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Week 2: Polypharmacy Discussion

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Polypharmacy is a common concern, especially in the elderly.

  • List the definitions of polypharmacy you encounter in your assigned reading. Include an additional reference from an evidence-based practice journal article or national guideline.
  • Discuss three risk factors that can lead to polypharmacy. Explain the rationale for why each listed item is a risk factor. Risk factors are different than adverse drug reactions. ADRs can be a result of polypharmacy, and is important, but ADRs are not a risk factor.
  • Discuss three action steps that a provider can take to prevent polypharmacy.
  • Provide an example of how your clinical preceptors have addressed polypharmacy.

Discussion Guiding Principles

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Direct Quotes

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Lesson:

Polypharmacy

As patients age and develop more chronic conditions, the number of medications tend to increase, making our geriatric clients at high risk for polypharmacy. Polypharmacy, the use of multiple pharmacies (in this case providers and self-prescribers) is a public health concern. Multiple prescribers, use of over-the-counter medications, and readily available supplements are all challenges of prescribing for older adults.

We know that adverse outcomes are increased when patients are taking more medications. Over 2 million adverse drug reactions (ADRs) are estimated yearly at a cost of $136 billion with 350,000 of these occurring in nursing home patients. We also know that ADRs can be reduced by 35% with even the smallest reduction in medications (Sengstock & Zimmerman, 2014).

As our population continue to age, providers need to adopt a process to routinely evaluate medication appropriateness and avoid the risk of polypharmacy.

Ways to prevent polypharmacy: a step wise approach

  1. Have new patients bring all medications to their first visit (the brown bag medication review). This includes any prescriptions. OTCs, creams, ointments, et cetera

This medication review has multiple purposes. The interviewer can assess

  • what the patient is actually taking
  • what the patient understands about each medication, identifying educational needs
  • the medication’s effectiveness
  • any possible side effects
  • Review the appropriateness of each medication. Does the evidence support continuation? Is this medication duplicated?
  • Are there any adverse reactions? Are there any potential ADRs to monitor?

Ongoing polypharmacy surveillance: Medication Reconciliation

  • Review your patients medication list at every visit
  • Specifically ask if any other provider has changed or added any medications since the last visit
  • Update the office medication list with the patients medications evey visit

Three available polypharmacy tools you can use to evaluate your patients prescriptions:

STOPP (Payne, 2017) (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions)

MAI (Medication Appropriateness Index)

ARMOR (Assess, Review, Minimize, Optimize, Reassess)

Beers Criteria

Beers Criteria

The American Geriatrics Society has developed the Beers Criteria (BC) for healthcare providers to use as a guide for medical management of geriatric patients. The goal of the Beers criteria is to improve quality and safety. The BC is not a substitute for individualized care but should be incorporated into your prescribing practices for elderly patients. Nurse practitioners should become familiar with the lists to avoid prescribing potentially inappropriate medications (PIM).

Why do the elderly need a special criteria?

The changes that occur with aging change the body’s metabolism. This was discussed in last week’s readings. Also think back to your pharmacology class and if needed review pharmacodynamics, especially any changes noted in the elderly. Pharmacokinetics changes too with aging, these include changes in absorption, distribution, metabolism and elimination. Medication half-lives can also be altered, which has an effect on steady state and dosing intervals.

What is the risk for the elderly?

Adverse drug reactions (ADR) are a very real risk for elderly patients.

Potential risk factors for ADRs are:

  • 6 or more chronic diseases;
  • 9 or more prescription or OTC medications;
  • > 12 doses per day;
  • Age > 85 years;
  • BMI < 22 kg/m2;
  • Creatinine clearance < 50 mL/min; and
  • history of previous ADR (Terrery & Nicoteri, 2016).

The medications used most often in the elderly account for 60% of ADRs, often requiring hospital admission. The medication list includes common medications such as antibiotics and antihistamines and well as anticonvulsants, antipsychotics, diuretics, digoxin, hypoglycemic agents, antineoplastic medications, and NSAIDS.

Some 2015 noteworthy changes (Terrery & Nicoteri, 2016) include:

  • “Nitrofurantoin may be used with relative safety and efficacy in persons with a creatinine clearance of 30 mL/min but should be avoided long term due to concerns of irreversible pulmonary fibrosis, liver toxicity, and peripheral neuropathy”
  • “Non-benzodiazepine, benzodiazepine receptor agonist hypnotics (eszopiclone, zaleplon, zolpidem) should be avoided for insomnia regardless of duration due to associated harm”
  • “Proton pump inhibitors should be avoided beyond 8 weeks without justification due to associations with Clostridium difficile infection, bone loss, and fractures.”
  • “Opioids (CNS medications) should be avoided in those with a history of falls or fractures.”

These are some examples of applicable recommendations that you may see in clinical and in future work here in our course. The BC is updated regularly and I recommend that you check for changes yearly to assure your reference is up to date.

Important provider facts:

  1. The medications listed in the Beers criteria are not absolutely contraindicated in elderly patients. The recommendations are graded as high medium and low to assist with decision making
  2. The list includes dosage adjustments for kidney impairment
  3. The list includes drug to drug interactions to avoid

Responsible prescribing is an important part of the NP role. The Beers Criteria can assist you in determining the safest medications for your geriatric patients.

The iGeriatrics app contains the 2015 Beers Criteria. It is available for purchase from the GeriatricsCareOnline.org Web site (Links to an external site.)

Vascular Disorders

Peripheral vascular disease is an occlusive atherosclerotic process that generally develops in the legs and less commonly in the arms. The pathological process can be diffuse, but the flow limiting stenosis develops segmentally usually in the aortoiliac, femoral popliteal or tibial segment of the aortic system.

The femoral artery is the most commonly occluded artery in peripheral arterial disease (PAD). Pain and circulation in the extremity often often occurs during exercise due to restrictive blood flow and the inability to keep up with the increased oxygen demand. The pathologic process of (PAD) increases with the age of the patient. There are several modifiable risk factors for PAD that may help your patients reduce their risk:

  • Men and women are equally affected. Black individuals have an increased risk.
  • Hypertension
  • Diabetes
  • Hyperlipidemia
  • Cigarette smoking
  • Obesity
  • Advancing age-especially greater than 60 years old
  • Known atherosclerosis at other sites (e.g. coronary, carotid, or renal artery disease)

Peripheral Artery Disease (PAD) includes a group of diseases, with atherosclerosis being the most common type (White & Truax, 2007). Based on the pathologic process of PAD, it’s easy to understand the clinical presentation:

  • As many as 50% of people are asymptomatic
  • Most symptomatic patients with lower extremity pain either as classic intermittent claudication or atypical leg pain
  • Lower extremity pain can be unilaterally, bilaterally, as buttock and hip thigh, calf or foot pain
  • Ischemic rest pain may be present
  • Severe diffuse pain can occur suddenly progressing to numbness and paralysis
  • Diminished or absent pedal and/or posterior tibial pulses

Physical exam findings of the patient with PAD may include:

  • Atrophic changes and loss of hair
  • Cyanotic changes in legs, darkened areas, dry, scaly, pale or mottled skin
  • Palpation of the extremity may reveal cool and thickened skin
  • Abnormal capillary refill and clubbing
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