Geriatric Nursing and Drug Interaction
Drug Events in Old Age
One in seven Medicare beneficiaries experienced an adverse event
while hospitalized in 2008. Of those, 31% of the adverse events were related to
medications (Levinson, 2010).
Nearly 1.9 million adverse drug events (ADE)
occur each year in older adults enrolled in Medicare and 180,000 of those are
life threatening or fatal (Gurwitz et al., 2003). ADEs are common in older
adults yet are potentially preventable (Safran et al., 2005).
Persons older than the age of 65 years’ experience
medication-related events for seven major reasons:
(a) alteration in
pharmacokinetics (ie, reduced ability to metabolize and excrete medications)
and pharmacodynamics (Mangoni & Jackson, 2004; Rochon, 2010)
(b)
polypharmacy (Gallagher, Barry, & O’Mahony, 2007; Hajjar & Kotchen, 2003)
(c) incorrect doses of medications (more than or less than therapeutic dosage,
Doucene, McDonough. Klepser, & McCarthy, 2005, Hanlon, Schmader, Ruby,
& Weinberger, 2001; Sloane, Zimmerman, Brown, Ives, & Walsh, 2002 )
(d) using medication for treatment of symptoms that are not disease dependent
or specific (ie, self-medication or prescribing cascades: Neafey &
Shellman, 2001: Rochon & Gurwitz, 1997)
(e) iatrogenic causes such as ADEs
and inappropriate prescribing (Fick et al., 2003, Pirmohamed et al., 2004;
Rothberg et al., 2008)
(f) problems with medication adherence (Steinman &
Hanlon, 2010)
(g) medication errors (Agency for Healthcare Research and
Quality (AHRQ), 2001: Doucette et al., 2005).
Intrinsic factors such as
advanced age, frailty, and polypharmacy place older adults at greater risk for
adverse outcomes.
Older adults are the largest consumers of medications with
82% taking at least one medication, 29% -39% taking five or more drugs, and up
to 90% taking over-the-counter (OTC) drugs (Hanlon.
Fillenbaum, Ruby, Gray,
& Bohannon, 2001: Kohn, Corrigan, & Donaldson, 2000). Older adults
often combine OTC medications with prescription medications yet do not report
their OTC use to health care providers.
Likewise, providers often do not
inquire about OTCs or herbal remedies. Underreporting may lead to unrecognized
adverse drug-disease or drug-drug interactions (Astin, Pelletier, Marie, &
Haskell, 2000; Rochon, 2010).
These factors make it paramount that nurses
identify older adults at risk for adverse events.
Adverse Drug Events
An ADE is an adverse outcome that occurs during normal use of
medicine, inappropriate use, inappropriate or suboptimum prescribing, poor
adherence or self-medication, or harm caused by a medication error.
It is
estimated that 35% of older persons experience ADEs, almost half of which are
preventable (Safran et al., 2005). Older adults are also at significant risk
for further ADEs while in the hospital and after discharge.
Acute drug toxicity
represents 2.5% of emergency department (ED) visits for unintentional injuries.
of which 42% resulted in a hospital admission (Budnitz et al., 2006; Hanlon et
al., 2006).
Significant morbidity and mortality are associated with ADEs, with
the cost estimated to be approximately $75-$85 billion annually (Budnitz et
al., 2006; Fick et al., 2003: Hanlon et al., 2001).
ADEs are also associated
with preventable adverse outcomes such as depression, constipation, falls,
immobility, confusion, hip fractures, rehospitalization. anorexia, and death
(Aspden, Wolcott, Bootman, & Cronenwett, 2007).
Latrogenic Causes of Adverse Drug Events
Older adults’ susceptibility to ADEs is well documented in the
literature on iatrogenic events and medication errors (Gurwitz et al., 2003;
Hohl et al., 2005). The term iatrogenic, as it relates to ADEs, means any
undesirable condition in a patient occurring as the result of treatment by a
health care professional, specifically pertaining to an ill-ness or injury
resulting from a medication/drug or treatment.
An iatrogenic medication event
is one that is preventable, such as the wrong dose of a given medication
resulting in an adverse outcome. Adverse drug reactions (ADRs), inappropriate
prescribing of high-risk medication to older adults, and medication errors are
also considered iatrogenic ADEs.
In a systematic review, the most common
preventable ADEs included antiplatelet medications, diuretics, and
anticoagulants. Prescribing problems, adherence problems, and monitoring
problems have been associated with preventable admissions as well (Howard et
al., 2007; Steinman & Hanlon, 2010).
Frail older adults with multiple
medical problems, memory issues, and multiple prescribed and nonprescribed
medications are at highest risk for ADEs (Rochon, 2010).
Adverse Drug Reactions
An ADR, a type of ADE, is any toxic or unintended response to a
medication (Committee of Experts [COE] on Safe Medication Practices, 2005). The
prevalence rate of hospital admissions caused by ADRs has been reported between
5% and 35% (Gurwitz et al., 2003: Kohn et al., 2000).
A recent systematic
review reported 10.7% prevalence rate of hospital admissions caused by ADRs in
older adults; however, a confounding factor in the accuracy is the different
methods and studies employed to gather the data (Kongkaew, Noyce, &
Ashcroft, 2008).
Among a community-dwelling population of older adults, 38% of
ADRs were considered serious, life threatening, or fatal and 27% were
considered preventable (Gurwitz et al., 2005).
Pirmohamed et al. (2004)
reported that 70% of ADRs were either possibly avoidable or definitely
avoidable in a study of 18,820 older adults,
Twenty-nine percent of ADEs require evaluation by a physician,
evaluation in the emergency room, or hospitalization for clinical management
(Hohl et al., 2005; Petrone & Katz, 2005).
A meta-analysis revealed that
ADRs accounted for 6.7% of hospital admissions and in-hospital ADRs; when
extrapolated, they would be the fourth-sixth leading cause of in-hospital
mortality for all causes of death, which does not include ADRs related to
errors, nonadherence, overdose, or therapeutic failures (Lazarou, Pomeranz,
& Corey, 1998; Steinman & Hanlon, 2010).
Drug-drug and drug-disease
interactions are the most common ADRs (Hansten, Horn, & Hazlet, 2001:
Juurlink. Mamdani, Kopp, Laupacis, & Redelmeier, 2003; Zhan et al., 2005).
Drug-drug interactions occur when one therapeutic agent either alters the
concentration (ic. pharmacokinetic interactions) or the biological effect of
another agent-pharmacodynamic interactions (Leucuta & Vlase, 2006).
Gray
and Gardner (2009) reported that polypharmacy and multiple prescribers tend to
be key factors in these adverse reactions. Older adults with multiple chronic
medical problems requiring multiple medications are at high risk for these
interactions (Rochon, 2010).
Medication Errors
The Institute of Medicine (IOM) reported in 1999 that almost 7,000
hospital deaths were associated with medication errors (Kohn et al., 2000).
Medication errors occur frequently, yet many hospitals still lack automated
physician order entry systems that are reported to decrease the number of
medication errors (National Coordinating Council for Medication Errors
Reporting and Prevention [NCC MERP), 2001).
A medication error is defined by the COE on Management of Safety
and Quality in Health Care (COE, 2005) as any preventable event that may cause
or lead to inappropriate medication use or patient harm while the medication is
in the control of the health care professional , patient, or consumer.
Such
events may be related to professional practice, health care products,
procedures, and systems, including prescribing; order communication, product
labeling, packaging, and nomenclature; compounding, dispensing, and
distributing; administration, education, and use.
A large percentage of errors
are caused by administration of the wrong medication or the correct medication
with the wrong dose or at the wrong time interval between dosing (Rochon,
2010).
There are many reasons medication errors occur; however, it is beyond
the scope of this chapter. Information regarding the immense literature on
medication errors is provided in the Resources section of this chapter.
Adhesion
Medication adherence (or compliance) with a medication regimen is
generally defined as “the extent to which a person’s medication-taking behavior
corresponds with agreed recommendations of a health care provider” (Sabaté,
2003, pp. 3).
Seventy percent of patients who begin taking a prescribed drug
discontinue it within 1 year, with the greatest drop-off rate at 6 months
(Osterberg & Blaschke, 2005).
A national survey of 17,685 Medicare
beneficiaries older than age 65 years found that 52% do not take medications as
prescribed (Safran et al., 2005).
Nonadherence was primarily associated with a
belief that the drug made them feel worse or was not helping (25%), or cost of
the medicine, resulting in a decision to skip or take a smaller dose (26%).
Prescription drug coverage significantly impacted adherence, with 37%
nonadherence among those with our coverage compared with 22% nonadherence
beneficiaries with coverage. Patients are often reluctant to admit
nonadherence; however, pill counts and refill history can aid in determining
this issue (Osterberg & Blaschke, 2005; Steinman & Hanlon, 2010).
Acute care nurses are ideally positioned to identify and aid in
preventing ADEs in hospitalized older adults and in transitions to other levels
of care.
Areas in which nurses must be familiar are iatrogenic causes of ADEs
such as ADRs, inappropriate medications, identifying system issues to reduce
medicine errors, and risk of nonadherence in older adults.
Education of patient
and families, recognizing inappropriate medications, and reinforcing the need
for drug monitoring are areas where nurses can make a difference in aging
persons (Fick et al., 2003; Rochon, 2010).
Nurses must take a proactive role in
ensuring patient safety through interdisciplinary collaboration with patient
and family, doctors, advance practice nurses, and pharmacists to prevent
adverse medication outcomes.
Assessment Tools
Assessment tools are used to evaluate an older adult’s ability to
self-administer medications (ie., functional capacity assessment); assessment
of the medication list for potential inappropriate medications, drug-drug or
drug-disease interactions; and assessment of renal function in collaboration
with interdisciplinary team members.
Commonly used tools include the following:2002 Criteria for Potentially Inappropriate Medication Use in Older
Adults: Independent of Diagnoses or Condition (Fick et al., 2003).
Used to
assess medication list for medications that should generally be avoided in
older adults. (See http://www.consultgerirn.org/resources, “Try This” series,
issue number 16.1.) 2002 Criteria for Potentially Inappropriate Medication Use
in Older Adults: Considering Diagnoses or Condition (Fick et al., 2003; see “
Try This” series, issue number 16.2).
Used to assess for the presence of
medications that may interact adversely with a disease or condition a person
has. Drug-Drug Interactions. List of medications known to interact
with other medications.
This may be performed by a computer or personal digital
assistant (PDA) program, such as Facts and Comparisons PDA program to identify
drug-drug and drug-disease interactions or “Physician Order Entry (POE)”
programs.
Cockroft-Gault Formula (Table 17.2). Useful for estimating
creatinine clearance based on age, weight, and serum creatinine levels
(Terrell, Heard, & Miller, 2006). Functional Capacity (activity of daily
living (ADL), independent activity of daily living (ADL). Mini-Cog/Mini-Mental
State Exam (MMSE).
Assessment Strategies
Changes With Aging
Aging changes in pharmacokinetics and pharmacodynamics are
important to consider when assessing medications in older adults (Mangoni &
Jackson, 2004; Rochon, 2010). Pharmacokinetics is best defined as the time
course of absorption, distribution across compartments, metabolism, and
excretion of drugs in the body.
As the body ages, the metabolism and excretion
of many drugs declines and physiological changes require dosage adjustment for
some drugs (Cusak & Vestal, 2000). Pharmacodynamics is defined as the
response of the body to the drug that is affected by receptor binding, post
receptor effects, and chemical interactions (Cusak & Vestal, 2000).
Pharmacodynamic problems occur when two drugs act at the same or interrelated
receptor sites, resulting in additive, synergistic, or antagonistic effects.
Many interactions of drugs are multifactorial, with sequence of events that are
both pharmacokinetic and pharmacodynamic (Spina & Scordo, 2002).
The
following are changes that may occur with aging:Changes in drug absorption (ie, increased gastric pH and decreased
gastrointestinal [GI] motility in an absorptive surface) once thought to be
caused mainly by aging changes are now thought to be caused by underlying
disease states (Mangoni & Jackson, 2004).
There may, however, be a change
of absorption rate in persons taking many medications, for example,
fluoroquinolones taken with iron may impair absorption (Semla & Rochon,
2004).
Complete Medication History
Date Performed
Patient Name
Medication allergies and type of reaction (eg, hives)
Prescription medications
Specifically ask about eye drops, topical creams, B injections, or
other injections (at home or at medical office, how often). Recently
discontinued medications and why. Medication reconciliation performed and
verified Discrepancies found and reason(s) Over-the-counter drugs How often do
you exceed the recommended dose on package? Do you read the labels? Why or why
not? Do you ask a pharmacist or your provider about interactions with your
prescriptions? Ask specifically what patient is taking in the following
classes:
Pain relievers
What have you tried, what works, and what does not? What pain do
you take it for? How often?
Allergy medications When do you take them? Year round? What season?
Or When symptoms develop?
Sinus congestion/cold or cough medications (combined products with
more than one ingredient?)
Heart burn medications, how often?
Diarrhea or constipation treatments, how often?
Sleeping medications, ask specifically diphenhydramine (Benadryl)
Eye drops-how often what do you take them for?
Herbal remedies (orally or as a tea) or Chinese medicine
– ginkgo biloba
-ginseng-glucosamine
– St. John’s wort
– echinacea
Nutritional supplements
Ask specifically about:
Calcium with vitamin D, vitamin E, C, or B’s
Megavitamins
Protein supplements such as Ensure, Boost, or protein bars
vitamin drinks
Medications that have been stopped and why? (Did you discontinue or
provider?) Alcohol
Ask about type/amount per day
Smoking (what and how much; eg, cigarette packs per day, how many
years) Past or annual immunizations, date last received Pneumonia vaccine Flu
vaccine
Regular lab tests-performed to evaluate medication levels or side
effects (eg potassium level, digoxin level, INR, liver toxicity, renal
function). Inquire about those not drawn that should be based on the
aforementioned medical list.
Use of memory aids-reminders to take medications (eg, pill
dispenser box) Assess adherence: Consider using DRUGS tool (Edelberg et al.,
1999; Hutchison et al., 2006).
Drug distribution changes associated with aging
decreased include cardiac out- put, reduced total body water, decreased serum
albumin (which is more likely to be related to malnutrition or acute illness
than aging), and increased body fat.
Reduced total body water creates a
potential for higher serum drug levels because of a low volume of distribution and
occurs with water-soluble drugs (hydrophilic) such as alcohol or lithium.
Decreased serum albumin results in higher unbound drug levels with
protein-bound drugs such as warfarin, phenytoin, digoxin, and theophylline.
Lipophilic drugs (eg, long-acting benzodiaz-epines [BZDs) are stored in the
body fat of older persons and slowly leech out, resulting in increased
half-life and resulting in the drug staying around longer (Gallagher et al.,
2007).
A significant change in drug metabolism is a reduction in the
cytochrome p-450 system, which affects metabolism of many drugs cleared by this
enzyme system (Cusak & Vestal, 2000; Mangoni & Jackson, 2004; Tune,
2001).
Many classes of drugs are cleared by the cytochrome p-450 enzyme system
including cardiovascular drugs, analgesics, nonsteroidal anti-inflammatory
drugs (NSAIDs). antibiotics, diuretics, psychoactive drugs, and others (Mangoni
& Jackson, 2004).
Drugs such as beta-blockers that have a first pass effect
in the liver may be effective in lower doses in older adults (Gallagher et al.,
2007). For a list of drugs cleared by this enzyme system see The Merck Manual
of Geriatrics at http://www.merckmanuals.com/mm geriatrics.
Metabolism may be
affected by disease states common in older individuals (eg, thyroid disease,
congestive heart failure [CHF), and cancer) or drug induced metabolic changes
(Cusak & Vestal, 2000). Several drugs are cleared by multistage hepatic
metabolism, which is more likely to be prolonged in older persons (Mangoni
& Jackson, 2004).
Some drugs undergo hepatic metabolism then renal
clearance. Such drugs (diazepam) have enormously longer half-lives in the older
adult because both systems are impaired.
Elimination or clearance of medications from the body may be slowed
because of decline in glomerular filtration rate, renal tubular secretion, and
renal blood flow that naturally decreases with age (Semla & Rochon, 2004).
Decrease in clearance prolongs drug half-life and leads to increase plasma
concentrations (Gallagher et al., 2007). A decrease in glomerular filtration is
usually not accompanied by an increase in serum creatinine because of
decreasing lean muscle mass with age and subsequent decline in creatinine
production.
Lack of dosage adjustment for renal insufficiency is a common
reason for ADEs (Rochon, 2010). Therefore, serum creatinine is not an accurate
measure of renal function in the older adult.
Instead, assessment of renal
function using the Cockroft-Gault formula (Table 17.2) should be calculated
prior to initiation of renal clearing medications (Mangoni & Jackson, 2004;
Semla & Rochon, 2004).
Beers Criteria
In 1999, the Centers for Medicare and Medicaid Services (CMS)
incorporated the Beers criteria into regulatory guidelines in long-term care
(Lapane, Hughes, & Quilliam, 2007). Long-term care facilities can be cited
if any of the drugs on the list are prescribed.
The Joint Commission (TIC) also
adopted the criteria as a potential sentinel event (2007) in hospitals. The
Beers criteria address two key areas:
(a) medications or medication classes
that should generally be avoided in persons aged 65 years and older
(b)
medications that should be avoided in older persons with specific medical
conditions
A severity rating of high or low is given to each medication based
on its potential negative impact on older adults.
The most recent Beer’s
criteria, updated in 2003 by Fick et al., identifies 48 medications or classes
that should generally be avoided in persons older than 65 years, as well as 20
specific medications that should not be used in the presence of specific
conditions.
Inappropriate medications on the Beers list that resulted in ED
visit for ADEs included insulin, warfarin, and digoxin (Fu, Liu, &
Christensen, 2004); these drugs are commonly reported as high risk in other studies
(see High-Risk Medications section). See “Try This series, issue numbers 16.1
and 16.2 at http://www.consultgerirn.org for Beer’s criteria.
Medications on the Beers inappropriate list have been shown to be
associated with poor health outcomes. Fick and colleagues (2003) reported that
ambulatory older adults prescribed with medications from the Beers list were
more likely to be hospitalized or evaluated in an emergency room than those not
taking such medications.
Other studies report a positive association between
potentially inappropriate drug prescribing and ADRs in first-visit older adult
outpatients (Chang et al., 2005; Fu et al., 2004).
Although the Beers criteria
for inappropriate medications are an excellent guideline for assessing
potential inappropriate medications, they need to be used in conjunction with
patient-centered care (Swagerty, Brickley, American Medical Directors
Association [AMDA), & American Society of Consultant Pharmacists [ASCP ],
2005).
A joint position statement by the AMDA and ASCP points out that the
Beers criteria are based on consensus data (eg, lower level of evidence) rather
than on higher levels of evidence such as systematic reviews or randomized
controlled trials.
Jano and Aparasu (2007) found that use of inappropriate
medications (Beers list) was associated with an increase in ADRs and increased
costs across settings; however, they suggest the predictive ability of the
criteria needs to improve.
Assessment for Potential Adverse Drug Reactions
ADRs commonly occur because of the number of medications taken
(polypharmacy) by older persons and their concomitant medical conditions. The
severity of adverse reactions increases because of changes in pharmacokinetics
and pharmacodynamics in older adults.
Assessment for older adults’ risk of ADRs
and potential drug-disease and drug-drug interactions must be considered before
initiating medications in the older adult.
Potential medication-related and patient-related risk factors for
ADRs in older people were examined and reported by Hajjar and Kotchen (2003). A
consensus panel of four geriatric pharmacists and geriatric physician experts
reviewed a list of evidence-based risk factors compiled by two experts from the
literature to ascertain older adult risk factors for ADRs.
The most preventable ADRs in the outpatient setting reported by
Gurwitz and colleagues (2003) are cardiovascular medications followed by
diuretics, nonopioids analgesics, hypoglycemics, and anticoagulants.
In 2005,
the largest number of preventable ADRs occurred at the prescribing or
monitoring stages and includes wrong drug choices or dosages, inadequate
patient education, or clinically important drug-drug interactions (Gurwitz et
al., 2005).
Monitoring for errors include inadequate evaluation of drug levels
and failure to respond to signs, symptoms, or abnormal lab levels indicative of
toxicity.
Nurses can help to prevent ADRs in the acute care setting by monitor
in gor recommending lab values, determining appropriateness of drugs and doses
when orders are written, and monitoring for signs and symptoms of toxicity.
It
is important for nurses to understand that ADRs may be difficult to recognize
as they often present as atypical symptoms such as confusion, falls, lethargy,
constipation, and depression (Hanlon et al., 1997).
Drug Drug Interactions
Concurrent use of more than one drug simultaneously, particularly
those with similar properties, can result in serious toxicities in older adults
resulting in synergistic, additive, or antagonistic effects.
For example,
concurrent use of any two of the following drugs: antiparkinsonian drugs,
tricyclic antidepressants (eg, amitriptyline), antipsychotics (eg, Haldol),
antiarrhythmics (eg, disopyramide), and OTC antihistamines (eg,
diphenhydramine, chlorpheniramine) may cause or dry mouth, gum disease, blurred
vision, constipation, urinary retention, and/or cognitive deficits (Cusak &
Vestal, 2000) . ); however, studies indicate that drug-drug interactions are a
common cause of predictable ADEs (Hansten et al., 2001).
Drug-drug interactions
have resulted in serious adverse events among several classes of medications.
For example, hypoglycemia resulted in around 900 patients out of 179,000 older
patients treated with glyburide along with cotrimoxazole, and 12 patients died.
Digoxin toxicity was experienced by more than 1,000 out of 230,000 patients
admitted and 33 died while hospitalized (Juurlink et al., 2003). Those with
digoxin toxicity were 13 times more likely to have received clarithromycin 1
week prior to hospitalization; suggesting avoidance of concomitant use of
digoxin and clarithromycin may have prevented the toxicity.
In the same study,
concomitant prescribing of angiotensin-converting enzyme (ACE) inhibitors and
potassium-sparing diuretics 1 week before admission were observed in 622,285
older persons with ADRs. The researchers estimated that 7.8% of
hospitalizations for hyperkalemia could have been prevented if addition of
potassium-sparing diuretics had been avoided (Juurlink et al., 2003).
In a
retrospective review of the National Hospital Ambulatory Medical Care Survey,
Zhan and colleagues (2005) reported that older adults with two or more
prescriptions had at least one inappropriate drug-drug combination present, and
6.6% of patients on warfarin were prescribed a drug with a potentially harmful
interaction.
Interactions With Over-The-Counter and Herbal Remedies
Drug interactions between prescription medications and herbal
remedies or OTC medications are often not reviewed during medication
reconciliation, hospital admission, or office visits, yet 40% of all OTCs are
consumed by older adults (Astin et al., 2000; Kohn et al., 2000).
In a survey
of 1,001 older adults, up to 75% reported using OTCs that increased as age
increased. Twenty-three percent reported use of two or more OTCs for chronic
conditions in the past month: OTC use has increased over the last decade as
well as polypharmacy (Hanlon et al., 2001; Radimer et al., 2004; Sloane et al.
, 2002).
Community-dwelling older adults in the United States approximately
consume 1.8 OTC medications per day (Hanlon et al., 2001). Herbal or dietary
supplement use such as ginseng, ginkgo biloba extract, and glucosamine is on
the rise among older adults, increasing from 14% in 1998 to 26% in 2002
(Kaufman, Kelly.
Rosenberg, Anderson, & Mitchell, 2002; Kelly et al., 2005).
In a study examining community-dwelling older adults’ use of prescription, OTC,
and dietary supplements, 68% of older adults used prescription medications
concurrently with OTCs, dietary supplements, or both (Qato et al., 2008).
More
than 50% of older adults used five or more prescriptions, OTC, or dietary
supplements, concurrently. The prevalence rate of 5 or more prescription
medications increased steadily with age, and 1 in 8 older adults regularly used
five or more dietary supplements.
This substantially increases the risk of
drug-drug interactions in older adults (Qato et al., 2008). The researchers
also reported 46 potential drug-drug interactions with 11 classified as
potentially of major severity, 28 classified as moderate severity, and 7 as
minor severity. Overall, 1 in 25 older adults (2.2 million) were at risk for
potential major drug-drug interactions.
Half of all potential major drug-drug
interactions involved nonprescription medications (Qato et al., 2008).
The most
commonly reported prescription or OTC medications, according to Qato et al.
(2008), included single or multicomponent products that were cardiovascular
drugs such as antihyperlipidemic, aspirin, hydrochlorothiazide, lisinopril,
metoprolol, and others; dietary supplements were primarily multivitamins or
minerals.
Alternative therapies included garlic, coenzyme Q, omega-3 fatty
acids, and glucosamine-chondroitin. In a review of herbal products and
potential interactions with cardiovascular (CV) diseases, Tachjian, Maria, and
Jahangir (2010) described herbal remedies that produce adverse effects on the
CV system.
These include St. John’s wort, motherwort. ginseng, ginkgo biloba,
garlic, grapefruit juice, hawthorn, saw palmetto, danshen, echinacea,
tetrandrine, aconite, yohimbine, gynura, licorice, and black cohosh. Herbal
agents that interfere with digoxin levels include Chan Su, danshen, Asian and
Siberian ginseng, licorice, and uzara root.
Those that may adversely interact
with warfarin include St. John’s wort, ginseng, ginkgo biloba, and garlic.
Motherwort and BZDs together have a synergistic sedative effect and can result
in coma. Ginseng may have either a hypotensive or hypertensive effect. Several
other interactions are presented in this review.
St. John’s wort was reported as being in the top selling herbs in
the United States yet could potentially result in serious adverse reactions.
Its effect on drug metabolism induces the cytochrome p-450 enzyme system where
many prescription medications are metabolized.
OTC and herbal supplements are
typically not reported to medical providers as most consumers do not consider
them medication and many health care providers do not ask about herbal remedies
and OTC drugs (Astin et al., 2000: Gardiner, Graham, Legedza, Eisenberg, &
Phillips, 2006; Tachjian et al., 2010).
Other concerns are herbal products that
lack scientific evidence of safety, lack regulatory oversight, and there is an
abundance of public misinformation (Tachjian et al., 2010). The implications
for unidentified drug-drug and drug-disease interactions are astounding.
Medication Adherence
As individuals age, they may encounter difficulties that decrease
their ability to adhere to medication regimens (eg, vision impairment,
arthritis, economics). Medication adherence with older adults is complex and
needs careful nursing assessment.
There are a number of ways to assess for
potential adherence-related problems (Bergman-Evans, 2006; Edelberg et al.,
1999) as well as to ascertain if a patient is adhering to recommended treatment
(Rohay, Dunbar-Jacob, Sereika, Kwoh, & Burke, 1996).
Barriers to medication
adherence include forgetting to take or limited organizational skills; belief
that the drug is either not needed, is ineffective, or too many drugs are being
taken; patient has difficulty taking such as opening bottles or swallowing; and
cost (Steinman & Hanlon, 2010).
Several interventions are available in this
systematic review but are beyond the scope of this chapter. An array of devices
can assist in enhancing adherence behavior (Fulmer et al., 1999; Haynes et al.,
2005; Steinman & Hanlon, 2010). See Resources section for further
information.
Reconciliation of Medications
Medication reconciliation (MR) confirms the patient’s current
medication regimen and compares this against the physician’s admission,
transfer, and discharge orders to identify and resolve discrepancies.
Discrepancies between physician-acquired prescription medication histories and
comprehensive medication histories at the time of hospital admission were
common, occurring in up to 67% of cases (Tam et al., 2005).
Around 22% of medication
discrepancies could have resulted in patient harm during their hospitalization
and59% of the discrepancies could have resulted in patient harm if the
discrepancy continued after discharge (Sullivan, Gleason, Rooney, Groszek,
& Barnard, 2005).
Poor communication of medical information at transition points of
care (ar admission. transfer, and discharge) often results in medication
errors, but appropriate strategies can reduce the likelihood of errors
(Santell, 2006).
Adverse events were seen on transfer from hospital to a
nursing home in 20% of patients, particularly those readmitted to the nursing
home (Boockvar et al., 2004). TJC has recommended standards for communicating
drug therapies to other levels of care and across the continuum (Nickerson,
MacKinnon, Roberts, & Saulnier, 2005).
MR is often performed by pharmacists
or nurses; however, MR can be performed by a nurse with pharmacist
collaboration or computer-based programs (Doucette et al., 2005; Gleason et
al., 2004; Nickerson et al., 2005). Accuracy of the list can mean the
difference between patient safety and patient harm.
The MR process includes comparison of medications on patient and
family report or admission and transfer documents with medication orders at the
time of admission, time of transfer to other units, or discharge to other
levels of care.
Barriers for nurses performing MR reported in one study
included lack of confidence in existing institutional safety systems,
inconsistent practices (whether pharmacists are consulted or not), lack of
communication between health professionals, and staffing concerns (MR is time
consuming: Chevalier, Parker, MacKinnon, & Sketris, 2006).
The brown bag
method can be used for corroborating medications (Nathan et al., 1999) with
community dwelling older adults, when used in conjunction with a good
medication or admission history.
At discharge, the pharmacist has been involved in identifying
problems with drug therapy and communicating with the community pharmacy,
medical provider, or admitting staff at the transitional site of care (Hanlon
et al., 2001; Nickerson et al., 2005).
A systematic review across many health
care settings and at home found that interventions by clinical pharmacist
showed a considerable reduction in drug-related problems as well as reduced
morbidity, mortality, and health care costs (Hanlon, Lindblad, & Gray,
2004).
Many hospital pharmacies are now linked electronically to health care
providers and/or local pharmacies. Finally, discharge education and counseling
to patients including assessment of factors that might affect adherence has
shown to reduce ADEs (Hanlon et al., 2001).
Methodologies known to enhance
understanding such as “teach back” especially low-literacy populations
(Schillinger et al ., 2003). See Resources section for evidence based
information on medication reconciliation.
High-Risk Medications
Many studies have revealed common high-risk medications in older
adults. Special attention should be paid to drugs that carry a high risk of
serious adverse effects such as warfarin, hypoglycemic drugs, and digoxin that
result in one-third of all emergency room visits for ADEs (Steinman &
Hanlon, 2010).
Additionally, taking BZDs is an independent risk factor for
falls; diphenhydramine (Benadryl) may lead to impaired cognition or urinary
retention (in men); and antipsychotics may lead to falls, death, or pneumonia
(Steinman & Hanlon, 2010).
Antipsychotics and other psychotropics are also
associated with an increased risk for falls (Rochon et al., 2007). Nurses should
become familiar with high-risk medications and medication classes prescribed
for older adults in order to aid in preventing ADEs.
Many tools are available
for the nurse to assess for high-risk medications, for potential drug-drug,
drug-disease, or drug-herbal interactions. Common high-risk medications are
discussed in the following sections.
Warfarin
Warfarin has been identified throughout many research studies as
among the highest risk medications taken by older persons (Gaddis, Holt, &
Woods, 2002: Hanlon et al., 2006).
Warfarin leads to ED visits, preventable
hospital readmission, and adverse events after discharge (Alexopoulou et al.,
2008; Budnitz et al., 2006; Howard et al., 2007: Pirmohamed et al., 2004).
Together, polypharmacy and warfarin use consistently increases the risk of ADRs
(Hanlon et al., 2006).
Warfarin is highly bound (approximately 97%) to plasma protein,
mainly albumin. The high degree of protein binding is one of several mechanisms
whereby other drugs interact with warfarin (Olson et al., 2010).
Those with
malnutrition and low albumin levels are at risk for unbound warfarin in the
bloodstream and higher risk of bleeding. Warfarin is metabolized by hepatic
cytochrome P450 isoenzymes predominately to inactive metabolites excreted in
the bile; it is also excreted by the kidneys.
Warfarin metabolism may be
changed in advanced age and in the presence of liver problems. Drug
interactions are extensive and include
(a) drugs that inhibit warfarin
metabolism and prolong prothrombin time (eg. Cipro, phenytoin, amiodarone)
(b)
drugs that inhibit vitamin K activity (eg, cephalosporins and high-dose
penicillins)
(c) additive effects with other anticoagulants such as aspirin,
Lovenox, and others; and
(d) drugs that reduce the effectiveness of warfarin such
as phenytoin, barbiturates, cholestyramine. and others (Olson et al., 2010)
Fifty-eight percent of older persons do not report use of herbal
supplements. Commonly used herbal remedies (ginkgo biloba and garlic) interact
with warfarin to augment its anticoagulant effect and may lead to serious
bleeding problems (Astin et al.. 2000; Miller, 1998).
Many foods may interact
with warfarin, specifically those with high vitamin K content such as
chickpeas, spinach, and green tea (Miller, 1998). It is imperative to identify
older adults on warfarin who fall or are at risk for falling as their risk of
serious injury increases on warfarin.
The risk of harm versus the benefit must
be weighed and the nurse should clarify the risk versus benefit with the
primary prescriber (Steinman & Hanlon, 2010).
Anti-Hypertensive Agents
Hypertension affects approximately two thirds of individuals older
than age 65 years but only 27% of people have adequate control. Physiological
changes of aging can alter the pharmacokinetics and pharmacodynamics of
cardiovascular drugs in older persons, thus increasing the risk of ADEs (Nolan
& Marcus, 2000).
The antihypertensives, as a class, tend to produce a
variety of unintended effects including orthostatic hypotension (associated
with diuretics and alpha-blockers), sedation and depression (associated with
some beta-blockers), confusion (associated with alpha-blockers), impotence ,
and constipation (eg, verapamil).
Comprehensive and ongoing assessment for
potential adverse effects (eg, routinely checking orthostatic blood pressure)
is key to monitoring drug efficacy and safety while hospitalized. Nurses should
monitor for symptoms such as dizziness and lightheadedness on standing.
The use
of four or more medications should prompt the measurement of postural blood
pressure (Tinetti & Kumar, 2010). Particular attention should be given to
the possible discontinuation or dose reduction of medications known to increase
orthostasis or fall risk.
Dose for dose, water-soluble compounds are more potent in aging
persons, whereas fat-soluble drugs (such as propranolol and carvedilol) can be
expected to have an extended half-life because of their higher volume of
distribution.
Because of changes in fat or lean body mass, older adults may
require an increase in dosing intervals of fat-soluble beta-blockers.
Additionally, because of age-related changes that decrease the integrity of the
blood-brain barrier, it predisposes older adults to untoward events with
alpha-agonists.
Bronstein and colleagues (2008) reported lipid soluble
beta-blockers that have marked antidysrhythmic effects more lethal (eg.
propranolol, oxprenolol).
The lethality significantly increases when given with
calcium channel blockers, cyclic antidepressants, and/or psychotropics, even if
the amount of beta-blocker is relatively small (Bronstein et al., 2008).
Orthostatic hypotension is a serious problem that can affect older
adults on continuous antihypertensive therapy. Sustained treatment makes them
more susceptible to diuretic-induced dehydration and orthostatic changes.
Orthostasis may also be caused by concomitant illness (eg, infection). The
known sequelae of orthostatic hypotension in older adults include falls that is
a true trauma and a medical emergency in physically frail, anticoagulated, or
functionally compromised older adults.
Orthostatic hypotension is an
independent risk factor for recurrent falls in nursing home residents (Ooi.
Hossain, & Lipsitz, 2000).
Psychoactive Drugs
Mental health disorders are not part of normal aging. Nearly 20% of
persons older than age 55 years experience mental disorders with the most
common prevalence being anxiety, severe cognitive impairment, and mood
disorders, respectively.
Mental disorders are underreported and suicide rates
are highest among older adults compared to younger adults. Adults older than
age 85 years have the highest suicide rates of all- more than twice the
national rate.
Sedative-hypnotic drugs significantly increase risk for adverse
events in older adults and should generally be used sparingly and monitored
very closely. BZDs, regardless of half-life, have been associated with
cognitive impairment, hip fractures, and falls (Bloch et al., 2011: Hajjar et
al., 2003).
In a prospective study of 9,093 patients, older adults who take
BZDs are at greater risk for mobility problems and ADL disability, and
short-acting BZDs did not appear to improve safety benefits over long-acting
agents (Gray et al., 2006).
Higher plasma concentrations of sedatives and
hypnotics are seen because of increased volume of distribution as well as
increased sensitivity, including BZDs and opioids (Rochon, 2010).
The
likelihood of falls with fractures is more than twice as high for the
long-acting BZDs than short-acting agents. Likewise, Tamblyn, Abrahamowicz, du
Berger, McLeod, and Bartlett (2005) reported that 17.7% of older persons given
at least one prescription for BZDs at hospital discharge were treated for at
least one injury on follow-up visit of which fractures were the most common.
In
a study of intubated ICU patients, lorazepam was identified as an independent
risk factor for development of delirium (Pandharipande et al., 2006).
Oversedation, respiratory depression, confusion, and other alterations in
cognitive capacity, as well as falls, are frequently associated with
sedative-hypnotic drug use.
Psychoactive medications include antidepressants (tricyclics,
selective serotonin reuptake inhibitors (SSRIs]), anxiolytic agents (eg,
diazepam, lorazepam), antipsychotics (also referred to as neuroleptics),
mood-stabilizing compounds (lithium), and psychoactive stimulants.
Psychoactive
compounds are prescribed to stabilize mood, agitated behaviors, and for
therapeutic effects in clinical depression. Mood stabilizers and psychoactive
stimulants are known to have a relatively narrow therapeutic window even in
younger adults.
Lithium, in particular, requires very close monitoring of
levels and signs of toxicity in older adults; it also interacts with many other
drugs. Some unintended interactions may be prevented if age-related changes are
considered and careful surveillance is part of routine care (Budnitz et al.,
2006).
The half-life of psychoactive drugs is prolonged in older adults
and, in general, this class of drugs must be used with extreme caution to avoid
inducing delirium, falls, and other traumatic events.
In a systematic review,
medications strongly linked with falls included sedatives, hypnotics, BZDs, and
antidepressants (Woolcott et al., 2009). A significant association between
falls and psychotropic medications has also been reflected in two other
meta-analyses (Bloch et al., 2011: Leipzig.
Cumming, & Tinetti, 1999). Drug
classes determined to be a risk factor for falls included psychotropics,
antidepressants, BZDs, hypnotics, neuroleptics, and tranquilizers. Risk seemed
to be more significant for adults older than age 80 years in each of the
classes.
Drug classes that had double the odds of traumatic falls included
neuroleptics, antidepressants, and BZDs. An extensive list of specific drugs
for each class is listed in the review by Bloch et al. (2011).
Although
antianxiety agents such as BZDs and sedative-hypnotics are generally
overprescribed for older adults, the antidepressants are generally considered
to be under prescribed.
It is estimated that almost 15% of older persons living
in the community , 5% in primary care, and 15%-25% in nursing homes have
significant depressive symptoms (Spina & Scordo, 2002).
The SSRIs, as a class of antidepressants, have strikingly different
side effects than other antidepressants (eg, tricyclics). This class does not
cause cardiotoxicity or orthostatic hypotension and does not have anticholinergic
effects as do tricyclic antidepressants.
In general, these drugs tend to be a
better choice of antidepressants in older adults. The most common side effects
are GI related (nausea, anorexia) that may be ameliorated by starting with a
low dose (half that for younger adults; eg, fluoxetine 5 mg) and slowly
increasing (eg, to 10 mg) after 1 week.
A serious but uncommon sequela of SSRIs
is serotonin syndrome. This syndrome may occur if more than one antidepressant
is prescribed with an SSRI or if concurrent use of St. John’s wort, a commonly
self-administered OTC herbal remedy for depression.
The antipsychotics are often used inappropriately as first-line
treatment for persons older than age 65 years presenting with agitation and
behavioral problems associated with dementia (Kindermann, Dolder, Bailey, Katz,
& Jeste, 2002).
Evidence-based recommendations suggest the underlying cause
of agitation should be determined (may be caused by delirium or pain) and
nonpharmacological interventions attempted prior to administering
antipsychotics such as Haldol (Zwicker & Fletcher, 2009).
Most antipsychotics are not US Food and Drug Administration (FDA)
approved for agitation (without a psychotic diagnosis) and data on their
effectiveness suggest that the risk is greater than the benefit (Leipzeig et
al., 1999; Woolcott et al., 2009).
Antipsychotics must be used with extreme
caution in this population, largely because of the potential for development of
abnormal, and often irreversible, involuntary movements (extrapyramidal
symptoms) associated with their administration and increased risk for falls.
The newer antipsychotics present a much lower risk of extrapyramidal movement
disorders than conventional antipsychotics. Unlike conventional antipsychotics,
the newer atypical ones (eg, clozapine, risperidone, olanzapine, and
quetiapine) apparently provide several advantages with respect to both efficacy
and safety.
A major study examining the effectiveness of antipsychotic use in
Alzheimer’s disease concluded that the adverse effects are greater than the
advantages of these therapies (Schneider et al., 2006).
In 2004, the FDA issued
a warning against off-label use of antipsychotics for dementia-related
psychotic symptoms because of potential adverse effects.
Data from the CMS
indicate that newer atypical antipsychotic medications, compared to older
antipsychotics, do not appear to be associated with an increased risk of
ventricular arrhythmias or cardiac arrest (Liperoti et al., 2005).
Psychotropic
medications are associated with an increased risk for falls (Gurwitz et al.,
2005). Drug-drug interactions with antipsychotics are common.
Anti-Cholinergics
Medications with high anticholinergic properties must be used with
great caution in older adults because of adverse effects such as inability to
concentrate to frank delirium, agitation, hallucinations, blurred vision,
slowed Gl motility, decreased secretions, urinary retention, tachycardia,
impaired sweating, and constipation (Rochon, 2010; Spina & Scordo, 2002;
Terrell et al., 2006; Tune, 2001).
Studies have reported that patients with
dementia are at higher risk for delirium associated with anticholinergics;
however, a recent study indicates that use of anticholinergic drugs is
“independently and specifically” associated with a subsequent increase in
delirium symptom severity in older medical inpatients (Han et al., 2001).
Urinary retention, resulting from an anticholinergic, can be a
lethal side effect in a male with benign prostatic hypertrophy (BPH) and a
history of UTIs; urosepsis and death may result in men.
Catterson and
colleagues (1997) discussed the vicious cycle of treatment and/or iatrogenesis
that may occur with administration of anticholinergic drugs. An illustrative
example is an older adult with dementia and BPH who is administered
diphenhydramine (Benadryl) for sleep and who is also taking oxybutynin
(Ditropan), both of which have anticholinergic properties.
The additive effects
of the two medications may lead to urinary retention and agitation that may, in
turn, lead to treatment of the agitation with antipsychotics (which also have
anticholinergic effects) and exacerbate the problem and cascade of events
further. Rochon (2010) referred to this as the “prescribing cascade” that leads
to cascade iatrogenesis.
Anticholinergic properties occur not only in antidepressant and
antipsychotic medications, as previously mentioned, but are also properties of
most OTC antihistamines and sleep aids, intestinal and bladder relaxants,
corticosteroids, antihypertensives, antiarrhythmics and other cardiovascular
drugs, and some antibiotics.
See Tune (2001) or Kemper, Steiner, Hicks, Pierce,
and Iwuagwu (2007) for a list of medications with anticholinergic effects. An
anticholinergic risk scale (ARS) has been developed by Rudolph, Salow,
Angelini, and McGlinchey (2008) to identify older adults at highest risk for
adverse effects from anticholinergic drugs.
Cardiotonic
Digoxin is useful in treating CHF because of systolic dysfunction
in the older adult but is not the recommended treatment for CHF from underlying
diastolic dysfunction in older adults. Digoxin toxicity occurs more frequently
in older adults, presents atypically, and may result in death.
Juurlink and
colleagues (2003) reported that about 2.3% of cases of digoxin toxicity could
have been prevented in hospitalized older adults. Ahmed, Allman, and Delong
(2002) reported that digoxin is often prescribed inappropriately in hospital
patients.
Classic symptoms of digoxin toxicity (nausea, anorexia, visual
disturbance) may occur; however, symptomatic cardiac disturbance and
arrhythmias are more common in the older adult and are not often thought to be
caused by digoxin toxicity.
Older adults may experience toxicity symptoms even
with normal plasma levels of digoxin (Flaherty. Perry, Lynchard, & Morley,
2000).
Many older people will have some reduction in renal function with aging;
therefore, monitoring for symptoms, especially atypical symptoms of digoxin
toxicity, and monitoring renal function and potassium levels is important.
Particular caution must be exercised when digoxin is prescribed
with diuretics; this combination can cause hypokalemia and exacerbate renal
impairment that can potentiate digoxin toxicity.
Because the therapeutic window
for digoxin is narrow and because it is water-soluble (eg, the drug has a
smaller volume of distribution and, thus, higher plasma concentration), correct
and safe dosing of older adults is challenging.
The maximum recommended dose in
older persons for treating systolic heart failure is 0.125 mg (Fick et al.,
2003). Debilitated older adults who often have low serum albumin levels are at
risk for higher plasma level and digoxin toxicity.
Despite the recommendation that ACE inhibitors (ACEIS) should be
prescribed for all patients with heart failure because of left ventricular or
systolic dysfunction and who have normal renal function (Packer et al., 1999).
Sloane and colleagues (2002) found that 62% of adults in assisted living
residents (n=2,014) were not on an ACEL Monitoring of renal function and serum
potassium should continue as the ACEI dose is titrated up.
Rarely do older
patients on an ACE inhibitor need potassium supplementation, the combination of
which can be lethal. Juurlink and colleagues (2003) reported that 523 out of
1,222,093 patients on ACEIs were hospitalized with hyperkalemia; of these
patients, 21 died while hospitalized.
Hypoglycemic Agents
Hypoglycemic agents carry a high risk of serious adverse effects in
older adults. Control of blood glucose level is paramount to prevent
microvascular and macrovascular complications of diabetes.
However, the use of
general disease-specific evidence guidelines for diabetic control can lead to
overmedication in older adults. Tight glycemic control in advance age or in
older person with multiple comorbidities can result in greater harm than
benefit (Greenfield et al., 2009; Steinman & Hanlon, 2010).
The American Geriatrics Society (AGS) has issued guidelines for
improving the care of older people with diabetes (Brown, Mangione, Saliba,
Sarkisian, & California Healthcare Foundation (CHF)/American Geriatrics
Society [AGS] Panel on Improving Care for Elders with Diabetes, 2003).
They
suggest that the risks of intensive glycemic control, including hypoglycemia,
polypharmacy, and drug-drug and drug-disease interactions, may significantly
alter the risk-benefit equation.
For frail older adults, persons with limited
life expectancy, and others in whom the risks of intensive glycemic control
appear to outweigh the potential benefits, a less stringent target than the
American Diabetes Association (ADA) recommendation of 7% or 8% in frail older
adult is appropriate.
Oral agents with shorter half-life are also recommended
and insulin is less often recommended because of vision changes and common
arthritic conditions, unless it is provided in pre-filled syringes. Metformin
is not recommended for those older than age 80 years because it may lead to
metabolic acidosis.
Blood pressure and lipid control, however, are recommended
to help reduce microvascular and macrovascular problems along with a daily
low-dose of aspirin (Greenfield et al., 2009; Steinman & Hanlon, 2010).
Over-The-Counter Medications
supplements may lead to adverse drug-disease interactions and drug-drug
interactions (Astin et al.. 2000: Rochon, 2010).
Neafsey and Shellman (2001)
found that 86% of sample of 168 older adults attending a hypertension clinic
reported at least two or more self-medication practices that could result in an
adverse drug interaction.
In the United States, community-dwelling older adults
take about as many OTC drugs as prescription drugs (Hanlon et al., 2001).
Salicylates, such as aspirin, are a significant concern regarding ADRs in older
persons.
In a study of 18,820 patients, 18% of all ADR hospital admissions were
aspirin-related and low dose aspirin was involved most often (Pirmohamed et
al., 2004). In combination with alcohol, because of its water solubility,
age-related renal insufficiency can worsen and result in chronic salicylate
intoxication.
Cold remedies that include alcohol are a significant source of
drug potentiation in aging adults. Indeed, alcohol consumption is frequently
omitted from history taking of older adults, even though it interacts with OTC
and prescription medications in frank and subtle ways to produce unintended
drug harm.
The OTCs most commonly implicated in hospital admissions are low
dose aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs, Pirmohamed et
al., 2004).
The FDA has been evaluating OTC ingredients and labeling of OTCs;
however, it is a long-range project and yet to be seen if the FDA will be more
specific on safety issues that relate to older adults.
Astin and colleagues
(2000) reported that 24% of seniors use herbal remedies (the most common being
ginkgo biloba and garlic), and 58% did not report usage to their primary
provider.
Ginkgo biloba and garlic interact with warfarin to augment its
anticoagulant effect and may lead to bleeding (Miller, 1998); the potential
adverse consequences are staggering.
Interventions And Care Strategies
Medication assessment begins with a thorough drug history and
assessment obtained from the older adult or a reliable informant. Medication
history errors occur in up to 67% of patients at the time of admission to the
hospital and increased up to 83% when nonprescription drugs were included (Tam
et al., 2005).
This suggests a need for systematic approach to accurate
medication histories at the time of admission. No studies provide a systematic
approach to history taking, although specific aspects of the medication
assessment include the following evidence-based activities.
Obtain a complete medical history and validate that the medication
history is true (Lau Florax, Porsius, & De Boer, 2000), ascertaining the
numbers and types of medications typically consumed, as well as an estimate of
how long it has been taken.
Nathan and colleagues (1999) recommended that older adults bring
all their medications and OTCs to provider or hospital or other health care
setting in a brown bag in order to document medication types, instructions for
self-administration, dates, and duration of the drug regimen.
This method
fosters identification of multiple prescribers and dispensing pharmacies and
can signal polypharmacy and/or possible substance abuse, particularly regarding
analgesics. anxiolytics, and sedative hypnotics.
Focused questions by the
clinician should address nicotine and alcohol use. as well as vitamins, herbal
remedies, and OTC medications that are routinely used (Astin et al., 2000; Lau
et al., 2000).
Ask detailed questions about OTC and “recreational” drugs, alcohol
use, and herbal or other folk remedies. Provide a list of herbal remedies and
folk medicines to choose from (Tachjian et al., 2010). Be specific about the
actual amount and under what circumstances these substances are used.
Accurate
information can help explain symptoms that otherwise may not make sense.
Evaluate for duplicate medications or classes that occur because of
unrecognized trade names versus generic names, and OTCs with the same active
ingredients in them, especially acetaminophen (Astin et al., 2000).
Perform MR to verify actual medication regimen at hospital
admission and discharge and across the continuum of care (Gleason et al., 2004;
Nickerson et al., 2005: Tangalos & Zarowitz, 2006).
Patients are often reluctant to admit to nonadherence; however,
pill counts and refill history can aid in determining this issue (Steinman
& Hanlon, 2010). Employ a medication discrepancy tool to facilitate
discrepancy across settings (University of Colorado Health Sciences Center,
2005).
Monitor new symptoms and consider their likelihood of being caused
by an ADR before adding new medications to treat the symptom (Petrone &
Katz, 2005: Rochon, 2010) prior to requesting a new medication to treat
symptoms, avoid the prescribing cascade.
a trial of nonpharmacological interventions and treatments
prior to requesting medication for new symptoms (eg, agitation). Nurses often
make these recommendations when notifying primary provider for a new problem or
symptom.
Continuously monitor for possible toxicity to those drugs with high
prevalence rate of toxicity (see Beers criteria: Beers, 1997; Beers et al.,
1992). PDA technology can help nurses assess high-risk medications such as facts
and comparisons.
Consider medications as the underlying cause when falls occur.
Particularly, consider recently added medications that are high risk for
causing falls such as diuretics and psychotropics.
Collaborate with the interdisciplinary team to effect change in
reducing the numbers of ADEs and ADRs, many of which are preventable (Hanlon et
al., 2001).
Although many studies describe and recommend an interdisciplinary
approach as the best method for improving drug treatment outcomes, most do not
delineate the specific role or function of the individual team members not do
they measure outcomes of the team (Lam & Ruby, 2005; Williams et al.,
2004).
Recommendations to consider for an interdisciplinary approach include a
medication care team (nurse, pharmacist, primary physician/nurse practitioner,
social worker) with specific functions assigned to review medications at
admission and discharge utilizing evidence-based recommendations.
Discharge
interventions may be performed by various team members including the following:
Reminder systems may be instituted by pharmacists in
collaboration with nurses as reported effective by Muir, Sanders, Wilkinson,
and Schmader (2001). A visual intervention (medication grid) was delivered to
physicians to see if it could reduce medication regimen complexity, and
researchers report that the simple intervention had a significant impact on
medication regimen complexity in older adults.
program) medication list at admission, when new medications are added and prior
to discharge for potential drug-drug interactions, drug-disease interactions,
and/or inappropriate medications for older adults.
Age-specific alerts sustained the effectiveness of drug-specific alerts
to reduce potentially inappropriate prescribing in older people and resulted
in a considerably decreased burden of the alerts (Simon et al., 2006).
Computerized physician order entry system has the potential to
prevent an estimated 84% of dose, frequency, and route errors. Anywhere from
28% to 95% of ADEs can be prevented by reducing medication errors through
computerized monitoring systems (AHRQ, 2001).
Medication interaction alerts may reduce the frequency of
prescribing of interacting medications (Feldman et al., 2006).
Pharmacist may also function as the communicator of the hospital
drug regimen to community pharmacy, primary care provider, and/or other levels
of care.
Social worker may review issues at home such as access to
medications, costs, caregiver support, and barriers to discharge interventions.
Nurses and other interdisciplinary members need to be proactive participants in
reducing rehospitalization related to ADEs and implement discharge education
and counseling to patients including the following:
Devices to accommodate some impairments or barriers may be
recommended. For example, tamperproof lids are often difficult for older adults
to remove. particularly if there are arthritic changes.
A simple request to the
pharmacist to provide a nonchild proof lid may improve the safe and effective
use of prescribed medication. Consult with occupational therapy.
Other health literacy (Curry et al., 2005). Query whether the
older person understands what the drug is to be used for, how often it is to be
taken, circumstances of ingestion (eg with food), and other aspects of drug
self-administration that signal intelligent drug use; use teach-back method to
verify understanding (Hutchison et al., 2006: Schillinger et al., 2003).
Assess for ability to recognize generic versus brand name
medication and their use (Curry et al., 2005). Ask the older adult to describe
the circumstances in which the medication was not used or was used differently
than prescribed.
If the older adult cannot describe medication use, consider
removing the drug or provide written instruction for the home (Muir et al., 2001).
regimen. Ask older adult if she or he believes that the drug is actually doing
what it is intended to do.
If the medication is not useful, not creating
symptom relief, or causing adverse effects, consider removing it or replacing
it with a more acceptable substitute.
Discuss the impact of medication expenses. Many medications
particularly those that are new to the market can be prohibitively expensive,
particularly for people on fixed incomes. Discuss influence of TV ads.
Ask the
older adult what concerns they have about the costs and risks of administration
(Curry et al., 2005). In addition, discuss Medicare Part D concerns or
confusion. Where economic problems are identified, generic drugs and other
avenues should be explored to manage the cost issue.
Consider instrumental issues related to drug use, such as
availability of family members or other social supports to facilitate
medication adherence, and who monitors the need to change specific medications
dictated by third-party reimbursement and medication coverage plans.
Patients should be given the necessary information and the
opportunity to exercise the degree of control they choose over health care
decisions that affect them and the necessary information to effectuate this.
Patients who are informed and are involved in decision making are less likely
to make decisions that may lead to ADRs, such as abruptly discontinuing a
medication that should be tapered off slowly (NCC MERP, 2001).