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F 329 Unnecessary Medications:
Geriatric PrinciplesMeets Regulations
F 329 Unnecessary Medications:
Geriatric PrinciplesMeets Regulations
Charles Crecelius MD PhD FACP CMD
F-tag 329 Unnecessary Medications
F-tag 329 Unnecessary Medications
• Updated, consolidated
• Incorporates newest geriatric principles
• Written by CMS with advise of leading geriatricians, pharmacists, nurses
• Associated pharmacy tags– F428 Medication Regiment Review
• Sets guidance for all – physicians, pharmacists, homes, surveyors
F 329 Unnecessary Meds Intent F 329 Unnecessary Meds Intent
• Meds clinically required to treat a condition• Non-pharmacologic measures used• Medication promotes highest well-being• Avoid actual or potential negative outcome• Negative outcome promptly found / treated
Doesn’t empower surveyor to practice medicine - should investigate the basis for decisions and interventions
Key DefinitionsKey Definitions
• Adverse consequences & ADR
• Behavior interventions
• Distressed behavior
• Gradual dose reduction
• Monitoring
• Non-pharmacologic intervention
• Psychopharmacological medication
Basic Pharmacologic PrinciplesBasic Pharmacologic Principles
• Promote non-pharmacologic interventions• Indication for use• Select based on individual risk / benefit• Appropriate dose / duration• Avoid duplicative therapy• Monitor efficacy & side effects• Prevention, identification, and response to
adverse consequences• GDR (gradual dose reduction)
Non-pharmacologic InterventionsNon-pharmacologic Interventions• Require:
– assessing and understanding causes for need of medication
– reduction/elimination of impediments, triggers and causes:
• Examples– Modification of environment– Modification/elimination of psychological
stressors• Accommodation of previous lifelong
activities or roles• Modification of staff/resident interactions• Behavioral Interventions
Individual Risk & BenefitIndividual Risk & Benefit
• Distinct / unique review of needs & goals • Informed choice
– Condition, options, risk / benefit, outcomes– Effects refusing treatment – Regular review
• Can’t refuse physician directed treatment to treat imminent danger
• Advance directives don’t preclude other treatment (no code is not no care)
Monitoring CriteriaMonitoring Criteria
• Identify essential information– who collects, how recorded
• Determine frequency of monitoring– Condition, risk ADR
• Define communication and analysis– Interdisciplinary team, goal
• Re-evaluate & update plan– Change meds/conditions/diet
When to Evaluate Medication for Benefit / Adverse Consequences When to Evaluate Medication for Benefit / Adverse Consequences
• Admit / readmit
• Clinically significant change in status
• New symptom / problem
• Worsening existing problem
• Unexpected decline function / cognition
• Non specific symptom without cause
• New med, review of med, med irregularity
• MMRR
Special ConsiderationsSpecial Considerations
• New Admits– Justify each med, consider ADR
• New med order as an emergency– Address underlying cause– Re-evaluate after acute phase over
• Psychiatric disorder or distressed behavior– Appropriate diagnosis, seek cause
• Multiple prescribers
GDR GDR
• All Medication Potential Candidates
– When condition stable or improved, causes target symptoms resolved, non-pharmacologic tx success
– Opportunities• MMR• Quarterly MDS Review• Practitioner review
• Psychopharmacologic medication– Review & document risk/benefit q 3 months
GDRGDR• Antipsychotics / non-anxiolytic/sedatives
– 1st year – 2 separate quarters, at least 1 month between
– Annually thereafter – Unless clinically contraindicated
• Sedatives / Hypnotics– If used more than 3 times a week– Attempt taper at least quarterly, 3 out of 4
quarters– Unless clinically contraindicated
Medications of Particular Relevance to Long-Term Care
Medications of Particular Relevance to Long-Term Care
• Broad list of medications with potential concerns in the elderly & long term care
• Replaces revised “Beer’s list”• Lists medication class, then specific names• Ask to consider various factors
Indication Dosage / durationMonitoring Adverse consequencesDocumentation
• Documentation proportional to degree risk/benefit
Surveyor Investigative ProtocolUnnecessary Medications
Surveyor Investigative ProtocolUnnecessary Medications
Non-compliance• Inadequate indication for use• Inadequate monitoring• Excessive dose• Excessive duration• Adverse consequences• Antipsychotic
– Absence of specific condition– Without behavior intervention & GDR
Deficiency Categorization ExamplesDeficiency Categorization Examples
• Level 4 Immediate Jeopardy– INR > 9 with failure to assess / act– Failure to monitor INR without care plan, staff
knowledge potential problems– Failure to monitor or dose reduce for antipsychotic
in presence of side effect– Failure to do non-contraindicated GDR with
resulting tardive dyskinesia while on prolonged antipsychotics
– Failure to recognize, assess or respond to meds that caused a GI bleed
Deficiency Categorization ExamplesDeficiency Categorization Examples
• Level 3 Actual Harm that is not Immediate Jeopardy– INR 4-9 with failure to act with bleeding– Failure to evaluate seizure as a result of other
meds, adding potentially unneeded AED– Failure to perform GDR resulting in continued
antipsychotic use with decline, adverse effect
Deficiency Categorization ExamplesDeficiency Categorization Examples
• Level 2 No actual harm with potential for more than minimal harm– INR 3.5-9 with failure to act and no bleeding– Failure to monitor INR, prior stable INR, no
bleeding– Failure to identify med as cause of rash– Failure to monitor potential med adverse
effect (e.g. no TSH & on thyroid Rx)
Deficiency Categorization ExamplesDeficiency Categorization Examples
• Level 1 No actual harm with potential for minimal harm– Failure to provide appropriate care & services
to avoid unnecessary meds / minimize adverse outcomes place residents at risk for more than minimal harm
– No level 1 severity
The Medical Director & F329 Reducing Medication Related Problems
The Medical Director & F329 Reducing Medication Related Problems
Individualize approach depending on problematic areas facility
• Education of Staff & Attendings
• Improve systems which impact medication management
• Monitor performance & provide feedback
Educational Efforts for StaffEducational Efforts for Staff
• Non-pharmacological Interventions
• Top offending medications
• GDR Requirements
• Monitoring tools / requirements
• Targeting frail / declining residents• Common ADR (serotonin syndrome, EPS,
TD, NMS anticholinergic side-effect)
Educational Efforts for StaffEducational Efforts for Staff
Signs, Symptoms & Conditions Possibly Associated w/ Medications
• Anorexia, unplanned weight loss or gain• Behavioral changes, unusual behavior patterns• Bleeding / bruising, spontaneous / unexplained• Bowel dysfunction • Dehydration, fluid/electrolyte imbalance• Depression, mood disturbance• Dysphagia, swallowing difficulty
• Falls, dizziness, impaired coordination
Educational Efforts for StaffEducational Efforts for Staff Signs, Symptoms & Conditions Possibly
Associated w/ Medications• Gastrointestinal bleeding• Headaches, muscle pain, general nonspecific
aching or pain• Mental status changes, (new, worsening, delirium) • Rash, pruritus• Respiratory difficulty or changes• Sedation (excess), insomnia, disturbed sleep• Seizure activity• Urinary retention or incontinence
System ImprovementsUtilization Monitoring Tools
System ImprovementsUtilization Monitoring Tools
• Physiological, cognitive functional– Vital signs– Labs, EKGs, blood sugars, Hgb A1C– RAI, FAST, IADL, PSMS– MMSE, CAM, AIMS, FAST
• Mood/Affect (MDS / QI)– GDS, Cornell DDS, Mania Rating Scale
• Behavior (MDS / QI)– Behave AD, CMAI, NPI-NH
System ImprovementsProtime / INR MonitoringSystem Improvements
Protime / INR Monitoring
• System-wide use coumadin flow sheets– Pulled when labs drawn– Sent to physician for fax adjustment or read to
physician if called– Contains default orders for common situations
• Set standard protime draw days
• CMT “signs off” new order
• Recap orders require check last protime
Auditing Medication ManagementAuditing Medication ManagementMonitor Indication with Consulting
Pharmacist• Do target symptoms / causes warrant
therapy• Could non-Rx interventions be relevant• Is a particular medication pertinent to
managing symptoms or condition• Is risk worth benefit• If prn are circumstances for use clearly
delineated
Auditing Medication ManagementAuditing Medication Management
Review GDR & Psychopharmacologics
• Triggered with new order; tickler system for old orders
• Special form of MRR using pharmacist & medical director
• Placed in front of order section
• Lists requirements of F329, offers tapering suggestions
• Results audited, presented to attendings
Always consider medicationas a possible problem,
and not just as the solution
Any symptom in an elderly patient should be considered a drug side effect until proved otherwise (Gurwitz)
A medication is a poison with a desirable side-effect (Osler)
F329 Unnecessary Medications
Medications of Particular Interest in Long Term care
F329 Unnecessary Medications
Medications of Particular Interest in Long Term care
Appendix
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Analgesics– Acetaminophen– NSAIDs (Traditional, COX-2)– Opioids (esp. meperidine)– Pentazocine– Propoxyphene (and combinations)
• Antibiotics (all)– Vancomycin / aminoglycosides– Nitrofuration– Fluoroquinolones
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Anticoagulants– Warfarin
• Anticonvulsants– All– Seizure or mood stabalizer
• Antidepressants– All (class listings)– MAO inhibitors– Tricyclics
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Anti-diabetic Medication– Metformin– Glitazones– Chlorpropamide & glyburide
• Antifungals– Imidazoles
• Anti-manic medications– Lithium
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Anti-Parkinson medication (all) • Antipsychotics
– Conventionals– Atypicals
• Anxiolytics– Short-acting benzodiazepines– Long-acting benzodiazepines– Buspirone– Diphenhydramine / hydroxyzine– Meprobamate
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Cardiovascular medications– Antiarrhythmics (amiodarone,
disopyramide)– Antihypertensives - All– Methyldopa– Digoxin– Diuretics– Nitrates
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Cholesterol lowering medicines– Statins– cholestyramine
• Cognitive enhancers
• Cold, cough and allergy medication– All
– H1 blockers
– Oral decongestants
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Gastrointestinal medications– GI antispasmotics– Phenothiazines, trimethobenzamide– Metoclopramide– Proton pump inhibitors
• Glucocorticoids• Hematinics
– Erythropoiesis stimulants– Iron
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Laxatives• Muscle relaxants• Orexigenics (appetite stimulants)• Osteoporosis medications
(biphosphonates) • Platelet inhibitors
– Salicylates– Ticlopidine– Clopidogrel
Medication Issues of Particular Relevance to Long-Term Care
Medication Issues of Particular Relevance to Long-Term Care
• Respiratory medication – Theophylline– Inhalants
• Sedative / hypnotics– All– Barbituates
• Thyroid medication• OAB medication All
Medications with Significant Anticholinergic Properties
Medications with Significant Anticholinergic Properties
• Antihistamines• Respiratory (ipratropium)• GI drugs• Tricyclic antideressants• Trazedone• Muscle relaxants• Urinary antispasmodics• Antiparkinson• Antipsychotics