CTA Grant Medication Optimization using Monitor-Rx

1. CTA GrantMedication Optimization using Monitor-Rx The Role of Medications as a Cause or Aggravating Factor Contributing to Physical, Functional or Cognitive Decline Identifying Adverse Medication Effects

2. Learning Objectives • Understand and describe how medication effects can impact function and memory • Identify adverse medication effects that may increase the risk forfunctional and memory decline • List medication classes and/or specific medications that increase the risk • Apply this information to the care of patients/clients

3. “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.”~Jerry Gurwitz, MD Symptoms—such as confusion, forgetfulness, gait instability, incontinence, and fatigue—should not be attributed to the onset of new illness or to aging itself without first assessing whether they may in fact be adverse medication effects.

4. CTA GrantTarget Problem Areas • Anticholinergic Medications • Potentially Inappropriate Medications • Falls • Cognitive/Memory Loss • Mood State • Delirium

5. Additional Monitor-Rx Problem Areas • Urinary Incontinence • Dehydration • Nutritional Status • Behavioral Symptoms • Visual Function • Dental Care • Psychotropic Drugs

6. Anticholinergic Medications • Anticholinergic medications block the action of a chemical (acetylcholine) involved in the function of many organs in the body, including the brain and muscles of the eyes, intestines, and bladder. • Anticholinergic effects can be helpful when treating some conditions, such as overactive bladder or allergy or cold symptoms.

7. Anticholinergic Medications • Anticholinergic medications are also associated with increased risk for adverse drug effects in older adults.

8. Anticholinergic Adverse Effects • Dry mouth • Constipation • Blurred vision • Cognitive decline • Dry eyes • Urinary retention or hesitation • Confusion • Dizziness • Drowsiness, sedation • Delirium • Increased heart rate • Falls

9. Anticholinergic Effects – Focus on Cognitive Decline Cognitive decline can affect many areas of thought and action — such as language, attention, reasoning, judgment, reading and writing. The most common sign is memory problems.

10. Anticholinergic “Burden” • Anticholinergic effects have been identified in many drugs • Anticholinergic burden is the combined effect of the use of multiple anticholinergic medications • Total anticholinergic burden may determine the development of side effects rather than any single medication

11. Anticholinergic Burden and Cognitive Impairment • Anticholinergic burden is a strong predictor of cognitive impairment and reduced physical function and disability in older adults • Cumulative long-term use of anticholinergic medications can lead to cognitive impairment, including poor memory and executive function (ability to perform tasks such as handling money, using the telephone, and preparing meals)‏

12. Anticholinergic Burden and Cognitive Impairment • Discontinuing anticholinergic medications is associated with a decreased risk for cognitive impairment

13. Many over-the-counter and prescription medications have anticholinergic effects Handout -CommonAnticholinergicMedications

14. Therapeutic Uses of Anticholinergic Medications • Allergy, Cough & Cold Medicines • Motion Sickness, Nausea, Dizziness • Stomach Ulcer • Insomnia, Sleep • Diarrhea • Incontinence • Antidepressants (Tricyclic) • Antipsychotics • Muscle Relaxants • Movement disorders (Parkinson’s)

15. Anticholinergic MedicationsRecap • Anticholinergic meds are associated with increased risk for adverse drug effects in older adults • Anticholinergic burden is the combined effect of concurrent use of multiple anticholinergic medications • Anticholinergic burden is a strong predictor of cognitive impairment and reduced physical function and disability in older adults • Discontinuing anticholinergic medications is associated with a decreased risk

16. How Monitor-Rx Can Help

17. Potentially Inappropriate Medications for Older Adults Certain medications and medication classes should generally be avoided in older persons • either ineffective or • pose unnecessarily high risk for older persons, and • a safer alternative is available.

18. Handout -Potentially Inappropriate Medications • Many potentially inappropriate medications have anticholinergic effects.

19. Potentially Inappropriate Medications in Older Adults

20. Potentially Inappropriate Medications(Beer’s High Severity; HEDIS 2006)‏

21. Potentially Inappropriate Medications - Recap • Should generally be avoided in older persons • Ineffective • Pose unnecessarily high risk • Safer alternative is available • Many inappropriate medications have anticholinergic effects

22. How Monitor-Rx Can Help

23. Medication Effects and Risk for Falls “No risk factor for falls is as potentially preventable or reversible as medication use.” Leipzig RM, Cumming RG, Tinetti ME, JAGS, 47:30-39. 1999.

24. Medication Effects and Risk for Falls • Dizziness • Drowsiness, sedation, decreased alertness • Hypotension-low blood pressure • Parkinsonian movements • tremor, stiff muscles, slow movements, unsteady gait, difficulty maintaining balance and walking

25. Adverse Medication Effects and Falls Lethargy/ Drowsiness/ Sedation Dizziness/ vertigo Low/drop in blood pressure FALLS Tremors Unsteady Gait Difficulty Maintaining Balance

26. Adverse Medication Effects and Falls Medications may cause dizziness/vertigo directly or through other effects, such as postural hypotension Lethargy/ Drowsiness/ Sedation Dizziness/ vertigo Low/drop in blood pressure FALLS Tremors Unsteady Gait Difficulty Maintaining Balance

27. Risk for FallsDizziness/Vertigo Person is: • lightheaded or unsteady when sitting or standing • feeling “woozy” especially when changing from a sitting or lying position to a standing position • experiences sensation that he/she is turning or that surroundings are whirling around

28. Risk for Falls Dizziness/Vertigo • Dizziness or vertigo is a side effect of many medications, such as • Narcotics, Darvon, Darvocet • Benzodiazepines (Ativan/lorazepam, Valium/diazepam)‏ • Anticholinergics (see handout) • Other medications may cause dizziness/vertigo by other mechanisms, such as lowering blood pressure

29. Risk for FallsPostural Hypotension (PH) • A form of hypotension in which a person’s blood pressure suddenly falls when the person stands up

30. Medications that may Cause Postural Hypotension • Medications used to treat high blood pressure • Antidepressants • Antipsychotics • Diuretics (water pills) • Nitrates (for chest pain)

31. Adverse Medication Effects and Falls Recap: Medications may cause dizziness/vertigo directly orthrough other effects, such as postural hypotension Lethargy/ Drowsiness/ Sedation Dizziness/ vertigo Low/drop in blood pressure FALLS Tremors Unsteady Gait Difficulty Maintaining Balance

32. Adverse Medication Effects and Falls Lethargy, drowsiness or sedation may contribute to the risk for falls Lethargy/ Drowsiness/ Sedation Dizziness/ vertigo Low/drop in blood pressure FALLS Tremors Unsteady Gait Difficulty Maintaining Balance

33. Risk for Falls Lethargy, drowsiness, sedation Patient is • Sleepy • Sluggish • Staring into space • Difficult to arouse • Has little body movement

34. Risk for FallsLethargy, drowsiness, sedation • Medications used for sleep may cause a “hangover” effect resulting in lethargy during the day • Lethargy is a side effect of many other medications

35. Risk for FallsLethargy, Drowsiness, Sedation • Other Medications • Anticholinergics • Antidepressants • Anticonvulsants • Antihistamines • Narcotics, propoxyphene • Muscle relaxants

36. Lethargy/ Drowsiness/ Sedation Dizziness/ vertigo Low/drop in blood pressure FALLS Tremors Unsteady Gait Difficulty Maintaining Balance Adverse Medication Effects and Falls Recap: Lethargy/drowsiness may be a medication side effect or caused by a “hangover” effect from sleep meds

37. Adverse Medication Effects and Falls Parkinsonian Movements Lethargy/ Drowsiness/ Sedation Dizziness/ vertigo Low/drop in blood pressure FALLS Tremors Unsteady Gait Difficulty Maintaining Balance Parkinsonian Movements

38. Risk for Falls Parkinsonian Movements • Tremor, unsteady gait, difficulty maintaining balance and walking • Medications may cause Parkinsonian movements • Tricyclic antidepressants • Antipsychotics

39. Risk for Falls Tremor • Unintentional, somewhat rhythmic, muscle movement involving to-and-fro movements of one or more parts of the body. • Medications may cause tremor • Anticonvulsants • Antidepressants • Benzodiazepines • Theophylline • Stimulants

40. Risk for Falls Unsteady Gait Person: • Appears unbalanced or walks with sway • Has fast gait with large, careless movement • Has abnormally slow gait with shuffling steps • Has wide-based gait with halting, tentative steps

41. Risk for FallsUnsteady Gait May be Due to Asthenia • Asthenia-Muscle Weakness • Poor muscle conditioning, leading to the lack of or loss of strength • Medications may cause asthenia • Long-term steroid use (reversible)‏ • HMG CoA Reductase Inhibitors (“Statins”)‏

42. Risk for FallsUnsteady Gait May be Due to Ataxia • Ataxia -Partial or total loss of coordinated movement, resulting in body sway, loss of coordination or balance, unsteady gait • Medications may cause ataxia • Anticonvulsants • Benzodiazepines • Barbiturates

43. Adverse Medication Effects and Falls Recap: Balance may be impaired by different medication effects Lethargy/ Drowsiness/ Sedation Dizziness/ vertigo Low/drop in blood pressure FALLS Unsteady Gait thru asthenia or ataxia Tremors Difficulty Maintaining Balance Parkinsonian Movements

44. How Monitor-Rx Can Help

45. Cognitive Decline/Memory Loss • Older adults are more likely than younger persons to develop cognitive impairment as a result of taking medications • Cognitive decline can affect many areas of thought and action — such as language, attention, reasoning, judgment, reading and writing; the most common is memory problems

46. Cognitive Decline/Memory Loss • Psychoactive and other medications can be a factor in cognitive impairment or memory loss • Medications that cause confusion can contribute to the symptoms of cognitive impairment • Cognitive/memory impairment as a result of medications can masquerade as dementia

47. Medication Classes that Cause Cognitive Loss/Memory Impairment • Anticholinergics (see handout) • Anticonvulsants • Note that anticonvulsants are used, not just for seizure management, but also for pain and management of behavior symptoms

48. Medication Classes that Cause Confusion • Anticholinergics • Anticonvulsants • Antidepressants • Antiparkinson • Barbiturates • Narcotics • Antiulcer: cimetidine (Tagamet), ranitidine (Zantac)‏

49. Cognitive/Memory LossRecap • Cognitive/memory impairment as a result of medications can masquerade as dementia • Recognizing and safely discontinuing unnecessary and inappropriate medications is key to reducing cognitive side effects in older adults

50. How Monitor-Rx Can Help