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Reducing Polypharmacy

By: Monica Tenhunen, DNP
Post Acute Care/Long Term Care SIG

March 2014

 

Polypharmacy refers to the use of multiple medications and/or prescribing more medication than are clinically indicated (Hajjar, Cafiero and Hanlon, 2007). Often a medication is prescribed to counteract a side effect or adverse drug reaction from another medication.

  • Evaluate the drug regimen of long term care residents on each regulatory visit.
    • Ensure there is a reason (diagnosis) for every medication the patient is receiving.
    • Determine whether each medication has led to a significant improvement in this patient.  If not, consider discontinuing or changing.
    • Evaluate if non-pharmacological treatments been tried for the diagnosis
    • Is the patient on the right medications for that condition based on current guidelines?
    • Assess the risks and benefits of each medication in the context of the individual patient
  • Medication reconciliation at admission, readmission, transfer and discharge.
  • Check for drug-drug, drug-disease and drug-food interactions. Include over the counter (OTCs), eye drops, topicals, homeopathic/alternative remedies and nutritional supplements.
  • Always consider potential interactions with other medications, especially warfarin, phenytoin, amiodarone and antibiotics.
  • Assess for side effects, specifically orthostatic hypotension, increased confusion, unsteadiness, falls, nausea, anorexia, constipation, depression, anxiety.
  • Start low, go slow, but go all the way to achieve therapeutic benefit.
  • Avoid drugs with significant anticholinergic effects whenever possible.
  • Evaluate if the patient is on the most cost-effective alternatives.

There are various tools available to assist in the evaluation of medication regimens. Two of these are STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions; Gallagher & O’Mahoney, 2008) and ARMOR (Assess, Review, Minimize, Optimize, Reassess; Haque, 2009).

Skilled nursing facilities (SNF) are mandated by the Center of Medicare Services to avoid unnecessary drug use (CMS, 2011). There are penalties for SNFs that demonstrate unnecessary drug use. Surveyors assess the appropriateness of medications used in LTC and have a list of “medications of particular relevance”, which includes medications listed in the Beers criteria and they also possess a list of medications subject to "gradual dose reductions" (CMS, 2011). All NPs working in SNFs to be familiar with these guidelines and know how to perform and document medication related issues.

Resources:


References:

American Geriatrics Society. (2012). American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults.  Journal of the American Geriatrics Society, 60, 616-631. doi: 10.1111/j.1532-5415.2012.03923.x

Gallagher, P., & O’Mahony, D. (2008). STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): Application to acutely ill elderly patients and comparison with Beers' criteria. Age and Ageing, 37, 673-79. doi: 10.1093/agein/afn197

Hajjar, E.R., Cafiero, A.C., and Hanlon, J.T. (2007). Polypharmacy in elderly patients, The American Journal of Geriatric Pharmacotherapy, 5(4), 345-351.

Haque, R. (2009).  ARMOR: A tool to evaluate polypharmacy in elderly persons.  Annals of Long Term Care, 17(6), 26-30.

Morley, J. E. (2010).  Clinical practice in nursing homes as a key for progress.  Journal of Nutrition, Health & Aging, 14, 586-593.

Parsons, C., Lapane, K., Kerse, N., & Hughes, C. (2011). Prescribing for older people in nursing homes: A review of the key issues. International Journal of Older People Nursing , 6, 45–54.  doi: 10.1111/j.1748-3743.2010.00264.x

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