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Chapter 11: Polypharmacy 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. 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. 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. 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-atbirth capacity to metabolize medications through different pathways, each one working at a different rate in different people. 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 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 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 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 • Deduction Diagnosis – 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 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 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 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 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. 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. 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. 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 medsdiuretics • 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. 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