Nevada RNformation - December 2021

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Page 4 • Nevada RNformation December 2021, January, February 2022 NNA is excited to provide our RNF readers with this FREE CEU course! Authored by: Tracey Long PhD, MS, MSN, RN, APRN-BC, CDE, CNE, CHUC, COI, CCRN NNA Course #001 Polypharmacy Problems and Solutions Outline Section 1: The Problems of Polypharmacy Section 2: Adverse Effects of Overmedication Risks Overview Risk for Falls Section 3: Pharmacokinetics Absorption Distribution Metabolism Excretion Other Factors Section 4: Screening Strategies Beers Criteria STOPP/START The ARMOR Tool Section 5: Improving Medication Management Reducing Inappropriate Prescribing Decreasing Polypharmacy Avoiding Adverse Events and Reactions Section 6: Implications for Healthcare Professionals Section 7: Resources and References Section 8: Post-Test Polypharmacy: Problems and Solutions (Image Source: wiki commons images url: https://www.dreamstime.com/stock-photooverflowing-pillbox-closeup-image25488840) 1.0 contact hours Author: Tracey Long PhD, MS, MSN, RN, APRN-BC, CDE, CNE, CHUC, COI, CCRN Course Summary: This course discusses the problems of polypharmacy, especially seen in the elderly. Pharmacodynamics will be explained in context to the aging body. It includes an introduction to Beer’s criteria, which is used to identify inappropriate medications for older adults. Measures to improve safe medication management and adherence will be discussed. Accreditation ANCC NNA Course Objectives When you finish this course, you will be able to: • Identify the problem of polypharmacy and summarize the risks of multiple medications. • Distinguish between pharmacokinetics and pharmacodynamics. • Explain Beers criteria and additional screening strategies to identify inappropriate medications for older adults. • Identify adverse results of polypharmacy. • List ways of improving medication management and avoiding polypharmacy. (Image Source: https://jeffreysterlingmd.files. wordpress.com/2016/02/medmngt.jpg) Introduction Case Scenario Walter, 78-year-old Caucasian male didn’t sound like himself on the phone while visiting with his son. As a widow he lives alone after raising his five children with his wife. In his retirement years he generally sits home watching TV and reading. His medical conditions include COPD, diabetes, neuropathy, hypertension, hypothyroidism, hyperlipidemia, obesity, and depression. He receives medications for each of these diseases in addition to over-the-counter vitamin supplements and herbal remedies a friend told him about, which total over 12 medications daily. His primary care provider (PCP) recently added a new medication for hypertension. In addition to his PCP, he sees a nephrologist, a cardiologist, and a pulmonologist. As his vision has worsened so has his memory of which medications he has already taken for the day. While talking to his son, the son noticed his father’s speech was slurred and he couldn’t stay up with the conversation. Later after work, the son drove to his father’s home and brought him to the emergency department at the local hospital. Hours later in the emergency department, and after multiple tests, it was determined he had taken too many medications over the past week and had induced delirium. Unfortunately, this scenario is all too common in the United States, especially in the geriatric population. Nurses need to be aware of the dangers of polypharmacy, the need for medication reconciliation at each visit, and proper patient education regarding medication management. Section 1: The Problems of Polypharmacy The concurrent use of several drugs, defined as polypharmacy, is a serious and often fatal issue. Polypharmacy is the use of five or more daily medications, including over-the-counter (OTC) medications, dietary supplements, and herbal remedies. Polypharmacy includes prescribing more medication than is clinically indicated, using inappropriate medications, and using the correct medication for an inappropriate length of time (Masnoon, et al, 2017; Pazan, et al, 2021, AHRQ, 2015). Research shows polypharmcy of five or more drugs creates more potential adverse drug reactions (ADRs), also called adverse drug effects, as the medications interact with each other. Increased complications from comorbidities also impact the combination of various medications that each is each is trying to treat (AHRQ, 2015; Sirois, et al, 2017). Other challenges include medical illiteracy, which may lead to nonadherence to the treatment regimen and prescription instructions, which may become more confusing to understand as each medication may have a different schedule. Medication management is an even greater challenge for the older adult due to decreasing vision and dexterity, comorbid conditions, often multiple caregivers and physicians involved, barriers to financial ability to pay for medications, nonadherence, declining metabolism and often memory decline. It is estimated that nearly half of older adults are taking one or more mediations that are not clinically necessary. More than 90% of those 65 or older use at least one medication per week, 58% take five or more, and 12% use ten or more (Sirois, et al, 2019). Medication errors cause 10- 30% of all hospitalizations annually in older patients (Parameswaran, 2016). Not only does polypharmacy create preventable healthcare costs, but significantly increases morbidity and mortality. It is estimated almost one third of older home health care patients are taking a medication that is considered inappropriate for older people (Cadenas, et al, 2021). Home medication management systems range from the careful and methodical to the random and arbitrary. Elders who have difficulty opening medication bottles may utilize the “candy dish” method—dumping multiple medications into one bowl and fishing out the appropriate medication at the scheduled time. Some older adults store medications in shopping bags or shoeboxes while others carefully fill medication dividers weeks in advance. As the number of older adults increase, health professionals need to spend more time evaluating medication management in the home setting. The rate of growth in the number and proportion of older adults is unprecedented in the history of the United States. Two factors—longer life spans and the large cohort of aging baby boomers—will combine to double the population aged 65 and older in the next twenty-five years. By 2050 the population of age 65 and older is estimated jump to 16% compared to the 9% in 2020 (CDC, 2020). Globally the proportion of elderly adults is 10.5% and is projected to rise to 1.5 billion people aged 65 and older (CDC, 2020). Proper use of medications is critical to proper and costeffective chronic disease management. Improved medical care and prevention efforts have contributed to dramatic increases in life expectancy in the United States over the past century. These factors have caused a major shift in the leading causes of death, from infectious diseases and acute illnesses to chronic diseases and degenerative illnesses. The incidence of chronic disease increases with advancing age, causing Medicare expenditures to rise proportionally. Currently, about 92% of older Americans are living with at least one chronic condition and 77% suffer from at least two diseases. (NCOA, 2016). Elders who have developed multiple chronic diseases will therefore be at greater risk of being prescribed additional medicine as part of the treatment. The cost of providing healthcare for an older American is three to five times greater than the cost for someone younger than 65. By 2030 the nation’s healthcare spending is projected to increase by 33% (CMS, 2019). A large portion of medical expense is attributable to medication-related problems, which cost the United States 300,000 lives and $3.6 a year (CDC, 2021). The elderly are at risk because of their high rate of medication use. Polypharmacy significantly increases the chance for medication non-adherence, medication errors, and drug-drug, drug-food, and drug-disease interactions. The risk for adverse drug reactions (ADRs) increases as the number of medications increases. The older adult who has cognitive impairment, who is living alone, or who is seeing multiple prescribers, is especially at risk. In addition, normal changes of aging alter the effect of medications, so that medications that are appropriate for younger people may be contraindicated in older adults due to a lower muscle mass, slower renal clearance and intestinal absorption. In the United States, nearly 30% of all hospital admissions are older adults who have not taken their medications properly. The classes of drugs most commonly associated with adverse drug reactions in older adults include diuretics, warfarin, nonsteroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), beta blockers, and angiotensin-converting enzyme inhibitors (ACEI) (Christensen, et al, 2019; Neuman, et al, 2015).
December 2021, January, February 2022 Nevada RNformation • Page 5 Common Drug Classes Taken in Medicare Patients • Cardiovascular (53.2%) • Antibiotics/antiinfectives (44.5%) • Diuretics (29.5%) • Opioids (21.9%) • Anti-hyperlipidemic (21.7%) • Nonopioid analgesics (19.8%) o Gastrointestinal tract (19.0%) o Respiratory tract (15.6%) o Dermatologic (14.8%) • Antidepressants (13.2%) • Sedatives/hypnotics (12.9%) • Nutrients/ supplements (12.3%) • Hypoglycemics (11.5%) • Steroids (9.7%) • Ophthalmics (9.6%) • Thyroid (9.4%) • Antihistamines (9.2%) • Hormones (9.1%) • Anticoagulants (7.0%) • Muscle relaxants (5.4%) • Osteoporotic (5.3%) • Anti-seizure (3.4%) • Anti-gout (3.2%) • Anti-neoplastic (2.8%) • Anti-platelets (1.3%) • Anti-psychotics (1.2%) • Anti-parkinsonians (0.9%) • Alzheimer disease (0.9%) • Immunomodulators (0.04%) Apply Your Knowledge: What could have been done for Walter in our case scenario to avoid the overdose of polypharmacy and resultant hospitalization? If you as the healthcare professional interacted with Walter, it would be helpful to ask for a list of his medications and what he knows about each one, including the over-the-counter medications. Patients should be encouraged to know about all their medications, what they’re for and what adverse effects to watch for. For elderly patients, a written list is helpful and can be created as easily as writing them on a note card for the patient to keep in their wallet or purse. Medic-Alert style bracelets should be encouraged, especially for diabetics. Case Scenario Continues Walter’s symptoms of slurred speech, disorientation and confusion are classic for overmedication. Walter also experienced drowsiness and slight confusion, which he mistakenly identified as normal for him since he is aging. When he woke up from his second daytime nap, he stumbled to get up to the bathroom and thought it was just because he was still drowsy. He had to brace himself against the wall down the hall to the bathroom and passed it off to being clumsy. After speaking to his son on the phone he couldn’t remember what the conversation was about. Walter was admitted into the hospital to monitor him for adverse drug effects and medication adjustments. His hospital bill came to over $5800 for a two-day hospital stay. In collaboration with the emergency physician, hospitalist and nurses, a medication reconciliation was completed, and several medications were discontinued. He was discharged with instructions to follow up with his primary care physician. At the follow-up, the primary care physician realized that the patient had been taking additional medications he was unaware of that were prescribed by other doctors. The patient had been taking medications from various doctors and each physician was unaware of the additional treatments. Walter didn’t know what each medication was for and stated, “my doctors know all about that.” Section 2: Adverse Effects of Overmedication Healthcare providers need to be alert to the potential for polypharmacy and its complications. It is essential to identify risk factors in the patients we treat in order to manage medications appropriately. Risks Overview Polypharmacy increases the risk of potentially inappropriate prescriptions, cognitive disorders, falls, hip fractures, depression, and incontinence. Inappropriate medications complicate polypharmacy because many of the drugs classified as potentially inappropriate are associated with adverse drug reactions (ADRs), some offer little or no advantage over other, safer drugs, and some have a long half-life in older patients (Soler and Barreto, 2019). Risk Factors for Adverse Effects from Polypharmacy Category Age Living situation Medications Medical Cognition Physical Characteristic(s) indicating high risk Over 75 years of age Living alone or with an elderly spouse Taking multiple drugs, OTC, social drugs • Multiple prescribers, such as physicians, psychiatrists, dentists, podiatrists, or nurse practitioners • Multiple medical problems • Multiple caregivers • Poor communication between older patients and health professionals • Impaired alertness or memory • Psychiatric problems • Inability to take medications as directed • Appears weak and with impaired mobility • Needing a walker or cane Risk for Falls It has been well-established that polypharmacy is a risk factor for falls. An estimated 30% of elderly report falling each year and falls claim the leading cause of fatal and nonfatal injuries among adults age 65 and older (Zaniotto, et al, 2020, Gomez, 2015). Classes of medications that have been linked to increased fall risk, especially in the elderly include nonsteroidal anti-inflammatory drugs (NSAIDS), benzodiazepines, anticholinergics, opioids, antidepressants and neuroleptics (Zaninotto, et al, 2020). It is recommended that each of these medications begin at low-dose entry levels and titrate upward slowly as needed. Careful monitoring should be done within the first 2 weeks of drug therapy with benzodiazepines, opoids and antidepressants when the fall and fracture risk is highest. Assessment tools have been created and even screening tools for fall-risk prediction in the elderly that can be used (Bongue, 2010). The Home Health Quality Improvement organization has gathered helpful research and created practice guidelines for medication management. Less well known is that fall risk can increase significantly in the days following a medication change. Short-term risk of single and recurring falls may triple within two days after a medication change. Key factors involved that need to be assessed for fall and fracture risk and include the following: • Postural hypotension • Use of sedatives • Use of at least four prescription medications • Impairment in arm or leg strength or range of motion • Balance • Ability to move safely from bed to chair or to the bathtub or toilet (transfer skills) • Gait Another strategy to decrease fall risk is to complete a medication reconcilliation at every medical office visit or hospitalization. It is the process of creating an updated list of all the current medications a patient may be receiving and includes the dosage, route, time, purpose and frequency of the drug. Both generic and brand names should be identified so as not to duplicate drugs. Many times a patient may be confused and be taking the drug twice as often as prescribed because the names are different even when the drug is the same. Physicians, Physician Assistants, Nurse Practitioners, nurses and other health care professionals should be completing this process upon hospital admission, discharge, home visits, care plan reviews, annual comprehensive exams, office visits and any time the patient is being transferred from one facility to another or has medication changes. What can you do for your patients to help assess for and prevent falls? According to HHQI, you can use many fall assessment tools including the Get Up and Go test and fall risk tools such as the Fall MedQIC Fall Risk form, which answers questions about past falls, the number of medications prescribed, physical strength, confusion and orientation status and more to come up with a number that quantifies the patient’s fall risk. Download the form at: http://www.homehealthquality.org/Education/Best- Practices/BPIPs/Fall-Prevention-BPIP.aspx Teaching the patient about the purpose of their medications can also help them evaluate the medication’s usefulness. Section 3: Pharmacokinetics and Aging Pharmacodynamics refers to the effect that the drug has on the body, and pharmacokinetics is the way the drug moves through the body of a person. This includes the separate processes of ingestion, absorption, distribution, metabolism, and excretion (ASHP, 2020). Age-related changes in physiology can render an older adult more sensitive to medications, making polypharmacy a major issue associated with adverse drug events (ADEs), and increased hospitalizations. In the elderly, general intestinal absorption slows as well as renal and the liver’s ability to effectively metabolize drugs in the first-pass effect making drugs potentially more toxic in the body. Pharmacokinetics is the study of the absorption, distribution, metabolism, and excretion (ADME) of drugs. Changes associated with aging affect the pharmacokinetics of medications. Once taken, a medication must obtain therapeutic levels in the bloodstream to exert a clinical action. This section discusses how normal changes of aging and alterations due to age-related conditions affect the body’s response to polypharmacy. Absorption Drugs are administered orally, parenterally, or topically. Drugs taken orally are absorbed in the gastrointestinal (GI) tract. Drugs administered parenterally are absorbed by the vascular circulation, while topical drugs are absorbed by skin or mucosa. Incomplete absorption of orally administered drugs occurs mainly because of lack of absorption from the gut. If a drug is too hydrophilic (easily absorbed by or dissolved in water) it will have trouble crossing the cell’s lipid membrane. If a drug is too lipophilic (fat-soluble) it will not be soluble enough to cross the water layer surrounding the cell (Le, 2020). Following administration of a drug by any route, some fraction of the unchanged drug will reach the systemic circulation. The amount of drug reaching the systemic circulation after administration is referred to as its bioavailability. In general, absorption is unchanged in later adulthood; however, there are some important changes to consider related to aging. Age-related changes can impede absorption due to decreased blood flow to the tissues and the GI tract and changes in gastric pH (Le, 2020). In most older adults this normative change of aging has no clinical consequence; however, the use of certain medications can enhance this effect and alter absorption significantly. For example, proton pump inhibitors (PPIs) such as omeprazole lower gastric pH and can inhibit Vitamin B12 absorption (Marieb, 2016). Elders should take PPIs for the least time necessary to ameliorate the condition they are meant to treat. An older adult taking a PPI for a prolonged period of time should have periodic monitoring of vitamin B12 or take supplements. Chronic illness and age-related variations in plasma proteins may also cause significant problems with CEU Course continued on page 6
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