Judicious Use of Medications

1. Judicious Use of Medications Considerations for the Aging Adult Jane Zaccardi MA, RN, GCNS-BC

2. Objectives: • Describe the responsibilities of the health care provider and the client relative 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Discrepancies @ hospital admission

10. 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

11. 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.

12. 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.

13. 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

14. 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.

15. 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

16. 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? • Pharmacists • Physicians • Nurses • Clients themselves

17. 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?

18. 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!

19. 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

20. 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)

21. “How did I Get on These Meds?” • Does the Healthcare Provider (HCP) hesitate to discontinue 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?

22. 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?

23. 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

24. 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

25. 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 *

26. 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

27. 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

28. 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) • 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

29. 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?

30. 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

31. Joint Responsibilities • When the HCP hand writes a prescription • 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) • Discard unused or expired meds

32. 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

33. 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

34. 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

35. Potentially Risky Situations • 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

36. “High Alert” Medications(more likely to cause interactions or adverse effects) Norpace Elavil Aldomet Seconal Librium Klonopin Valium Dalmane Bentyl Diabinese Demerol Ticlid

37. 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!

38. Conclusion • There are many effective medications on the market. • Health and Safety can be ensured through • 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

39. Bibliography • Brager, Rosemarie. “ Polypharmacy: A Hazard to Your Older Patient’s 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-SurgicalNursing. New Jersey: Pearson Prentice Hall. • Roach. Introductory Clinical Pharmacology. USA: Lippincott.  

40. 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. • 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 • National Patient Safety Foundation http://www.npsf.org