Transcript Judicious Use of Medications

Judicious Use of Medications
Considerations for the Aging Adult
Jane Zaccardi MA, RN, GCNS-BC
Objectives:
1. Describe the responsibilities of the health care provider and the client relative
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to judicious use of medications.
Discuss changes associated with aging that impact absorption, distribution,
metabolism and excretion of medications.
Outline ethical, legal and regulatory aspects of judicious use of medications.
List medications that are deemed inappropriate for aging adults.
Define “High Risk” medications and review additional safeguards in their
prescription and use for aging adults.
Review key components of Risk/Benefit Analyses.
Define “Informed” decision-making; and, review consumer rights regarding
participation in health care decisions.
Discuss vital aspects of “Drug Reconciliation”
Explore the role of EMAR’s in promoting safety in medication administration.
Age & Pharmacokinetics:
How the body handles drugs
 Absorption:
– Changes in gastric ph
– Slower gastric emptying
– Decreased surface area of small intestine
• Leads to more drug remaining in GI tract slowing
absorption & metabolism
Pharmacokinetics cont.
 Distribution:
– Increased body fat content
– Decreased water content
– Decreased lean muscle mass
• Leads to decreased blood levels of drugs that bind with fat
(valium)
• Leads to increased blood levels of drugs that bind with water
(alcohol, digoxin, morphine)
– Altered Protein Levels (albumin levels tend to decline with age and
further decline with illness)
• Many medications are protein-bond
– Example, Albumin binds with salicylates ~ decreased albumin levels can
result in aspirin toxicity
Pharmacokinetics cont.
 Metabolism:
– The Liver shrinks
– Output of blood from the heart decreases
impacting blood flow through the liver
– Enzyme system in the liver becomes less
efficient
• Leads to slower drug metabolism, longer duration of
action and a risk for accumulation of drugs with
chronic use
Pharmacokinetics cont.
 Excretion:
– Kidney excretion slows
– Blood flow through the kidneys declines about
40% by age 75
• Leads to increased risk of toxicity from medications
that have a narrow therapeutic range and are
excreted through the kidneys
– Examples: Digoxin, Coumadin, Tagamet and
Aminoglycoside Antibiotics
Other Factors that Impact
Vulnerability
 Multiple Chronic Health Problems
– Studies have shown that some conditions (Parkinson’s
Disease, Alzheimer’s Disease) are associated with
increased drug sensitivity
 Multiple Medications (Polypharmacy)
– Studies have shown that the % of adverse effects go up
from 10% for those taking only one medication to
100% for those taking ten medications
 Failure to Follow Medication Regimens
 Difficulty Determining the Difference between
side effects of medications v. changes associated
with aging
Drug Reconciliation
 The process of creating the most accurate
list possible of all medications a client is
taking; and,
 Comparing that list against the physician’s
admission, transfer, and/or discharge orders;
with,
 The goal of providing correct medications
to the patient at all transition points in care
Discrepancies @ hospital admission
Discrepancies @ other transition points
 Unintended inconsistencies may occur at
any point of transition in care
 Studies have indicated that there are
inconsistencies in:
– 1/3 of patients at hospital admission
– A similar proportion at time of transfer from
one site of care within the hospital to another
– 14% of patients at hospital discharge
Case Study
 72-year old female w h/o heart disease & A.
Fib admitted with pneumonia.
 Home meds: Warfarin 3mg daily, Lipitor
10mg daily, and Toprol XL 100mg daily.
 Hospital meds: Pravachol in place of
Lipitor (hospital formulary); Warfarin dose
was decreased to 2mg daily d/t interaction
with Levofloxacin; Toprol XL 100mg was
continued.
Hospital Discharge
 D/C home with prescriptions for Coumadin
2mg by mouth daily, Pravachol 40mg daily,
Toprol XL 100mg daily; and, Levoquin
500mg daily for 5 days.
 Ten days later she returned with severe
body aches, weakness and bright red blood
per rectum.
 Lab values: Hgb -8.6 CPK - 3200 PT -44.
Findings on Readmission
 Her bag of medications had Coumadin 2 mg
daily, Warfarin 3mg daily, Pravachol 40 mg
daily, Lipitor 10 mg daily, and Toprol XL
100 mg daily.
 When asked why she was taking the
Warfarin and the Lipitor when they weren't
on her discharge list, she said they had been
prescribed by her cardiologist who told her
it was very important to keep taking these
Outcomes
 Once the excess (duplicate) meds were
stopped ~ she recovered completely.
 She was given a list of medications that
clearly specified which meds were to be
stopped.
 The information was communicated by
phone and fax to the cardiologist with
whom she was to follow up.
Challenges for Health Care Providers
 Access to complete medication lists
– Multiple Providers
– Multiple Sites for health care delivery
– Reliability of client information
– Knowledge of DPOA’s/family members
– Client’s interpretation of what constitutes a
“medication”
– Accuracy and Complexity of discharge/transfer
instructions
Completing a Drug Reconciliation
 Importance of doing so is acknowledged;
but, the best method of doing so has not
been determined
 Who should be responsible?
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Pharmacists
Physicians
Nurses
Clients themselves
How should it be done?
 Have pharmacists perform the entire
process?
 Link medication reconciliation to existing
computerized order entry systems?
 Integrate medication reconciliation within
the electronic medication record system?
 Involving clients especially in ambulatory
care settings and the home?
Joint Commission
 2005 National Patient Safety Goal #8:
– accurately and completely reconcile
medications across the continuum of care”
 2006: accredited organizations were
charged with
– documenting a complete list on admit with
involvement of the client & communicating that
list to next provider of service
 2009: No longer formally score medication
reconciliation during on-site visits!
What information is needed
 Complete Drug List on admission to care:
– All Health Care Providers & PCP
– All pharmacies in use
– All prescription drugs in use, name of
prescriber, reason for use
• Dose, route, frequency, last dose taken
– List all over-the-counter products including:
• Vitamins
• Dietary Supplements
• Herbal Products
The Actual Reconciliation
 Review all medications in use at admission;
i.e. the “active admission medication list”
 Decide which to continue, hold or
discontinue
 Compare medication reconciliation form
with medication administration record (in a
health care setting) or with medications in
use (in home setting)
“How did I Get on These Meds?”
 Does the Healthcare Provider (HCP) hesitate to discontinue
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medications the client has been on for a long time?
When was the last time the HCP and client looked at all medications
and discussed their purpose and effectiveness?
When the client has a new condition does the HCP add more
medications without considering removing any?
Is the HCP ordering medications to manage side effects from another
medication causing a cascading effect?
Has the client or provider been influenced by advertisements or reports
from friends about the wonders of a new medication?
Does the client or nurse expect a prescription every time the HCP is
contacted?
More About OTC’s
 Has the client read the label carefully so that they
are aware of what the product contains?
 Does the HCP know about these OTC’s?
 Have potential drug-drug and/or drug-food
interactions been considered?
 Is the correct dose being taken?
 Have the instructions regarding duration of use
been considered?
OTC Cautions
 Risks for salicylate poisoning:
– Many adults are already taking low-dose aspirin
therapy to prevent heart attack, strokes or
peripheral vascular disease
– Many OTC products contain aspirin
– Taking more than the recommended daily
amount of Vitamin C can also increase levels of
salicylates
– Low albumin levels increase risk for salicylate
toxicity
OTC Cautions cont.
 NSAIDs (non-steroidal anti-inflammatory
drugs) like ibuprofen (Motrin, Advil) and
Naprosyn (Alleve) should be used with
caution due to:
– Age-related increased risk of peptic ulcer
disease and GI bleeding
– Long-term use can increase blood pressure,
counteract antihypertensive medication and
cause kidney dysfunction
OTC Cautions cont.
 Acetaminophen (Tylenol) is the pain
reliever of choice for aging adults but it can
cause liver damage when:
– Doses exceed 4 grams per day
– Administered with alcohol
• NOTE: many OTC’s contain acetaminophen
• FDA recommends limiting maximum single to 650
milligrams.
*Acetaminophen has been used in suicide
attempts *
OTC Cautions cont.
 Antacids used frequently can interfere with
other medications, cause high calcium
levels in the blood, cause kidney stones or
kidney failure
– Take antacids and calcium supplements 2 hours
apart from other medications
– Calcium supplements and antacids can dissolve
the enteric coating on other medications
– Some antacids contain sodium and thus may
impact blood pressure
OTC Cautions cont.
 Laxatives used frequently can cause diarrhea,
nausea, vomiting, nutritional deficiencies and low
potassium levels in the blood
– Take bulk laxatives (Metamucil) with sufficient fluids
to avoid bowel obstructions and dehydration
– Long-term use of stimulant laxatives (except in patients
taking narcotics) may lead to dysfunction of the bowel
and laxative dependency
Responsibilities of the Consumer
 Truthful reporting to healthcare providers
 A current list of allergies ~ with a description of
the type of reaction experienced
 A Current List of all of medications (or bring in
the meds in their original containers)
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Full name of each medication
Dose
How often its taken each day
Reason for use
What it looks like
Who ordered it
Pharmacy who fills scripts
Joint Responsibilities:
 When a HCP orders new medication the client should be
provided with these instructions:
• Name of medication (generic & brand)
• What is it supposed to do for client? How will client
know if its working?
• What side effects to look for? Which side effects
should to report? Risk for an allergic reaction?
• Are there any risks associated with this medication?
• Any special instructions related to the med?
• How much to take and how often?
• Duration of therapy?
Risk/Benefit Analysis
 Should be performed for client as needed,
especially with “high risk” medications
– Does the potential benefit of the medication
outweigh the potential for adverse drug effects
– What are the potential adverse drug effects
– Quality of Like implications
– How does life style complicate the situation
• Ex. Use of anticoagulants to prevent a stroke in a
client with high fall risk and history of repeat falls
• Ex. Use of psychoactive medications for clients with
Dementia with behavioral issues
Joint Responsibilities
 When the HCP hand writes a prescription
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• Be sure it is legible
• The client should make a copy for his/her records
Check the pharmacy label for the brand and generic name
• Ask the pharmacist to include the reason for its use on the label
Urge client to Check and recheck the bottle even when getting refills
• If it looks different, the client should ask “why”?
Take as prescribed
• Do not skip or double up on doses
• Establish a system for remembering to take meds
• Do not share or borrow meds
• Do not split or crush meds without checking with pharmacist
Store correctly
• Usually a cool, dry place
• In original container (may use a medication minder as needed)
Joint Responsibilities
 In the hospital, rehab facility or nursing home:
– Client should ask/nurse should explain about the
medication administration system
– Check identity every time meds are administered
– Client should have their HCP list the meds ordered
– Nurse should name/explain each med they administer
– Client should look at meds and question anything that
does not look “right”
– Nurse should provide education about meds prior to the
day of discharge
Client Responsibilities
 When traveling
– Check for an adequate supply of meds for the
duration of trip and for any potential mishap
– Do not place in checked luggage
– Keep a current list of medications, allergies and
HCP’s in carry-on or purse
– Follow appropriate storage recommendations
Joint Responsibilities
 Participation in decision-making regarding all
aspects of care ~ including use of medications
 Request/Provide additional information or a
second opinion as needed before making a
decision
 HCP should do a Risk/Benefit Analysis for client
when prescribing new medications (especially
high risk meds or meds new to the market)
 Consult with Pharmacist as needed
Potentially Risky Situations
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Using two or more meds to treat the same problem
Taking > five meds
Taking dietary supplements and OTC’s
Taking homeopathic or herbal medicines
Using different pharmacies to fill prescriptions
Having more than one HCP prescribing
medications
 Taking meds multiple times each day
 Having problems with opening med bottles
 Poor eyesight or hearing
 Putting medications in unmarked containers
“High Alert” Medications
(more likely to cause interactions or adverse effects)
Norpace
Aldomet
Librium
Valium
Bentyl
Demerol
Elavil
Seconal
Klonopin
Dalmane
Diabinese
Ticlid
Grapefruit Juice
 To metabolize grapefruit juice you use the
same enzymes in the liver and small
intestines that metabolize many drugs.
 If grapefruit or its juice are consumed
within eight hours of taking certain meds
(ex. Lipitor), the enzyme will be
unavailable to break down the drugs.
 This increases risk of drug toxicity!
Conclusion
 There are many effective medications on the
market.
 Health and Safety can be ensured through
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Open, Honest & Accurate Communication
Being informed about care and medications
Client taking responsibility for self-care when possible
Provision of quality service by healthcare providers
Following policies, procedures, protocols
Keeping informed about best practices
Bibliography
 Brager, Rosemarie. “ Polypharmacy: A Hazard to Your Older Patient’s
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Health?” LPN2006. Volume 2, Number 5. September/October 2005.
CHSRA U.W.-Madison. “Comprehensive Assessment of Top Drugs used in
Nursing Homes”. June 2003.
CMS. “Interpretive Guidelines:Unnecessary Medications”.2004.
Cohen, Hedy. “Getting to the Root of Medication Errors”. Nursing 2003.
Volume, 33, Number 9. September 2003.
Grogan, Tracy A. “Keep Your Older Patients out of Medication Trouble”.
Nursing 2006, Volume 36, Number 9, September 2006.
Institute of Medicine (IOM). To Err is Human: Building a Safer Health Care
System. Washington DC: National Academy Press, 2000.
Murray, Teri A. “Patient Safety and a Just Culture”. Missouri State Board of
Nursing Newsletter. Volume 8, Number 4, November/December 2006.
Ramont, Roberta and Dolores Niedringhaus. Fundamental Nursing Care.
New Jersey: Pearson Prentice Hall.
Ramont, Roberta and Dolores Niedringhaus. Introduction to Medical-Surgical
Nursing. New Jersey: Pearson Prentice Hall.
Roach. Introductory Clinical Pharmacology. USA: Lippincott.
Bibliography cont.
 Roizen, Michael, M.D. and Mehmet C Oz, M.D. YOU:
The Smart Patient
~ An Insider’s Handbook for Getting the Best Treatment. New York:
Free Press, 2005.
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Turner, Linette. “Keeping Warfarin Therapy in Balance”. Nursing 2006, Number 36,
Volume 11, November 2006.
Woods, Anne. “How to Use Medicine Safely” (Patient Education Series). Nursing
2003, Volume 33, Number 12, December 2003.
Zweig, Steven C. MD. “Transition Planning: Tips for a Thoughtful and Thorough
Discharge”. Long-Term Care Links. Volume 15, Number 2, Summer 2005.
Related Web Sites:
Institute for safe Medication Practices
http://www.ismp.org
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National Patient Safety Foundation
http://www.npsf.org