Chapter 11: Polypharmacy

Learning Objectives• Identify evidence and references in medical literature

that demonstrate polypharmacy’s impact on patient outcomes.

• Recognize the symptoms of the syndrome of polypharmacy in elderly patients, acknowledging that the symptoms may be quite distant from the cause.

• Understand how goals of care influence appropriateness of medication choice.

• Identify drugs that are being used to treat side effects of other drugs.

Learning Objectives (cont’d)• Develop a personal system of addressing

polypharmacy and medication-related problems in the clinical setting.

• Discuss how increasing medication burden can pose a hazard to the cognitively impaired elder.

• Describe why nurses have a unique perspective and role in the healthcare team when it comes to medication use and outcomes.

Polypharmacy Background• Polypharmacy

– Concurrent use of multiple medications

• Geriatric syndrome– Common health condition in older adults that is

not a discrete disease

• Pharmacokinetics– How drugs are absorbed, metabolized, and

eliminated; How drugs move through the body.

• Pharmacodynamics– How drugs work in the body; What drugs do in

the body.

Significance of the Polyp. Problem• Morbidity, mortality, and costs

– Adverse drug reactions (ADRs): overlooked. The reported statistics on ADRs are underestimated.

– Medication-related problems (MRPs): the 5th highest cost of disease (if MRPs were considered disease)

• Historical perspective– Pharmacogenomics: people have a genetic, set-at-

birth capacity to metabolize medications through different pathways, each one working at a different rate in different people.

Risk Factors of Polypharmacy

• Prescribing cascade: treating med side effects with other medication

• Multiple prescribers and iatrogenic harm (iatrogenesis): doctor or healthcare created harm

• Multiple pharmacies• Older Age: Frailty, Chronic Disease, Cognitive

Impairment, and Altered Pharmacokinetics• Transitions of care• Isolation

Warning Signs• Nonspecific complaints

– Symptoms caused by medication side effects can seem unrelated to the actual medication

• Timeline– Be aware of new problems that emerge after a

new medication is introduced– Challenges

• Poor patient record keeping• Hidden use of OTC drugs, herbal and other

supplements

Warning Signs• Drugs usually associated with falls

– Benzodiazepines– Muscle relaxants– First generation antihistamines– Opioids

• Sudden change in ADLs or IADLs– Global sign of a problem in the elderly– Anticholinergic drugs

Assessment• Brown bag assessment• Gait and frailty• Medication adherence rating scales and tests• Take-home medical administration record• Literacy screen• Swallowing status• Collateral History: Adult Child or Caregiver• Beers Criteria (inappropriate med list for elders) and

START (screening tool to alert doctors) and STOPP (screening tool of older people’s potentially inappropriate meds ) Criteria

Diagnosis• Deduction

– Polypharmacy-induced harm and MRPs are typically diagnosed through deductive means

• Patient adherence• Medication list

• Laboratory results– Complete Metabolic Panel (monitor kidney and liver

function, glucose, calcium, protein levels, electrolyte/fluid balance) and Basic Metabolic Panel (kidney function, glucose, calcium, and electrolyte/fluid balance)

• Trial Discontinuations– Must be carefully considered

Interventions and Strategies for Care

• Strategies for intervention can help lower the risk of polypharmacy and medication misadventures

• Decrease the number of unnecessary or harmful medications

• Appropriate choices and doses• Foster medication literacy

Interventions and Strategies for Care (cont’d)

• Access to medications: Cost of medication– Medicare D “doughnut hole”: when Medicare D hit

maximum spending limit that stops coverage but then picks up above a much higher amount.

– http://plancompare.medicare.gov/pfdn/ FormularyFinder/LocationSearch allows seniors or caregivers to compare plan coverage for their specific medications to find the plan that offers the best coverage

– Pharmacies offering discounts or one-price medications on their formularies

Interventions and Strategies for Care (cont’d)

• Medications to Avoid in the Elderly (Drugs associated with increased risk of falls): Benzodiazepines, psychotropic meds, anagesics, vasodilators, antihistamin, diuretics,.

• Do not crush any oral medication that is labeled as: EC (Enteric-coated), ER (Extended-release) or SR (Slow-release), medication that ends in the following letters – CD, CR, LA, SR, XL, XR, XT

Nursing Interventions• Medication review:

– Compare patient medications to the medical records.

– “start low; go slow”: start low dosage, increase slowly to prevent toxic side effect.

– Ensure that medications no longer prescribed are discarded.

– Discard any expired medications.– All medications in a multi-dose vial such as insulin

will be dated and initialed.– All liquid medication will be poured at eye level

to ensure the correct amount.

Nursing Interventions– Internal medication will be separated from

external medication.– All medications administered via NG/G-tube will be

administered via gravity.– All residents on G-tube feeding will have the HOB

elevated to 30 degrees.– The reason for administering any PRN medication

should be documented on the rear of the MAR.– Medication refrigerator temperature should be

checked once a day. Check twice a day if there are vaccines.

Nursing Interventions– Oral meds should be given with a nutritious liquid

rather than water if a patient is anorexic.– Suspect an adverse drug effect if a patient has

cognitive changes, falls, or experiences anorexia, nausea, or weight loss.

– Wash hands before pass meds.– Check ID bands always before administer meds.– ATB order: carry out within 4 hours– Non-pharmacological approach instead of using

psychotropic meds.

Alternatives

• Laxative: Increase bulk in diet (apple, bran muffin), avoid excessive use of calcium

• Hypnotics: suggest warm milk (contains natural tryptophan), adapt environment (noise, light, music..), awake & active activity during day, review meds-diuretics

• Antacids: small frequent meals, keep upright position at least 30 mins after taking meds.

• Antianxiety agents: suggest counseling, stress reduction techniques, tai chi, yoga.

• Analgesics: distraction, positioning, ice or heat.

Summary

• Likelihood that medication will cause harm or impairment to elderly patients is heightened by – impaired physiology– heavy medication burden– increased inappropriate medication use by

healthcare system and patient