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F 329 Unnecessary Medications: Geriatric Principles Meets Regulations
Charles Crecelius MD PhD FACP CMD
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F-tag 329 Unnecessary Medications
Updated, consolidated Incorporates newest geriatric principles Written by CMS with advise of leading geriatricians, pharmacists, nurses Associated pharmacy tags F428 Medication Regiment Review Sets guidance for all – physicians, pharmacists, homes, surveyors
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F 329 Unnecessary Meds Intent
Meds clinically required to treat a condition Non-pharmacologic measures used Medication promotes highest well-being Avoid actual or potential negative outcome Negative outcome promptly found / treated Doesn’t empower surveyor to practice medicine - should investigate the basis for decisions and interventions
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Key Definitions Adverse consequences & ADR Behavior interventions
Distressed behavior Gradual dose reduction Monitoring Non-pharmacologic intervention Psychopharmacological medication
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Basic Pharmacologic Principles
Promote non-pharmacologic interventions Indication for use Select based on individual risk / benefit Appropriate dose / duration Avoid duplicative therapy Monitor efficacy & side effects Prevention, identification, and response to adverse consequences GDR (gradual dose reduction)
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Non-pharmacologic Interventions
Require: assessing and understanding causes for need of medication reduction/elimination of impediments, triggers and causes: Examples Modification of environment Modification/elimination of psychological stressors Accommodation of previous lifelong activities or roles Modification of staff/resident interactions Behavioral Interventions
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Individual Risk & Benefit
Distinct / unique review of needs & goals Informed choice Condition, options, risk / benefit, outcomes Effects refusing treatment Regular review Can’t refuse physician directed treatment to treat imminent danger Advance directives don’t preclude other treatment (no code is not no care)
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Monitoring Criteria Identify essential information
who collects, how recorded Determine frequency of monitoring Condition, risk ADR Define communication and analysis Interdisciplinary team, goal Re-evaluate & update plan Change meds/conditions/diet
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When to Evaluate Medication for Benefit / Adverse Consequences
Admit / readmit Clinically significant change in status New symptom / problem Worsening existing problem Unexpected decline function / cognition Non specific symptom without cause New med, review of med, med irregularity MMRR
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Special Considerations
New Admits Justify each med, consider ADR New med order as an emergency Address underlying cause Re-evaluate after acute phase over Psychiatric disorder or distressed behavior Appropriate diagnosis, seek cause Multiple prescribers
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GDR All Medication Potential Candidates
When condition stable or improved, causes target symptoms resolved, non-pharmacologic tx success Opportunities MMR Quarterly MDS Review Practitioner review Psychopharmacologic medication Review & document risk/benefit q 3 months
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GDR Antipsychotics / non-anxiolytic/sedatives Sedatives / Hypnotics
1st year – 2 separate quarters, at least 1 month between Annually thereafter Unless clinically contraindicated Sedatives / Hypnotics If used more than 3 times a week Attempt taper at least quarterly, 3 out of 4 quarters
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Medications of Particular Relevance to Long-Term Care
Broad list of medications with potential concerns in the elderly & long term care Replaces revised “Beer’s list” Lists medication class, then specific names Ask to consider various factors Indication Dosage / duration Monitoring Adverse consequences Documentation Documentation proportional to degree risk/benefit
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Surveyor Investigative Protocol Unnecessary Medications
Non-compliance Inadequate indication for use Inadequate monitoring Excessive dose Excessive duration Adverse consequences Antipsychotic Absence of specific condition Without behavior intervention & GDR
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Deficiency Categorization Examples
Level 4 Immediate Jeopardy INR > 9 with failure to assess / act Failure to monitor INR without care plan, staff knowledge potential problems Failure to monitor or dose reduce for antipsychotic in presence of side effect Failure to do non-contraindicated GDR with resulting tardive dyskinesia while on prolonged antipsychotics Failure to recognize, assess or respond to meds that caused a GI bleed
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Deficiency Categorization Examples
Level 3 Actual Harm that is not Immediate Jeopardy INR 4-9 with failure to act with bleeding Failure to evaluate seizure as a result of other meds, adding potentially unneeded AED Failure to perform GDR resulting in continued antipsychotic use with decline, adverse effect
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Deficiency Categorization Examples
Level 2 No actual harm with potential for more than minimal harm INR with failure to act and no bleeding Failure to monitor INR, prior stable INR, no bleeding Failure to identify med as cause of rash Failure to monitor potential med adverse effect (e.g. no TSH & on thyroid Rx)
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Deficiency Categorization Examples
Level 1 No actual harm with potential for minimal harm Failure to provide appropriate care & services to avoid unnecessary meds / minimize adverse outcomes place residents at risk for more than minimal harm No level 1 severity
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The Medical Director & F329 Reducing Medication Related Problems
Individualize approach depending on problematic areas facility Education of Staff & Attendings Improve systems which impact medication management Monitor performance & provide feedback
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Educational Efforts for Staff
Non-pharmacological Interventions Top offending medications GDR Requirements Monitoring tools / requirements Targeting frail / declining residents Common ADR (serotonin syndrome, EPS, TD, NMS anticholinergic side-effect)
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Educational Efforts for Staff
Signs, Symptoms & Conditions Possibly Associated w/ Medications Anorexia, unplanned weight loss or gain Behavioral changes, unusual behavior patterns Bleeding / bruising, spontaneous / unexplained Bowel dysfunction Dehydration, fluid/electrolyte imbalance Depression, mood disturbance Dysphagia, swallowing difficulty Falls, dizziness, impaired coordination
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Educational Efforts for Staff
Signs, Symptoms & Conditions Possibly Associated w/ Medications Gastrointestinal bleeding Headaches, muscle pain, general nonspecific aching or pain Mental status changes, (new, worsening, delirium) Rash, pruritus Respiratory difficulty or changes Sedation (excess), insomnia, disturbed sleep Seizure activity Urinary retention or incontinence
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System Improvements Utilization Monitoring Tools
Physiological, cognitive functional Vital signs Labs, EKGs, blood sugars, Hgb A1C RAI, FAST, IADL, PSMS MMSE, CAM, AIMS, FAST Mood/Affect (MDS / QI) GDS, Cornell DDS, Mania Rating Scale Behavior (MDS / QI) Behave AD, CMAI, NPI-NH
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System Improvements Protime / INR Monitoring
System-wide use coumadin flow sheets Pulled when labs drawn Sent to physician for fax adjustment or read to physician if called Contains default orders for common situations Set standard protime draw days CMT “signs off” new order Recap orders require check last protime
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Auditing Medication Management
Monitor Indication with Consulting Pharmacist Do target symptoms / causes warrant therapy Could non-Rx interventions be relevant Is a particular medication pertinent to managing symptoms or condition Is risk worth benefit If prn are circumstances for use clearly delineated
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Auditing Medication Management
Review GDR & Psychopharmacologics Triggered with new order; tickler system for old orders Special form of MRR using pharmacist & medical director Placed in front of order section Lists requirements of F329, offers tapering suggestions Results audited, presented to attendings
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Always consider medication as a possible problem,
and not just as the solution Any symptom in an elderly patient should be considered a drug side effect until proved otherwise (Gurwitz) A medication is a poison with a desirable side-effect (Osler)
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Appendix F329 Unnecessary Medications Medications of Particular Interest in Long Term care
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Medication Issues of Particular Relevance to Long-Term Care
Analgesics Acetaminophen NSAIDs (Traditional, COX-2) Opioids (esp. meperidine) Pentazocine Propoxyphene (and combinations) Antibiotics (all) Vancomycin / aminoglycosides Nitrofuration Fluoroquinolones
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Medication Issues of Particular Relevance to Long-Term Care
Anticoagulants Warfarin Anticonvulsants All Seizure or mood stabalizer Antidepressants All (class listings) MAO inhibitors Tricyclics
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Medication Issues of Particular Relevance to Long-Term Care
Anti-diabetic Medication Metformin Glitazones Chlorpropamide & glyburide Antifungals Imidazoles Anti-manic medications Lithium
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Medication Issues of Particular Relevance to Long-Term Care
Anti-Parkinson medication (all) Antipsychotics Conventionals Atypicals Anxiolytics Short-acting benzodiazepines Long-acting benzodiazepines Buspirone Diphenhydramine / hydroxyzine Meprobamate
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Medication Issues of Particular Relevance to Long-Term Care
Cardiovascular medications Antiarrhythmics (amiodarone, disopyramide) Antihypertensives - All Methyldopa Digoxin Diuretics Nitrates
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Medication Issues of Particular Relevance to Long-Term Care
Cholesterol lowering medicines Statins cholestyramine Cognitive enhancers Cold, cough and allergy medication All H1 blockers Oral decongestants
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Medication Issues of Particular Relevance to Long-Term Care
Gastrointestinal medications GI antispasmotics Phenothiazines, trimethobenzamide Metoclopramide Proton pump inhibitors Glucocorticoids Hematinics Erythropoiesis stimulants Iron
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Medication Issues of Particular Relevance to Long-Term Care
Laxatives Muscle relaxants Orexigenics (appetite stimulants) Osteoporosis medications (biphosphonates) Platelet inhibitors Salicylates Ticlopidine Clopidogrel
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Medication Issues of Particular Relevance to Long-Term Care
Respiratory medication Theophylline Inhalants Sedative / hypnotics All Barbituates Thyroid medication OAB medication All
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Medications with Significant Anticholinergic Properties
Antihistamines Respiratory (ipratropium) GI drugs Tricyclic antideressants Trazedone Muscle relaxants Urinary antispasmodics Antiparkinson Antipsychotics
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