Medication Reduction in Persons with Dementia

Medical Staff Education

The Problem Too many residents are taking

too many medications! Are all of these medications

necessary? What are the risks associated with

unnecessary medication dosing? What can physicians do??

Why so many drugs? multiple medical co-morbidities

often multiple drugs for single diagnosis cognitive and behavioral issues (70-

80% of facility residents) weight loss infections pharma advertising to public family pressure

Why so many drugs? most residents enter facility with a long

list of medications and they are written as part of admitting orders and then, they simply are continued

“drug holidays”, withdrawal (OBRA) easily circumvented

nursing requests for ‘something’ for: fever, cough, infection, weight loss, behavioral issues

Symptom control skin lungs pain behaviors the ‘symptom’ of abnormal labs…

Caregiver burden and well-being well-being directly affected by

perceived social support burden self-esteem hours of informal care

Chappell, Reid. Burden and well-being among caregivers: examining the distinction. Gerontologist. Dec 2002;42(6):772-80

Caregiver burden and well-being burden directly affected by

behavioral problems break frequency self-esteem hours of informal care

Chappell, Reid. Burden and well-being among caregivers: examining the distinction. Gerontologist. Dec 2002;42(6):772-80

Risks of excessive medications administration issues

missed doses more meds to pass more documentation higher cost (to family/resident and to

facility)

Risks of excessive medications side effects

drug-drug, drug-disease interactions somnolence, lethargy, decreased

cognition less active, increasing debilitation, falls increase in ADL support needs weight loss, contractures sentinel events: dehydration, fecal impaction,

pressure sores resistance to care

Risks of having ADR related to number of medications

Number of meds

Risk of ADR

2 6%

5 50%

8 100%

Shaughnessay AF. Common drug reactions in the elderly. Emerg Med. 1992;24:21-32., as quoted in Dayer-Berenson L. Polypharmacy in the Elderly. Nursing Spectrum website. Available at http://nsweb.nursingspectrum.com/ce/ce214.htm. Accessed February 24, 2003.

Adverse Drug Reactions in real life… rate of ADR: 67% 14% of ADR’s required

hospitalization

Cooper J. Adverse Drug Reaction-Related Hospitalizations of Nursing Facility Patients.Southern Medical Journal. May 1999;92(6):772-80.

Adverse Drug Reactions in real life… 16% of residents in snf hospitalized for

ADR (additional 50% of residents had ADR, but did not require hospitalization)

hospitalization most commonly due to NSAID (GI bleed) psychotropic-related fall with fracture digoxin toxicity insulin hypoglycemia

account for

80% of ADR’s

Cooper J. Adverse Drug Reaction-Related Hospitalizations of Nursing Facility Patients.Southern Medical Journal. May 1999;92(6):772-80.

Adverse Drug Reactions in real life… 5 residents (of 52) had recurrence

of hospitalization for the same problem

number of meds (adjusted for number of problems)

ADR hospitalized

non-ADR

7.9 ± 2.6 3.3 ± 1.3

Cooper J. Adverse Drug Reaction-Related Hospitalizations of Nursing Facility Patients.Southern Medical Journal. May 1999;92(6):772-80.

Adverse Drug Reactions in real life…

psychotropics implicated in fall-related fractures

Cooper J. Adverse Drug Reaction-Related Hospitalizations of Nursing Facility Patients.Southern Medical Journal. May 1999;92(6):772-80.

Adverse Drug Reactions in real life… don’t forget anticoagulants

warfarin not the most common cause of ADR’s, BUT: ADR’s are overwhelmingly common in residents taking warfarin

wrong dose, inadequate monitoring incorrect response to monitoring results lack of observation for or response to

development of side effects

Physician contributions to preventable ADR’s 47% - caused by physician’s order

wrong dose guaranteed drug-drug interaction wrong drug

49% - failure to monitor therapy inadequate lab monitoring failure or delay in responding to labs

or symptoms or signs of drug toxicityNIH News Release, August 2000http://www.nia.nih.gov/news/pr/2000/0809.htm

Physician role in reducing medications learn behavior management skills

(70-80% of residents have dementia; 65 – 70% of those will have behavioral challenges)

resistance to care negative interpersonal interaction wandering calling out

insist on non-pharmacologic management - first and always

Physician role in reducing medications help nursing staff to learn/use good

assessment skills avoid knee-jerk response to

prescribe a medication for symptom control (especially in response to after-hours telephone call)

work with pharmacist in identifying possibilities for medication reduction

Physician role in reducing medications don’t add medications to the

resident’s drug regimen unless truly needed

when reducing medications give appropriate orders for monitoring

of withdrawal document appropriately do follow-up documentation as required

Physicians: practice habits needed when ordering new medication

drug regimen review don’t order drugs with long half-life avoid combination drugs: are all

components necessary? alert nursing staff to potential side effects

(not PDR list, but based on physician’s knowledge of patient, diseases, drug interactions)

establish appropriate monitoring

Physicians: Knowledge Needed geriatric pharmacology

pharmacokinetics: what the body does to the drug

time course of absorption, distribution, metabolism, excretion

pharmacodynamics: what the drug does to the body

therapeutic pharmacologic adverse

Physician drug regimen review for each drug order, consider

Is drug prescribed being administered to a high-risk patient? (Note: all geriatric patients are high risk!)

Is drug being prescribed a high-risk drug? Is drug being prescribed a ‘targeted’ drug

(high potential to cause ADR)? Is there a valid medically necessary reason

to prescribe the drug? Why can’t the drug be reduced/stopped?