record
Literacy screen
Swallowing status
Collateral History: Adult Child or Caregiver
Beers Criteria (inappropriate med list for elders)
and START (screening tool to alert doctors) and
STOPP (screening tool of older people’s potentially
inappropriate meds ) Criteria
• Deduction
Diagnosis
– Polypharmacy-induced harm and MRPs are
typically diagnosed through deductive means
• Patient adherence
• Medication list
• Laboratory results
– Complete Metabolic Panel (monitor kidney and
liver function, glucose, calcium, protein levels,
electrolyte/fluid balance) and Basic Metabolic
Panel (kidney function, glucose, calcium, and
electrolyte/fluid balance)
• Trial Discontinuations
– Must be carefully considered
Interventions and Strategies
for Care
• Strategies for intervention can help lower
the risk of polypharmacy and medication
misadventures
• Decrease the number of unnecessary or
harmful medications
• Appropriate choices and doses
• Foster medication literacy
Interventions and Strategies
for Care (cont’d)
• Access to medications: Cost of medication
– Medicare D “doughnut hole”: when Medicare D hit
maximum spending limit that stops coverage but then
picks up above a much higher amount.
– http://plancompare.medicare.gov/pfdn/
FormularyFinder/LocationSearch allows seniors or
caregivers to compare plan coverage for their
specific medications to find the plan that offers the
best coverage
– Pharmacies offering discounts or one-price
medications on their formularies
Interventions and Strategies
for Care (cont’d)
• Medications to Avoid in the Elderly (Drugs
associated with increased risk of falls):
Benzodiazepines, psychotropic meds,
anagesics, vasodilators, antihistamin,
diuretics,.
• Do not crush any oral medication that is
labeled as: EC (Enteric-coated), ER
(Extended-release) or SR (Slow-release),
medication that ends in the following letters –
CD, CR, LA, SR, XL, XR, XT
Nursing Interventions
• Medication review:
– Compare patient medications to the medical
records.
– “start low; go slow”: start low dosage, increase
slowly to prevent toxic side effect.
– Ensure that medications no longer prescribed are
discarded.
– Discard any expired medications.
– All medications in a multi-dose vial such as insulin
will be dated and initialed.
– All liquid medication will be poured at eye level
to ensure the correct amount.
Nursing Interventions
– Internal medication will be separated from
external medication.
– All medications administered via NG/G-tube will be
administered via gravity.
– All residents on G-tube feeding will have the HOB
elevated to 30 degrees.
– The reason for administering any PRN medication
should be documented on the rear of the MAR.
– Medication refrigerator temperature should be
checked once a day. Check twice a day if there are
vaccines.
Nursing Interventions
– Oral meds should be given with a nutritious liquid
rather than water if a patient is anorexic.
– Suspect an adverse drug effect if a patient has
cognitive changes, falls, or experiences anorexia,
nausea, or weight loss.
– Wash hands before pass meds.
– Check ID bands always before administer meds.
– ATB order: carry out within 4 hours
– Non-pharmacological approach instead of using
psychotropic meds.
Alternatives
• Laxative: Increase bulk in diet (apple, bran muffin),
avoid excessive use of calcium
• Hypnotics: suggest warm milk (contains natural
tryptophan), adapt environment (noise, light, music..),
awake & active activity during day, review medsdiuretics
• Antacids: small frequent meals, keep upright position
at least 30 mins after taking meds.
• Antianxiety agents: suggest counseling, stress
reduction techniques, tai chi, yoga.
• Analgesics: distraction, positioning, ice or heat.
Summary
• Likelihood that medication will cause
harm or impairment to elderly patients is
heightened by
– impaired physiology
– heavy medication burden
– increased inappropriate medication use by
healthcare system and patient