Download Medication Review

Geriatric Competency-Based Curriculum for IM Residents
Skills Module: Medication Review
Competency #3: Periodically review patients’ medications (including medications prescribed by
other physicians, over-the-counter and complementary and alternative medicines) with the
patient and/or caregiver to assess adherence; eliminate ineffective, duplicate, and unnecessary
medications; and ensure that all medically indicated pharmacotherapy is prescribed.
Skills Module:
1.) Review all active medications (including herbal, OTC) with patient and/or caregiver and
reconcile with EMR.
2.) Assess adherence and barriers to adherence (cost, access to transportation, side effects,
cognitive or functional impairment, health beliefs)
3.) Review indications for any high risk meds.
4.) Can any medicines be eliminated or doses changed?
5.) Should any medicines be added?
Selected High Risk Medicines for Older Adults (2012 Beers Criteria)
Medicine
Rationale
Anticholinergics
o 1st-gen. antihistamines (diphenhydramine,
hydroxyzine)
o Antispasmodics (scopolamine)
Antithrombotics: Dipyridamole, Ticlopidine
Anti-infectives: Nitrofurantoin
Alpha1 blockers: Doxazosin, Prazosin, Terazosin
Alpha blockers, central: Clonidine
Antiarrhythmics: amiodarone
Cardiac
o Digoxin >0.125mg/day
o Nifedipine, immediate release
o Spironolactone >25mg/day
Highly anticholinergic: increased risk
of confusion, dry mouth, constipation,
and other anticholinergic
effects/toxicity.
Safer, effective alternatives available
Safer alternatives, lack of efficacy in
CrCl<60
Orthostatic hypotension
Orthostatic hypotension, bradycardia,
CNS effects
Rate control better benefit:harm
No additional benefit, increased toxicity
Potential for hypotension, ischemia
Hyperkalemia
CNS
o
o
o
o
Tertiary TCAs (amitriptyline, imipramine)
Antipsychotics (conventional and atypical)
Benzodiazepines (short- and long-acting)
Nonbenzodiazepine hypnotics (eszopiclone,
zolpidem, zaleplon)
o
o
Sliding scale insulin
Sulfonylureas, long-duration
(chlorpropamide, glyburide)
Endocrine
Metoclopramide
Non-COX-selective NSAIDs (ASA>325mg/day, Ibuprofen,
naproxen, etc.)
Skeletal muscle relaxants
The American Geriatrics Society 2012 Beers Criteria Update Expert Panel.
AGS updated Beers Criteria for potentially inappropriate medication use
in older adults. J Am Geriatr Soc 2012; DOI: 10.1111/j.1532-5415.2012.
03923.x.
Orthostatic hypotension, anticholinergic
Dementia: incr. CVA & mortality risk
Incr. risk of delirium, falls, fractures,
MVAs, cognitive impairment in all
benzos and benzo-like meds
Higher risk of hypoglycemia without
improvement in hyperglycemia
Prolonged hypoglycemia risk
Risk for extrapyramidal effects
GI bleed/PUD
Anticholinergic effects, sedation, fracture
risk increased
Evaluator:________________________
Date:_______________
Resident:__________________________
Patient:
Age:____
Sex:____
Medication Review
Medical Interviewing Skills (□ Not observed): All meds reviewed (including OTC, herbal)? Adherence & barriers to adherence
assessed?
1
2
3
4
Unsatisfactory
Humanistic qualities/professionalism
1
2
5
6
7
Satisfactory
3
4
5
8
9
8
9
Superior
6
7
Unsatisfactory
Satisfactory
Superior
Clinical judgment (□ Not observed): High risk medicines identified? Ineffective/duplicate/unnecessary meds eliminated?
Medically indicated pharmacotherapy prescribed?
1
2
3
4
5
6
7
8
9
Unsatisfactory
Satisfactory
Superior
Counseling skills (□ Not observed): Medication adherence and tips to overcome barriers to adherence discussed?
1
2
3
4
5
Unsatisfactory
Organization/efficiency (□ Not observed)
Satisfactory
1
5
2
3
4
6
7
8
9
Superior
6
7
8
9
Unsatisfactory
Satisfactory
Superior
Overall clinical competence: Resident is competent at medication review in an older adult.
1
2
3
4
Unsatisfactory
Mini-CEX time:
5
6
7
Satisfactory
Observing:__________Min
8
9
Superior
Providing Feedback:___________Min
Evaluator satisfaction with mini-CEX
Low
1
2
3
4
5
6
7
8
9
High
3
4
5
6
7
8
9
High
Resident satisfaction with mini-CEX
Low
1
2
Comments:________________________________________________________________________________________________
_________________________________________________________________________________________________________
___________________________________
Resident signature
Adapted from: Norcini J. Annals Intern Med 2003;138:476-481
_________________________________
Evaluator signature