Polypharmacy in GerontologyCassandra Rodocker, Lauren Scarponi, Jessica Talbot, Lisa Tripp

Polypharmacy:The concurrent use of multiple medications(Mauk, 2014, p417)

The problem:Polypharmacy increases the risk of morbidity and mortality

30%

50%

41%

Clients that have 2 or more physicians; resulting in polypharmacy

Clients that are prescribed 5 or more medications

65 year olds admitted to hospital because of polypharmacy

Physiological Effects on Older AdultsNonspecific Complaints (i.e. cognitive impairment, falls, decreased functional status, malaise, abdominal discomfort, nausea/vomiting, sleep changes, fatigue/weakness) caused by

drug-drug interactions

food-drug interactions

disease-drug interactions

drug toxicity

Increased morbidity and mortality

The solutionEducation and Documentation

Clients should be encouraged to inform all of their doctors of all of their medications (or preferably, see only one doctor)Nurses and doctors should teach clients about what medications do, so clients can advocate for themselves

BEERS A Clinical Tool for Nurses

How it works: Beers catalogues medications that cause adverse drug events

Step 1

Inappropriate drug choice

Medications generally to be avoided in the elderly population

Step 2

Excess dosage

Medications at a dose or duration of therapy not to be exceeded

Step 3

Drug-disease interaction

Medications to be avoided for patients with specific co-morbid conditions

Category One: Inappropriate drug choice

Therapeutic/ Category Drug

Long-acting benzodiazepines, including:

diazepam (VALIUM)flurazepam (DALMANE)chlordiazepoxide

(LIBRIUM)

*all of which have long half-lives

Recommendation

AVOID

Rationale

This can lead to accumulation of the drug, leading to excessive sedation and an increase in the risk of falls and fractures

Category Two: Excess Dosage

Therapeutic/ Category Drug

Long-term use of stimulant laxatives

bisacodyl (DULCOLAX)cascara sagrada

(made from the dried bark of an American buckthorn)

Recommendation

AVOIDmay be appropriate in

the presence of opiate analgesic use

Rationale

Medication may exacerbate bowel dysfunction

Category Three: Drug-disease interaction

Therapeutic/ Category Drug

Pts with a hx of syncope (temporary loss of consciousness caused by a fall in BP) or falls receiving meds such as benzodiazepines and/or tricyclic antidepressants

amitriptyline (ELAVIL)doxepin (SINEQUAN)imipramine

(NORPRAMIN)

Recommendation

AVOID

Rationale

Medications may:Produce ataxiaImpair psychomotor

functionIncrease falls

Why do nurses need BEERS?Nurses are the only members of the healthcare team that actually witness the client’s use and outcome of medications

It is our job to advocate for our clients

BEERS will help bridge the knowledge gap for clients about medications

Nursing Care Plan

Assessment

Assess the patient for signs/symptoms of polypharmacy, review and reconcile patient medication lists, clarify the purpose and use of all medications.

Diagnosis

Drug toxicity/drug interaction r/t concurrent use of multiple medications manifested by cognitive/functional impairment, falls, malaise, abdominal complaints, etc.

Plan

GoalPatient will discontinue use of multiple concurrent medications and be actively involved in the process.

Nursing Care Plan

InterventionEducate the client about the

active ingredients in their medications and additive effects of taking multiple meds with the same active ingredients

Educate the client about only using one pharmacy and taking medications exactly as prescribed

Educate the client about lifestyle changes that could ultimately eliminate the use of a drug

Educate the client about the importance of reporting all medications to all doctors they visit

Educate the client and family about the signs of trouble (see physiological signs of polypharmacy) and that such symptoms should be reported to their doctors immediately.

Ask the patient to perform teach-back education:

How they will take their medications

When they should take their medications (and in what doses)

Signs/symptoms of interactions and toxicity

Evaluation

ReferencesAmerican Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

(2012). Journal of the American Geriatrics Society, 616-631.

Fusco D., Lattanzio F., Tosato M., Corsonello A., Cherubini A., Volpato S, et al. (2009). Development of CRIteria to

assess appropriate Medication use among Elderly complex patients. (CRIME) Project. Drugs Aging; 26 (Suppl. 1):S3–13.

Kinsella K., Phillips D.R. (2005). Global aging: the challenge of success. Popul Bull; 60:3–42.

Mauk, K. (2014). Gerontological nursing (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers.