Module 4 - Polypharmacy Flashcards
Polypharmacy
Poly = “Many”
Studies give different numbers but regardless it means use of many medications at once
It is the concurrent use of more than 1 medication either OTC, prescribed, or herbal supplement
Sometimes polypharmacy is about appropriateness, so what are some inappropriate polypharmacy situations?
Use without indication
Duplicate Therapy
Use of generic and brand at the same time
Prescribing Cascade
Excessive Duration
Excessive Dose
In presence of adverse consequences where drug should be reduced or discontinued
Prescribing Cascade
prescribing medications to solve other medications side effects and that continues and spirals from there
What sort of medications are included as part of the definition of polypharmacy
OTC - over the counter drugs
prescribed drugs
herbal supplements
Knowledge of polypharmacy requires awareness of …
increased risks of drug interactions and adverse effects
Why is a 78 yo male with BPH and dementia an inappropriate situation for use both ditropan and benadryl?
both drugs have anticholinergic effects that lead to increased urinary retention
this can lead to urosepsis and subsequent ER visits and hospitalization
Beers Criteria
A medication list for the elderly that lists meds that should be avoided in the elderly, avoided in elderly with certain conditions, and meds to use cautiously in the elderly with conditions like renal concerns
It is a guideline for what medications to be careful using when treating the elderly
When giving the elderly medications, it is important to be cognizant of…
dosages and monitoring reactions to medications
How big of a problem is polypharmacy?
In 2000: 13% of the US was under polypharm, but 33% of all Rx users and 40% of OTC users were
In 2015, This increased to 14% of the US and 33% of Rx Meds (costing 325 billion dollars)
As many as ___% of elderly take at least ONE med? ___% take 5+? ___% take 10+?
90% - 1
40% - 5+
12% - 10+
Why is polypharmacy not just a prescription issue?
There are over 100,000 OTC on the US market with elderly using as much as 40%, 50-90% take at least 1 OTC, and 50% >5 combined OTC and Rx
Common OTCs include…
sleep
analgesics
antacids
constipation
cough and cold
herbals
Risk factors for Polypharmacy
Multiple Medical Diagnoses
Multiple Medical Providers
Multiple Sources for Drugs
Lack of Patient Knowledge
Lack of Provider Knowledge
We do not really need a medication for every diagnosis, but…
we have been conditioned to think we do
Primum Non Nocere
“Do No Harm”
Before 1999, the elderly were never used in clinical drug trials, only health 20s males
So in the end we did not know the drug impacts on the elderly population leading to Iatrogenesis
Iatrogenesis
Harm coming from a therapeutic regimen
The most common form of iatrogenic illness is ADVERSE DRUG REACTIONS
Positive outcomes of polypharmacy?
Medication purposefully changes physiologic function for therapeutic effect(s) which can lead to improved quality of life
Potential negative outcomes of polypharmacy?
Adverse drug reactions (drug-drug, drug-food)
Adverse drug events (falls, ER visits, hospitalizations, death)
Medication errors
Non-adherence to medical regimen
Financial burden
Decreased quality of life from side effects or adverse reactions
What are two factors affecting polypharmacy related to an elders behavior?
- Accurate Diagnoses - elders may under report symptoms, attributing it to “old age”, but vague and atypical symptoms and overlap between physio/psycho symptoms can lead to bad diagnoses and wrong medications
- Tendency to treat with drugs - OTCH (1000s available)
ADR
Adverse Drug Reaction
What are the chances of an ADR with 2 meds? with 5 meds? with 8+ meds?
2 = 6%
5 = 50%
8+ = 100%
it grows exponentially fast!
Types of Meds associated with ADR occurrence
cardiovascular
diuretics
hypoglycemics
anticoagulants
pain meds
ADR incidence is ___x greater in the edlerly
2 to 3 x
ADRs manifest differently and vaguely sometimes, so we must monitor
elder status on a day by day basis
What are some ways ADRs can manifest differently?
May take prolonged time to be apparent
May manifest differently in elderly vague symptoms
May happen only after long term drug use
May be mistaken for geriatric conditions like falls and changes in cognition
Difference between a side effect and adverse effect?
Side effect are known to occur and common while adverse effects are unintended and need intervention
Ex: Side effects of Ibuprofen
Unintended event at normal dose
GI: Nausea
abdominal pain
headache
dizziness
Ex: Adverse Effects of Ibuprofen
Intervention needed to prevent harm
GI bleeding
Cardiac issues like MI or CHF
Renal damage or failure
Pharmacodynamics
What drugs do to the body
Receptors in the brain are more sensitive to what types of drugs?
- Opioids
- Benzodiazepines
- Anticholinergics
What are some age related changes when it comes to medications?
Pharmacodynamically:
- receptors in the brain become more sensitive
- heightened response to anticoagulants
- decreased sensitivity to beta blockers
Pharmacokinetically:
1. Absorption, distribution, metabolism, and elimination changes effecting concentration of drug in the body
Pharmacokinetics
What the body does to the drug
this determines the concentration of the drug in the body
What 4 factors determine concentration of drug in the body?
Absorption
Distribution
Metabolism
Elimination
What is the “First Pass” for a drug in the body?
Metabolism
Drug Metabolism
drug passes through the small intestines into a network of veins that surround it (“portal system”) and drain into portal vein which enters the liver
Drugs passing this way have high “FIRST PASS”
How does age effect drug metabolism?
Liver function, blood flow, and metabolism decrease so greater non-metabolized or free medication exists in plasma
So, main drugs and oral doses of the drugs will need to be adjusted downward to account for this
What 3 Elimination factors decrease with age?
- Decreased sweat and saliva
- Decreased respiratory function
- Decreased renal function
Glomerular Filtration Rate can be decreased as much as ___% in the elderly. Why is this important?
50%
Serum creatinine is not a good measure of renal function in the elderly, because decreased lean muscle mass leads to decreased creatinine production - so it is not a renal problem in this case
Increased risk of toxicity as medications remain in the body is related to …
delayed excretion
Cockcroft-Gault Calculation
Physician calculation to know how much a potentially toxic drug can be given
This is often referred to as “Creatinine Clearance”
Not done by the nurse
How does Drug half life impact the elderly?
Half life will increase with age.
For example: Xanax 5 mg - in a healthy adult HL is 11 hours but in an older adult it is 16.3 hours
If you give an 8 pm dose of xanax 5 mg to chemically restrain a patient with dementia exhibiting behaviors, how will that dose stay in their system?
- 5 mg will still be active at 12:20 pm that day
1. 25 mg will still be in their system at 4:40 a.m. - that is two days later!
S/S of Polypharmacy commonly misinterpreted as a part of aging?
Fatigue and tiredness, not as alert
constipation, Diarrhea, incontinence
confusion, LOC changes
depression
weakness, tremors, dizziness
anxiety
decreased sexual desire/performance
Nurse’s Role with Polypharmacy?
- Assessment
- Education - teach them and even write down meds so people clearly know what to take
- Monitoring - for change d/t drugs
- Coordination of Care - follow up with them and talk to physician about concerns
Why is coordination so important for the RN to do?
RNs are on the “front lines” perfectly positioned to enhance/support the communication between the patient and provider and should do so!
What are some aspects of Polypharmacy Assessment?
- Functional and cognitive ability to self manage meds
- Nutrition
- health beliefs of the individual - do they use herbals, recreational drugs, ETOH, nicotine
- Socioeconomic - can they pay for medications
- Complete medication lists - home inspection, know where all the drugs are
- Beers Criteria Review - the bible for elder drugs and online apps
- Drug-Drug Interaction Checkers - online apps
3 Things to Monitor in regard to patients and polypharmacy?
- Therapeutic effects
- Side effects
- Adverse effects
Central Anticholinergic Effects in the Elderly r/t polypharmacy
Agitation
Confusion
Disorientation
Poor Attention
Hallucinations
Psychoses
Peripheral Anticholinergic Effects in the elderly r/t polypharmacy
Constipation from decreased intestinal peristalsis
Urinary retention
Inhibition of sweating
Decreased salivary and bronchial secretions
Tachycardia
Pupil dilation
Anticholinergic Effects are dependent on what?
Effects are dose dependent!
We need to know the person and information about them to prevent too much effects slowing everything down
What things educate elders about an Rx/OTC drug in order to empower them?
Patient/Caregiver should know these things about each drug:
- Name
- Purpose
- Dose
- Best time to take
- With other drugs?
- how long to take
- what to do if you miss a dose?
- not to share the drug
- keep in original container
- common side effects
- what to do if side effects occur
- how to store properly
- How many refills
- how to dispose of
- not to take >1 year old or past expiration date
Examples of Safe Website for Online Rx
- National Association of Boards of Pharmacy
- VIPPS
- Anything in the US, where a license Rx can answer questions, requires a prescription from a provider that knows you, and has excellent customer service
How should safe disposal of medication be done?
- Discourage pill sharing/hoarding
- Check med cabinets 1x/year for expired and unused meds
- Sharps and unwanted medications should be disposed properly, potentially at a disposal area like a collections box at the sheriffs office or by putting it in kitty litter for disposal
The golden rule for medications in the elderly is…
START LOW AND GO SLOW
Gradual Dose Reduction
Gradual Dose Reduction (GDR)
Tapering of a dose in a stepwise manner
We start at the bottom and work up and taper or get rid of things that are unneeded
we ask if symptoms, risk, and condition could be managed with a lower dose and if drugs can be discontinued
We commonly see this in LTC with psychotropic drugs but you should ask this in any setting
It is particularly important to “Start low and go slow” when …
- drugs are new to market
- the drug has CNS, anticholinergic, renal elimination, strong 1st pass effects
- When the drug has a very narrow therapeutic window
Example: Why is it important to “start low and go slow” particularly for acetaminophen in the elderly?
- Increased risk of toxicity is r/t age related decreases in hepatic function
- Must be used cautiously in those with impaired hepatic function OR ETOH use
- Many meds contain acetaminophen in combination and the elderly may not recognize that
MDD (maximum adult daily dose) is 3 gms/24 hours, and it can interact with warfarin to increase INR
Also, liver damage can occur if 3-4 gms is used daily for a year
