Chapter 11: Polypharmacy

1. Chapter 11: Polypharmacy

2. 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.

3. 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.

4. 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.

5. 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-at-birth capacity to metabolize medications through different pathways, each one working at a different rate in different people.

6. 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

7. 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

8. Warning Signs • Drugs usually associated with falls • Benzodiazepines • Muscle relaxants • First generation antihistamines • Opioids • Sudden change in ADLs or IADLs • Global sign of a problem in the elderly • Anticholinergic drugs

9. Assessment • 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

10. Diagnosis • Deduction • 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

11. 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

12. 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

13. 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

14. 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.

15. 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.

16. 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.

17. 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 meds-diuretics • 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.

18. 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