polypharmacy and the importance of medication review in
Post on 23-May-2022
2 Views
Preview:
TRANSCRIPT
University of North DakotaUND Scholarly Commons
Nursing Capstones Department of Nursing
4-30-2016
Polypharmacy and the Importance of MedicationReview in the Elderly PopulationRose Betak Agbor
Follow this and additional works at: https://commons.und.edu/nurs-capstones
Part of the Nursing Commons
This Independent Study is brought to you for free and open access by the Department of Nursing at UND Scholarly Commons. It has been accepted forinclusion in Nursing Capstones by an authorized administrator of UND Scholarly Commons. For more information, please contactzeineb.yousif@library.und.edu.
Recommended CitationAgbor, Rose Betak, "Polypharmacy and the Importance of Medication Review in the Elderly Population" (2016). Nursing Capstones. 1.https://commons.und.edu/nurs-capstones/1
Running head: POLYPHARMACY AND MEDICATION REVIEW IN ELDERLY 1
POLYPHARMACY AND THE IMPORTANCE OF MEDICATION REVIEW IN THE
ELDERLY POPULATION
By
Rose Betak Agbor
The University of North Dakota
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 2
PERMISSION
Title Polypharmacy and the importance of medication review in the elderly population
Department Nursing
Degree Master of Science
In presenting this independent study in partial fulfillment of the requirements for a graduate
degree from the University of North Dakota, I agree that the College of Nursing of this
University shall make it freely available for inspection. I further agree that permission for
extensive copying or electronic access for scholarly purposes may be granted by the professor
who supervised my independent study work or, in her absence, by the chairperson of the
department or the dean of the Graduate School. It is understood that any copying or publication
or other use of this independent study or part thereof for financial gain shall not be allowed
without my written permission. It is also understood that due recognition shall be given to me
and to the University of North Dakota in any scholarly use which may be made of any material
in my independent study.
Signature ____________________________
Date _____________________________
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 3
Abstract
As people get older, they are at increased risks of increased co-morbidities. As such elderly
patients maybe prescribed many medications to manage these multiple medical conditions. An
attempt to treat one medical condition may result in complications or drug interactions. With
hospitalization, clinicians tend to prescribe more medications to the elderly. This becomes
complex, and sometimes lead to non-compliance, improper administration and negative effects
on the body. Clinicians do not usually focus on medication review. Elderly may continue to take
these medications indefinitely if they are not reviewed for effectiveness or appropriateness. The
case study presented a patient with multiple medications with possible adverse drug reactions.
This case report aims to examine polypharmacy, consequences of polypharmacy and the
importance of medication review in reducing negative consequences of polypharmacy.
Medication review in elderly patients is important in preventing drug adverse effects, improves
of prescription quality and patient outcomes. A literature review was conducted to review
polypharmacy, the process, benefits and tools used in medication review in older population
according to National Health Service (NHS) and National Institute for Health and Care
Excellence (NICE) guidelines.
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 4
Background
Polypharmacy is defined as prescribing at least four to five medications (Avery, 2011).
Polypharmacy can also be classified as “taking medications with no appropriate indication, use
of therapeutic equivalents to treat same illness, use of interactive medications, use of
inappropriate dosage and use of other medications to treat adverse drug reactions” (Farrell,
Shamji, Monahan, & Merkley, 2013). This includes prescription and over-the-counter
medications. In the United States, the incidence of polypharmacy is increasing in the geriatric
population. According to Pretorius and colleagues, older adults who are 65 years and older
consume about 30% of all prescription medications with a total cost of about $3 billion dollars in
annual prescription (Pretorius, Gataric, Swedlund &Miller, 2013). As people get older, the
prevalence of chronic diseases increases. Drug therapy is necessary in the management of these
diseases and the use of multiple medications makes drug regimen complex and increases risk for
complications such as polypharmacy.
With increasing age, many physiological changes occur which affect pharmacokinetics
of drugs in the elderly (Cope, 2013). This includes changes in absorption, distribution,
metabolism and excretion of drugs. Absorption of medication decreases with age due to decrease
in the intestinal epithelial surfaces (Pretorius et al, 2013). This increases drug concentration in
the body. Distribution of drugs depends on the water, protein and fat content of the body. Body
fat increases with age and muscle mass decreases. Drugs tend to remain longer in the body with
these changes; adding the potential of drug overdose (Pretorius et al, 2013). Drug metabolism
occurs in the liver. Supply of blood decreases with age with the potential increase drug
concentration. Decrease renal function also poses risk for increased drug toxicities.
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 5
There is also high risk of drug-drug interaction and adverse drug events with
polypharmacy, including falls, gastrointestinal bleeds, cognitive changes, constipation
(Kaufman, 2015; Pretorius et al, 2013). More and more people are being re-admitted due to
hospital as a result adverse drug reactions. According National Health Service, Scotland (NHS,
2012), there is little guidance to assist providers with balancing evidence based practice
recommendations when managing multiple co-morbidities to obtain better patient outcomes.
Medication review is an important process used in the management of polypharmacy.
Bergman-Evans (2012) defines medication review as the examination of patient’s
medication with the objective of reaching an agreement with patient regarding treatment and
optimizing positive impact of medications and reducing negative outcomes. When doing
medication review, the individual client should be taken into consideration. Tools that may be
used for medication review include; NO TEARS, BEER criteria, STOPP criteria and START
criteria (All Wales Medicine Strategy Group, 2015, American Geriatric Society, 2015 &
Bergman-Evans, 2012). The purpose of these tools is to improve care of older adults by reducing
potentially inappropriate medication, monitor drug use and to decrease adverse drug reactions.
Case Report
History of present illnesses: EE is an 87 year old Caucasian female who is seen today for
follow up after three days hospitalization for UTI and fatigue. Patient complained of fatigue and
dizziness. Fatigue is worst in the morning upon waking up. Stated she sleeps through the night.
Denies mood changes. Patient feels dizzy when changing position. Denies lightheadedness.
Denies headaches, fever or chills. Denies shortness of breath. Denies dysuria, urinary urgency or
frequency. Patient is on Nitrofurantoin 100mg, has 3 more days of antibiotic therapy. Patient
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 6
stated she feels better, has been sleeping well. Patient is alert and oriented with intermittent
forgetfulness.
Medications:
Donepezil 5mg po daily
Fluticasone propionate and Salmeterol 250/50, 1 puff twice daily
Losartan 50mg po daily
Metoprolol 50mg twice daily
Gabapentin 300 mg po three times daily
Paroxetine 20 mg po daily
Quetiapine 200mg po twice daily
Insulin glargine 30 units SQ at bedtime
Nitrofurantoin ER 100mg po twice daily x 7 days (3 days left)
Multivitamin po daily
Iron sulfate 325mg po twice daily
Allergies: NKDA
PMH: Dementia, Diabetes, COPD, Anemia, hypertension, depression and neuropathy.
Family history: Familial history of hypertension and heart disease. Patient unable to state which
family member was affected.
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 7
Social History: Lives in an assisted living. Daughter assists with medication set-up. Never
smoked, used alcohol or illicit drugs
ROS:
Constitutional: Denies any fever or chills, reported fatigue
Cardiovascular: Denies chest pain or palpitations
Respiratory: Mild shortness of breath with activity, has history of COPD
GI: Denies decreased in appetite, constipation, nausea, vomiting, diarrhea or abdominal pain
GU: Denies dysuria, urgency or frequency. Currently on antibiotic for urinary tract infection
Musculoskeletal: Denies muscle or joint pain
Neurological: Denies headaches or lightheadedness. Denies numbness or tingling
Skin: Denies rashes or skin lesions
Psychosocial: Denies mood changes. Denies sleep disturbance
Physical Examination:
VS: BP 88/40, HR 50, Temp 98.6, RR 24, FSBS morning 107
General appearance: Alert and oriented, in no acute distress. Well-groomed and engages in
conversation.
HEENT: Head Normocephalic, atraumatic. Wears glasses. Pupils equal and reactive to light.
Neck: Supple, with normal ROM, no thyroidomegaly.
CV: Regular rate and rhythm, S1, S2 no murmurs, gallops, or rubs. No JVD. 2+ bilateral pedal
pulses
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 8
Respiratory: Breathing effortless. Lung sounds clear to auscultation in all lung fields no
wheezes, rhonchi, or rales.
GI: Soft and non-distended. Positive bowel sounds in all quadrants. No tenderness with
palpation, no organomegaly.
Skin: warm and dry, no lesions
Extremities: Trace edema to bilateral lower extremities, no tenderness
Differential Diagnosis:
Urinary tract infection, Fatigue, Hypotension, Diabetes, orthostatic hypotension, polypharmacy,
Anemia, hypothyroidism
Labs/Imaging
-CBC, BMP, TSH studies
-EKG
Management and plan
1 Hypotension, likely due to use of hypertensive medications. Currently on Losartan 50 mg and
Metoprolol 50 mg twice daily.
Plan: continue Losartan 50 mg daily; Discontinue Metoprolol, start Metoprolol ER 50 mg daily;
Check orthostatic blood pressure x 3 days. Update provider on any drop in BP from sitting to
standing; avoid changing positions abruptly
2 Fatigue, probably due to anemia vs current UTI. Hemoglobin stable, denies symptoms of UTI
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 9
Plan: Continue Iron supplements, return to clinic if symptoms persist
3 Urinary tract infections, on Nitrofurantoin, has three more days of antibiotic
Plan; complete antibiotic regimen
4 Diabetes, stable
Plan, continue Lantus
5 Polypharmacy has multiple co-morbidities and takes 11 different prescription medications
daily. Review medications and discontinue potentially inappropriate medications
Plan; decrease Gabapentin from 300mg to 100 mg three times daily
Literature Review
In this literature review, I will be incorporating a case report of an 87 year old female
with multiple co-morbidities who was having potential adverse drug reaction from
polypharmacy. During her follow-up appointment she had hypotension which increases her risk
for falls. Medication review was done and dose reduction done. The aim of this literature review
is to describe polypharmacy, review evidence-based recommendations on medication review, the
process of medication review and tools used to carry out medication review in the elderly
population.
An online search was done using PubMed using keys words “Polypharmacy”, “older
adults”, “Medication review” and “Medication reconciliation” yielded 95 articles. Search was
narrowed to RCT in the last six years, 5 articles were retrieved that were relevant to case study
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 10
Another search was done using CINAHL database using key words “Polypharmacy”,
“Older adults”, “Medication review” and “Medication reconciliation”. 4162 articles were
retrieved. Search was narrowed to 2010-2016, peer reviewed, English language, age 65 and
older, and Medline excluded. Fifteen articles were retrieved that were relevant to case study.
Medication Review Process
Medication review is an important factor in determining medication prescription, safety
and compliance. Medication review should be a collaborative approach between the provider,
pharmacist and the patient. According to National Institute for Health Care Excellence (NICE,
2014), medication review should include the following:
Medication history taking into consideration new and existing medications
Is the medication appropriate for the age group?
Complexity of medication regimen, can the regimen be simplified to promote
adherence?
What are the barriers to medication adherence?
Medication pharmacokinetics
Is the patient experiencing adverse drug events including geriatric syndromes?
Medication regimen should be adjusted based on the findings of medication
review.
According to NHS guideline (2012), there are three levels in medication review. Level 1
involves doing a face to face review of medication with the patient. This involves checking
appropriateness, cost, adherence and potential side effects of the medication. Level 2 involves
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 11
treatment review which is if medication is yielding good outcomes. Level 3 is clinical
medication review and making recommendations as needed to reduce inappropriate medications.
Benefits of Medication Review
Prescribing a drug regimen using evidence based practice is important in managing
complex medical conditions. However there are many drug-related problems which may result
from this regimen including hospital readmission from adverse drug reactions. These problems
can be prevented by reviewing patients’ medication upon discharge from the hospital.
Medication review will identify clinically inappropriate medications, assist with monitoring of
necessary labs, improve communication between providers and also identifying which
medications may be contributing to adverse reaction (Hellstrom, Bondesson, Hoglund,
Holmdahl, & Rickhag, 2010).
Studies done on medication review and assessment describe a variety of interventions and
outcomes including hospitalization, morbidity, mortality, and quality of life. Mckean, Pillans &
Scott (2015) did a pilot study on medication review and deprescribing in hospitalized patients
receiving multiple medications. The physicians used pharmacist reconciled medication list and
formal sit-down meetings to do the medication review. The authors concluded that a standardized
method of medication may significantly reduce the number of medications. In this study, one in
four medications was deprescribed prior to hospital discharge.
Another study done by Hellstrom et al, 2011, investigated the impact of Lund integrated
medicines management (LIMM) model on medication appropriateness and drug-related hospital
revisits in elderly patients within three months of discharge. The LIMM model is a systematic
approach that optimizes and individualizes drug treatment in hospitalized patients upon
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 12
admission, during hospitalization and at discharge. The authors found out that this model is
important in decreasing the amount of inappropriate medications taken by hospitalized elderly
patients.
Lampela, Hartikainen, Sulkava & Huupponen (2010) did a population-based intervention
study to investigate the impact of medication assessment as part of a comprehensive geriatric
assessment (CGA) on drug use over a 1-year period. The participants in this study were home-
dwelling, greater than 75 years and took two to ten medications daily. Interventions included
medication adjustment, evaluation of indication for medication use, clinical evaluation of
patients (cognition, mood, orthostatic reactions) and monitoring of routine labs. At the end of the
review, some medications were adjusted (especially the drugs affecting central nervous systems)
inappropriate medications were discontinued and new medications started for new diagnoses.
Medication Review Tools
A BEERs criterion is a medication review tool implemented by the American Geriatric
Society (2015) to assist clinicians with safe prescription in the elderly population. This tool
enables clinicians to prescribe medications (1) based on the patient’s diagnosis and (2)
independent of the patient’s diagnosis. According to the BEERS criteria the following classes of
medications should be avoided in elderly patients as they have the potential of causing adverse
drug reactions even when normal doses are taken. This includes Benzodiazepines, digoxin, first
generation antihistamines, tricyclic antidepressants, Megestrol, and some hypoglycemic agents.
Screening tool for older person’s potentially inappropriate prescription (STOPP) and
screening tools to alert doctors to right treatment (START) are tools used to avoid medications
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 13
that are potentially inappropriate and to identify medications use where risk outweighs benefits.
(Pretorius et al, 2013).
Graziano et al (2014) did carry out a project to assess appropriate medication use in
elderly with complex medical conditions who have limited life expectancy, functionally impaired
and have geriatric syndromes. The purpose of the project was to come out with recommendations
that will guide providers do quality prescription in this population of adults. The tool used for
this project criteria to assess appropriate medications use among elderly complex patients
(CRIME). The authors came out with 19 recommendations for medication management in
patients with co-morbidities including diabetes, hypertension, congestive heart failure coronary
artery disease and atrial fibrillation.
Learning Points
Polypharmacy poses a challenge to both providers and patients. There should be
communication between providers, the pharmacist and the patient to prevent potential
adverse drug events.
The provider should be aware of potentially inappropriate drugs in the elderly population.
This can be made possible by making use of medication review tools and evidence-based
practice guidelines.
Medication review should be done with each office visit or hospitalization. Patients
should be encouraged to bring a current list of all their medications, prescription and
over- the- counter medications.
For patients with complex medication regimen, medication review should be done and
those medications that are not therapeutic be discontinued.
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 14
Medication review prevents serious complications, easier and safer medication regimen
and may also reduce health care spending by reducing re-hospitalization.
Conclusion
Polypharmacy is significant problem affecting the elderly population. Consequences of
polypharmacy include geriatric syndromes, poor adherence, re-hospitalization, mortality and
increase cost of health care spending. Careful medication assessment and review is important to
prevent some of these complications. There are a variety of tools to assist with medication
review including BEERs, STOPP and START. Medication review has been shown to be effective
reducing the number of inappropriate medications, reduce re-hospitalization and adverse drug
events. While medication review may be time consuming, in order to improve quality of life in
this population, clinicians should make it a routine to review medications with each office visit
or hospitalization.
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 15
References
All Wales Medicine Strategy Group (2014). Polypharmacy guidance for prescribing. Retrieved
from: http://www.awmsg.org
American Geriatric Society (2015). American geriatric society 2015 updated BEERs criteria for
potentially inappropriate medication use in older adults. Journal of American Geriatric
Society, 63(11), 2227-2246. doi: 10.1111/jgs.13702
Bergman-Evans, B. (2012). Improving medication management for older adult clients.
Retrieved from: http://www.guideline.gov/content.aspx?id=37826
Cope, D. G. (2013). Polypharmacy in older adults: The role of the advanced practitioner in
oncology. Journal of the Advanced Practitioner in Oncology, 4(2), 107-112.
Farrell, B., Shamji, S., Monahan, A. & Merkley, V. (2013). Reducing polypharmacy in the
elderly. Canadian Pharmacists Journal, 146(5), 243-244.
Graziano, O., Landi, F., Fusco, D., Corsonnello, A., Tosato, M., Battaglia, M.…… Lattanzio, F.
(2014). Recommendations to prescribe in complex older adults: Results of the criteria to
assess appropriate medication use among elderly complex patients (CRIME) project.
Drugs Aging, 31(1), 33-45. Doi.10.1007/s40266.013-0134-4
Hellstrom, L., Bondesson, A., Hoglund, P., Holmdahl, L. & Rickhag, E. (2011). Impact of the
Lund integrated medicines management (LIMM) on medication appropriateness and drug
related hospital revisits. European Journal of Clinical Pharmacology, 67, 741-752. doi:
10.1007/s00228-010-0982-3
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 16
Kaufman, G., (2015). Multiple medicines: The issues surrounding polypharmacy. Journal of
Nursing and Residential Care, 17(4), 198-203
Lampela, P., Hartikainen, P., Sulkava, R. & Huupponen, R. (2010). Effects of medication
assessment as part of a comprehensive geriatric assessment on drug use over a 1-year
period. Drugs Aging, 27(6), 507-521. doi: 1170-229x/10/0006-0507
McKean, M., Pillans, P. & Scott, I. (2015). A medication review and deprescribing method for
hospitalized older patients receiving multiple medications. Internal Medicine Journal,
46(1), 35-42.
National Health Services, Scotland (2013). Polypharmacy guidance. Retrieved from:
http://www.central.knowledge.scot.nhs.uk
National Institute for Health Care Excellence (2014). Managing medicines in care homes:
Guidance and guidelines. National Institute for Health Care Excellence. Retrieved from;
http://www.nice.uk>guidance
Pretorius, R., Gataric, G., Swedlund, S. & Miller J. (2013). Reducing risk of adverse drug events
in older adults. American Family Physicians, 87(5), 331-336
POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 17
top related