Presentation on theme: "Judicious Use of Medications"— Presentation transcript:
1 Judicious Use of Medications Considerations for the Aging AdultJane 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 phSlower gastric emptyingDecreased surface area of small intestineLeads to more drug remaining in GI tract slowing absorption & metabolism
4 Pharmacokinetics cont. Distribution:Increased body fat contentDecreased water contentDecreased lean muscle massLeads 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-bondExample, Albumin binds with salicylates ~ decreased albumin levels can result in aspirin toxicity
5 Pharmacokinetics cont. Metabolism:The Liver shrinksOutput of blood from the heart decreases impacting blood flow through the liverEnzyme system in the liver becomes less efficientLeads to slower drug metabolism, longer duration of action and a risk for accumulation of drugs with chronic use
6 Pharmacokinetics cont. Excretion:Kidney excretion slowsBlood flow through the kidneys declines about 40% by age 75Leads to increased risk of toxicity from medications that have a narrow therapeutic range and are excreted through the kidneysExamples: Digoxin, Coumadin, Tagamet and Aminoglycoside Antibiotics
7 Other Factors that Impact Vulnerability Multiple Chronic Health ProblemsStudies have shown that some conditions (Parkinson’s Disease, Alzheimer’s Disease) are associated with increased drug sensitivityMultiple 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 medicationsFailure to Follow Medication RegimensDifficulty Determining the Difference between side effects of medications v. changes associated with aging
8 Drug ReconciliationThe 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
10 Discrepancies @ other transition points Unintended inconsistencies may occur at any point of transition in careStudies have indicated that there are inconsistencies in:1/3 of patients at hospital admissionA similar proportion at time of transfer from one site of care within the hospital to another14% of patients at hospital discharge
11 Case Study72-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 DischargeD/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 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 OutcomesOnce 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 listsMultiple ProvidersMultiple Sites for health care deliveryReliability of client informationKnowledge of DPOA’s/family membersClient’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 determinedWho should be responsible?PharmacistsPhysiciansNursesClients 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 withdocumenting a complete list on admit with involvement of the client & communicating that list to next provider of service2009: 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 & PCPAll pharmacies in useAll prescription drugs in use, name of prescriber, reason for useDose, route, frequency, last dose takenList all over-the-counter products including:VitaminsDietary SupplementsHerbal 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 discontinueCompare 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’sHas 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 diseaseMany OTC products contain aspirinTaking more than the recommended daily amount of Vitamin C can also increase levels of salicylatesLow 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 bleedingLong-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 dayAdministered with alcoholNOTE: many OTC’s contain acetaminophenFDA 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 failureTake antacids and calcium supplements 2 hours apart from other medicationsCalcium supplements and antacids can dissolve the enteric coating on other medicationsSome 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 bloodTake bulk laxatives (Metamucil) with sufficient fluids to avoid bowel obstructions and dehydrationLong-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 providersA current list of allergies ~ with a description of the type of reaction experiencedA Current List of all of medications (or bring in the meds in their original containers)Full name of each medicationDoseHow often its taken each dayReason for useWhat it looks likeWho ordered itPharmacy 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” medicationsDoes the potential benefit of the medication outweigh the potential for adverse drug effectsWhat are the potential adverse drug effectsQuality of Like implicationsHow does life style complicate the situationEx. Use of anticoagulants to prevent a stroke in a client with high fall risk and history of repeat fallsEx. Use of psychoactive medications for clients with Dementia with behavioral issues
31 Joint Responsibilities When the HCP hand writes a prescriptionBe sure it is legibleThe client should make a copy for his/her recordsCheck the pharmacy label for the brand and generic nameAsk the pharmacist to include the reason for its use on the labelUrge client to Check and recheck the bottle even when getting refillsIf it looks different, the client should ask “why”?Take as prescribedDo not skip or double up on dosesEstablish a system for remembering to take medsDo not share or borrow medsDo not split or crush meds without checking with pharmacistStore correctlyUsually a cool, dry placeIn 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 systemCheck identity every time meds are administeredClient should have their HCP list the meds orderedNurse should name/explain each med they administerClient 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 travelingCheck for an adequate supply of meds for the duration of trip and for any potential mishapDo not place in checked luggageKeep a current list of medications, allergies and HCP’s in carry-on or purseFollow appropriate storage recommendations
34 Joint Responsibilities Participation in decision-making regarding all aspects of care ~ including use of medicationsRequest/Provide additional information or a second opinion as needed before making a decisionHCP 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 problemTaking > five medsTaking dietary supplements and OTC’sTaking homeopathic or herbal medicinesUsing different pharmacies to fill prescriptionsHaving more than one HCP prescribing medicationsTaking meds multiple times each dayHaving problems with opening med bottlesPoor eyesight or hearingPutting medications in unmarked containers
36 “High Alert” Medications (more likely to cause interactions or adverse effects) Norpace ElavilAldomet SeconalLibrium KlonopinValium DalmaneBentyl DiabineseDemerol Ticlid
37 Grapefruit JuiceTo 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 throughOpen, Honest & Accurate CommunicationBeing informed about care and medicationsClient taking responsibility for self-care when possibleProvision of quality service by healthcare providersFollowing policies, procedures, protocolsKeeping informed about best practices
39 BibliographyBrager, Rosemarie. “ Polypharmacy: A Hazard to Your Older Patient’s Health?” LPN 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 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-Surgical Nursing. 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 PracticesNational Patient Safety Foundation