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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