View
214
Download
0
Category
Tags:
Preview:
Citation preview
Managing Medications in Clinically Complex EldersMichael A. Steinman, MD, Joseph T. Hanlon, PharmD, MSJAMA, Oct 13, 2010, Vol 304, No 14
Payal Patel
Mercer University, Doctor of Pharmacy Candidate 2012
RTR Medical Group
Patient Case Mr L. is an 84 year old male with dementia who presents to the
clinic with initial concerns of forgetfulness, difficulty walking, and falling
PMH atrial fibrillation, diabetes mellitus, hypertension, hyperlipidemia, CKD,
gastritis, GERD
Medications Glyburide, digoxin, warfarin, etodolac, docusate sodium, multivitamin, iron,
memantine, metoprolol, gabapentin, essential fatty acids, acetaminophen prn, lactulose
Family Hx Unable to obtain
Social Hx Retired writer, plays tennis, lives with his wife
Presentation
Vitals BP: 135/60 HR: 50s CrCl: 42 ml/min
MMSE: 13/29
A1C: 5.9%
Multiple Medication Use About 20% of elderly who live in the community age 65 years and older
take 10 or more medications
Greater use of inappropriate medications
Adherence problems
Increased frequency of adverse events Adverse drug events affect 5 – 35% of elderly patients living in the
community per year
Adverse health outcomes
Cost burden
Introduction
This article summarizes evidence-based literature regarding improving medication use and describes a systematic approach for how healthcare professionals can improve medication regimens for the benefit of the patients
Information Gathering
Assessing current medication use Communication gaps are responsible for 37% of
remediable adverse drug events Discrepancy between patients’ understanding of
what they should be taking, what they are taking and what is in physicians record
Little direct evidence as to which method is best for medication review
Brown bag review can be useful Review meds, how the patient takes it, assess efficacy
Information Gathering
Assessing adherence Approximately one-half of older patients have adherence
problems to at least 1 medication Patients often do not admit to nonadherence Observe medication organization, pill count and refill history Address reasons underlying adherence ex: cost, difficulty
opening bottles, etc. Contact pharmacists regarding concerns about patient
adherence
Information Gathering
Assess patients’ goals of medication use Medications that increase longevity vs negative
effect on QOL Assess what the patient and family want to
achieve Prioritize values
Structured medication management
6 studies performed to assess the efficacy of medication management
Overall, these programs reduce medication burden, prevented underuse/overuse of medications
In a large study, medication management reduced the rate of serious adverse drug events from 0.6 to 0.4 events/1000 person-days (p=0.02)
Less evidence of its effect on clinical outcomes such as QOL, major clinical events and utilizing health services
Changing the medication regimen
However, it is recommended to structurally manage medications Match medications to conditions
Identify overused, underused or misused drugs
Make improvements by changing the dose, frequency or substituting another drug with a better side effect profile
Discontinuation of unnecessary medications
Studies of community based older patients have shown that they have an average of 1 unnecessary medication on their regimen
A large study found that 44% of older patients were discharged with at least 1 unnecessary medication
Drugs that should be avoided in older patients are used in approximately 20 to 30% of adults age 65 years and older
Discontinuation of Medications Look for drugs that lack clear indications and
consider discontinuing them
Screen for drugs that may be harmful in the elderly
Look for drugs that provide limited benefit Drugs that cause troublesome symptoms / adverse
effects Decisions of stopping medications should be based
on case and common sense
Discontinuation of Medications
Limited evidence about the best way to stop medications
In one of the studies, 26% drug discontinuations lead to worsening of underlying disease and 4% lead to withdrawal reactions
Use a stepwise approach in discontinuing medications
It is important to slowly taper the drugs
Educate patients and monitor patients for adverse withdrawal events
Underuse of Beneficial Medications Patients are often not prescribed potentially
beneficial medications
Symptoms such as pain and depression should be treated
Primary prevention if appropriate Vitamin D repletion in deficient patients can
prevent falls and risk of fractures
Improving adherence Randomized controlled trials of strategies to improve compliance
have shown mixed results
Most data suggests that oral counseling or written instructions are often insufficient
A more useful approach is simplifying medication dosing schedules
Clinicians should prescribe longer acting mediations or combination drugs when possible to decrease frequency
Behavioral interventions – medication organizers, packaging, cues
Lower cost generics can also help patients with financial problems
Monitoring and Follow-up
Ongoing monitoring for drug toxicity and efficacy is important in providing patient care
Approximately 1/3rd -2/3rd patients receiving digoxin, carbamazepine and other drugs that need monitoring are not monitored regularly
Patient’s medication list should be reviewed regularly
Medication review should also be done when there is sudden decline in function or onset or worsening of certain syndromes
Conclusion
Managing medications for older patients is a complex task
A careful, step-wise approach should be taken to reduce the complexity and to help the patient achieve beneficial outcomes
Patient Case - Assessment/Plan Patient no longer had pain from his lumbar laminectomy
Tapering off etodolac and gabapentin while watching for increased reports of pain
Tapering off digoxin watching for his heart rate
Hemoglobin 13 g/dL Discontinue iron
Recommend yoga and gym twice weekly
Low serum 1,25-dihydroxyvitamin D level Added Vitamin D 800 IU/day to Mr L’s regimen
Dr. S asked Mrs L if memantine was helping Mr L’s memory and she wasn’t sure Dr. S tapered off memantine and Mr. L had diffculty with nouns and names so
he resumed memantine
Outcomes
Mr. L is now socially improved and feeling better
His activities of daily living have been stable
Recommended