1. Medication Reduction in Persons with Dementia Medical Staff Education

2. The Problem Too many residents are taking too many medications! Are all of these medications necessary? What are the risks associated with unnecessary medication dosing? What can physicians do??

3. Why so many drugs? multiple medical co-morbidities often multiple drugs for single diagnosis cognitive and behavioral issues (70- 80% of facility residents) weight loss infections pharma advertising to public family pressure

4. Why so many drugs? most residents enter facility with a long list of medications and they are written as part of admitting orders and then, they simply are continued drug holidays, withdrawal (OBRA) easily circumvented nursing requests for something for: fever, cough, infection, weight loss, behavioral issues

5. Symptom control skin lungs pain behaviors the symptom of abnormal labs…

6. Caregiver burden and well- being well-being directly affected by perceived social support burden self-esteem hours of informal care Chappell, Reid. Burden and well-being among caregivers: examining the distinction. Gerontologist. Dec 2002;42(6):772-80

7. Caregiver burden and well- being burden directly affected by behavioral problems break frequency self-esteem hours of informal care Chappell, Reid. Burden and well-being among caregivers: examining the distinction. Gerontologist. Dec 2002;42(6):772-80

8. Risks of excessive medications administration issues missed doses more meds to pass more documentation higher cost (to family/resident and to facility)

9. Risks of excessive medications side effects drug-drug, drug-disease interactions somnolence, lethargy, decreased cognition less active, increasing debilitation, falls increase in ADL support needs weight loss, contractures sentinel events: dehydration, fecal impaction, pressure sores resistance to care

10. Risks of having ADR related to number of medications Number of medsRisk of ADR 26% 550% 8100% Shaughnessay AF. Common drug reactions in the elderly. Emerg Med. 1992;24:21-32., as quoted in Dayer-Berenson L. Polypharmacy in the Elderly. Nursing Spectrum website. Available at http://nsweb.nursingspectrum.com/ce/ce214.htm. Accessed February 24, 2003. http://nsweb.nursingspectrum.com/ce/ce214.htm

11. Adverse Drug Reactions in real life… rate of ADR: 67% 14% of ADRs required hospitalization Cooper J. Adverse Drug Reaction-Related Hospitalizations of Nursing Facility Patients. Southern Medical Journal. May 1999;92(6):772-80.

12. Adverse Drug Reactions in real life… 16% of residents in snf hospitalized for ADR (additional 50% of residents had ADR, but did not require hospitalization) hospitalization most commonly due to NSAID (GI bleed) psychotropic-related fall with fracture digoxin toxicity insulin hypoglycemia account for 80% of ADRs Cooper J. Adverse Drug Reaction-Related Hospitalizations of Nursing Facility Patients. Southern Medical Journal. May 1999;92(6):772-80.

13. Adverse Drug Reactions in real life… 5 residents (of 52) had recurrence of hospitalization for the same problem number of meds (adjusted for number of problems) ADR hospitalizednon-ADR 7.9 ± 2.63.3 ± 1.3 Cooper J. Adverse Drug Reaction-Related Hospitalizations of Nursing Facility Patients. Southern Medical Journal. May 1999;92(6):772-80.

14. Adverse Drug Reactions in real life… psychotropics implicated in fall-related fractures Cooper J. Adverse Drug Reaction-Related Hospitalizations of Nursing Facility Patients. Southern Medical Journal. May 1999;92(6):772-80.

15. Adverse Drug Reactions in real life… dont forget anticoagulants warfarin not the most common cause of ADRs, BUT: ADRs are overwhelmingly common in residents taking warfarin wrong dose, inadequate monitoring incorrect response to monitoring results lack of observation for or response to development of side effects

16. Physician contributions to preventable ADRs 47% - caused by physicians order wrong dose guaranteed drug-drug interaction wrong drug 49% - failure to monitor therapy inadequate lab monitoring failure or delay in responding to labs or symptoms or signs of drug toxicity NIH News Release, August 2000 http://www.nia.nih.gov/news/pr/2000/0809.htm

17. Physician role in reducing medications learn behavior management skills (70-80% of residents have dementia; 65 – 70% of those will have behavioral challenges) resistance to care negative interpersonal interaction wandering calling out insist on non-pharmacologic management - first and always

18. Physician role in reducing medications help nursing staff to learn/use good assessment skills avoid knee-jerk response to prescribe a medication for symptom control (especially in response to after-hours telephone call) work with pharmacist in identifying possibilities for medication reduction

19. Physician role in reducing medications dont add medications to the residents drug regimen unless truly needed when reducing medications give appropriate orders for monitoring of withdrawal document appropriately do follow-up documentation as required

20. Physicians: practice habits needed when ordering new medication drug regimen review dont order drugs with long half-life avoid combination drugs: are all components necessary? alert nursing staff to potential side effects (not PDR list, but based on physicians knowledge of patient, diseases, drug interactions) establish appropriate monitoring

21. Physicians: Knowledge Needed geriatric pharmacology pharmacokinetics: what the body does to the drug time course of absorption, distribution, metabolism, excretion pharmacodynamics: what the drug does to the body therapeutic pharmacologic adverse

22. Physician drug regimen review for each drug order, consider Is drug prescribed being administered to a high-risk patient? (Note: all geriatric patients are high risk!) Is drug being prescribed a high-risk drug? Is drug being prescribed a targeted drug (high potential to cause ADR)? Is there a valid medically necessary reason to prescribe the drug? Why cant the drug be reduced/stopped?