unnec med use 2010

MDSCarePlanBuilder.com

Meeting Professional Standards of Practice

Debbie Ohl RN, NHA, M.Msc., Ph.DOhl & Associates

Consultant and EducatorMDSCarePlanBuilder.com


What are Unnecessary Medications?

Excessive doses Excessive duration Without adequate monitoring Without adequate indications for use Presence of adverse consequences

indicating dose should be reduced or discontinued.


Question

In your own words, what do you consider to be unnecessary drugs?


UNNECESSARY MEDS ARE

D2UMDOSE, DURATION, USE, & MONITORING

ARE NOT IN PLACE


Regulatory Interrelationships

• Unnecessary Drug Use• Antipsychotic Drugs• Medication Errors• Drug Regimen Review• Comprehensive assessment • Care planning• Professional standards of practice

There are 5 questions to consider to prevent connecting these F-tags to one another

1. Do the target symptoms warrant medications?

2. Are non-pharmacological interventions in place and relevant?

3. Is medication appropriate to manage the symptoms or condition?

4. Do the intended or actual benefits justify the risk of use?

5. Is there a system in place to insure these criteria are adhered to?



Key TermsLinked to Unnecessary Med Use

1. ADE: Adverse Drug Effect

2. ADR: Adverse Drug Reaction

3. Poly-pharmacy

4. Predictability

5. Medication Errors

6. Beers List

7. Immediate Jeopardy

8. Professional standards of practice

Defining Key Terms

ADVERSE DRUG EFFECT:

Basket term that captures med errors and ADR’s.

• ADEs can have different outcomes: worsening of existing condition, or lack of expected

improvement.

• Statistically: 2 ADE’s /100 residents More than half of adverse drug events may be preventable.

ADVERSE DRUG REACTION:

• Any unintended response to a drug that is Harmful / noxious in doses for diagnosis, prophylaxis, or therapy.

• High risk med categories: Psycho tropics, analgesics, anticoagulants, antibiotics, cardiovascular


Key Terms cont’

• Polypharmacy : lots of meds

• Predicatblitiy: primary concern

• MEDICATION ERRORS Any preventable event that can cause or lead to inappropriate medication use or patient harm while the medication is in control of the health professional.

DAMP: mistakes are related to dispensing, administering, or monitoring , prescribing,

5 errors / 100 residents

• BEERS LIST: medication with high risk side effects that outweigh benefits of use; meds that are inappropriate at any dose; specific meds used at low with caution.

• Immediate Jeopardy: scope H I L K L

• STANDARDS of PRACTICE: The various practice regulations in each State, and commonly accepted health standards established by national organizations, boards and councils.



Failure to protect from undue adverse med consequences or failure to provide med as prescribed.

1. Administration of medication to an individual with a known history of allergic reaction to that medication.

2. Lack of monitoring and identification of potential serious drug interaction, side effects and adverse reactions.

3. Administration of contraindicated medications.

4. Pattern of repeated medication errors without intervention.

5. Lack of timely and appropriate monitoring required for drug titration.


Degree of the Problem

Isolated Pattern Wide-spread

Immediate Jeopardy J K L

Actual Harm G H I

Potential for Harm D E F

No harm likely A B C

From a citation

perspective, what are the

potential scope and severity of

slide 10 failures

and why?


Adverse Drug Events

• Pharmacodynamics: drugs with similar or opposing effects

• Pharmacokinetics: what the body does to a drug

AD ME• Absorption • Distribution • Metabolism • Elimination

Pharmacokinetics: ADMEWhat the body does to a drug

• ABSORPTION: bowel surface decreases with age and gastric juices increase.

• DISTRIBUTION: Total body water decreases 10 to 15% with aging. Results in possible higher blood concentrations of some water-soluble drugs;

• Body weight that is body fat increases from 18 to 36% in men and from 33 to 45% in women. Result is fat soluble drugs take longer to eliminate.

• METABOLISM: liver mass and blood flow decrease = harder to breakdown and eliminate

• ELIMINATION: renal mass and blood flow decrease = reduced elimination of drug.



Preventable Adverse Drug Effects

Occur at Ordering Wrong drug choice Failure to consider drug interactions Transcription errors

Occur at Monitoring Failure to order specific monitoring needs Delayed response or failure to respond to signs &

symptoms of toxicity or lab evidence of toxicity

An adverse drug reaction is any unexpected, unintended, undesired, or excessive response to a

drug that requires

• Discontinuing the drug (therapeutic or diagnostic)

• Changing the drug therapy

• Modifying the dose (except for minor dosage adjustments)

• Necessitates admission to a hospital

• Prolongs the stay in a health care facility

• Necessitates supportive treatment

• Significantly complicates diagnosis

• Negatively affects prognosis

• Results in temporary or permanent harm, disability, or death



ADE Drugs in Elderly

• Analgesics– Opioid

– NSAIDS

Anti-psychotics Anti-coagulants Anti-histamines Anti-convulsants

Cardiovascular Diabetic medications

– Insulins

– Oral agents

JAMA 2006; 296:1858-1866; AGS 2004;52:1349-1354; NEJM 2003;348:1556-64


Surveyor Assessment

1. Indications / reasons for use.2. Effectiveness, dose.3. Monitoring: drug regimen, response to

irregularities.4. Duplication of drug therapy.5. Presence of Adverse Drug Events6. Weight history of note.7. Hydration / intake records of note.

Surveyors assessing for

1. Indications / reasons for use: Assessment and rationale

2. Effectiveness, dose: Baseline, dose range, expected outcome and

time line to see it.

3.Monitoring: drug regimen, response to irregularities: MUST

ESTABILISH BASELINE, Gatekeepers are: direct care, charge nurse, physician, pharmacist.

4. Duplication of drug therapy: same class, similar side effects.

5. Presence of Adverse Drug Events: predictable v. unpredictable

6.Weight history of note: gain or loss, anorexia, dysphagia /

swallowing problems.

7.Hydration / intake records of note: evaluation of change in

hydration, fluid, electrolyte balance.



Regulator’s Looking For:

• Comprehensive Assessment

Condition, risk, needs, behaviors

• Quality of Care Lethargy, sedation, bowel problems, sleep disturbance, increased pain

• ADL decline NEW or rapid decline; decline in function or tolerance

• Urinary Incontinence Change in function or status

• Mental and Psychosocial function Change in behavior, depression, mood, agitation, restlessness, confusion, delirium

• Physician Services and Visits• Medical Director

Procedures in place to resolve concerns

• Pharmacy Services Medical Regimen Review


PredictabilityReactions can be immediate as in anaphylaxis, but generally

requires 5 days of treatment, most show by 12 weeks

PREDICTABLE • Usually dose dependent. • Most identified prior to

marketing.• Can be due to

concomitment disease, drug/drug, and food/drug interactions.

• Rarely life threatening but can produce significant disability.

UNPREDICTABLE • Usually not an extension

of the known drug properties.

• Generally independent of dose and route of administration.

• Includes idiosyncratic reactions, immunologic or allergic reactions.

• Tend to concentrate in liver, kidneys, and nervous system.


Types of Adverse Drug Reactions

1. Drug / Drug Interactions

2. Drug / Nutrient Interactions

3. Allergic Reactions / Hypersensitivity

4. Drug Toxicity

5. Idiosyncratic Reaction

6. Complications

7. DRUG / DISEASE INTERACTIONS

Prevalence of ADR-related Hospitalizations ranges from 5% to 35%. ADEs are estimated to cost the health care

system $75 billion to $85 billion annually.• Drug / Drug Interactions: PHARMACOKINETICS AND DYNAMICS

40% elderly at risk• Drug / Nutrient Interactions: • Allergic Reactions / Hypersensitivity• Drug Toxicity: concurrent use of different drugs with same toxicity

side effects• Idiosyncratic Reaction• Complications• DRUG / DISEASE INTERACTIONS: exacerbation of the disease by

the drug (i.e. anti-cholinergic are the most common cause: glaucoma, BPH, ALTZ, dry eye)


Minimizing Occurrence

• Understand pharmacokinetic and pharmacodynamics.

• Monitor drugs with narrow therapeutic range.

• Avoid polypharmacy. • Know, convey, and

document baseline status.

• The pharmacist is the primary gatekeeper: Monthly or more often (worsening status first 30 days).

• MRR (medication record review) is designed to:– Prevent– Identify– Report– Resolve MRP’s



Factors that Produce/ Contribute to Inappropriate Drug Use

1. Under use of medications 2. Over use of medications 3. Poly pharmacy 4. Excessive dose or duration5. Lack of assessment 6. Lack of monitoring 7. Lack of recognition of ADR’s 8. Lack of adherence to drug therapy


Assessing a Possible ADR

1. Review the current medications in use for associations with symptoms or condition change.

2. Assess other possible causes for signs and symptoms.

3. Validate the drug ordered is the drug given. 4. Verify that the onset of the event was AFTER

drug administration initiated.5. Determine the time interval between the

beginning of drug treatment and the onset of the event.


Safeguards Prevention of Adverse Drug Reactions

1. Consider any new symptom as a possible ADE before requesting/ administering new medication for the symptom.

2. Monitor medication orders for wrong drug choices (high-risk inappropriate medications, drug–disease and drug–drug interactions), wrong dosages, or admin errors.

3. Improve prescribing practices by documenting:+ indication for initiation of new drug therapy+ maintaining a current medication list+ documenting response to therapy.


Polypharmacy

• Concomitant use of multiple drugs, done by simply drug counting.

• Administration of more medications than is

clinically-indicated.• 34% of all drugs prescribed in the United States

are considered unnecessary.

References:Stewarb RB. Polypharmacy in elderly: a fair accompli? DICP 1990; 24; 321-323. Montamat SC, Cusack B. Overcome the problems with polypharmacy and drug misuse. Clin Geriatr Med 1992; 8: 143-158. LeSage J. Polypharmacy in the geriatric patient. Nurs Clin North Am 1991; 26: 273-

287.


Possible Impacts of Polypharmacy

• Adverse drug reactions

• Drug-drug interactions

• Medication errors made up of non-compliance

• Link to 5% of hospital admission


Preventing PolypharmacyGather information

• Determine all medications being used.

• Identify meds by generic name & drug class.

• Identify the clinical indication of each medication.

• Know the side effect profile of each medication.

• Identify risk factors for an adverse drug reaction.


Resident Medication Profile

Medications(brand and

generic)

Drug Class

Clinical indication

Common Side

Effects

Expected Response


Preventing Polypharmacy

Eliminate, Substitute and Simplify

• Eliminate medication with no therapeutic benefit.• Eliminate medication with no clinical indication.• Substitute a safer medication.• Avoid treating an adverse drug reaction with a

drug.• Use a single drug with an infrequent dosing

schedule.


Medication Errors

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health professional.


Pharmaceutical Process Where Drug Errors are Most Likely to Occur

• Prescribing

• Transcribing

• Dispensing

• Administering


ProcessCausative Problems

& Reasons For Potential Solutions

Prescribing

Transcribing

Dispensing

Administering


Psychoactive MedicationsTHINK

• Why are you using them?

• Consider:– Interpretive guidelines criteria for use– Potential benefits– Potential adverse effects– Impact on other health conditions


Causes of Behavior Disturbances

• Altered cognition

• Altered emotions

• Mood disturbances

• Physical illness

• Drug toxicity


Behavioral Disturbance Prompting PA Med Use

Aggression

• Is it offensive or defensive?

• Stimulus internal or external?


Cognitive Compromise

• Amnesia

• Aphasia

• Apraxia

• Agnosia


ALTERED MENTAL STATUS

Delirium• Acute confusion that

is reversible.

Dementia

Decline in multiple cognitive functions:

OrientationAttentionmemory language

occurring in clear consciousness.


Mood Disturbances

1. Emotionally Labile 2. Pathological Emotions 3. Catastrophic Reactions


Treatment Principles Psychoactive Medications

1. Rule out and/or stabilize medical problems

2. Check critical lab work

3. Create a list of behavior disturbances that need to be improved.

4. Augment therapy if needed.

5. Set realistic goals

6. Establish routine

7. Provide physical clues

8. Talk before touch

9. 1 step commands

10. Allow adequate time for medications trial

11. Specify and quantify improvement


Behavior Questions

1. What is the behavior; how long does it lasts?

2. Are psychoactive medications used?

3. Is behavior creating care resistance or is care creating behavior problem?

4. What do you believe are the potential causes or contributors to the behavior problem?

5. Can the behavior be easily altered?

6. If not, why not?7. Has the use of

medication been considered?

8. Have you evaluated the triggered RAPs and triggered Quality Indicators?


Questions for Behavior & PA Meds

What are the symptoms?

What is the frequency?

What is the severity?

What is the ease of alterability?

If easily altered• Are they receiving psychoactive

meds?• How long?• Are side effects present?• Is a reduction program needed or

underway?

If not easily altered• Have physical causes been ruled

out?• Might there be drug interactions

creating the problem? How do you know?

• Are they receiving Psych meds? How long? Has behavior improved? If not, why not? What now?


Questions for Depression & PA Meds

What are the symptoms ? If you don’t think these

symptoms are mood related, why?

How have you come to this decision?

How pervasive? How serious? How easily altered? Are psychoactive, anti-

anxiety, hypnotics in use?

If easily altered & receiving antidepressant are they a candidate for reduction?

• If NOT easily altered and receiving antidepressant

how long has med been given?

If NOT easily altered and NOT receiving antidepressant are they a candidate?


Antipsychotic MedsCan you justify use?

High Risk: Cognitive Impairment

Criteria: Harm to self or others; symptoms so distressing impacts ability to function

Low Risk: major mental illness, psychosis, schizophrenia, manic depression

Criteria: Supporting Diagnosis


Anti-Anxiety Med Questions

Is this a resident demand or clinical need?

What attempts have been made to address this?

Is there a risk plan in place?

Are there adverse effects that can be tied to other problems?

Is it clinically indicated? If so what are risks, concerns?

Is documentation in place?


Beers Criteria Anticholinergic Medications

Drug classes• Tricyclic antidepressants• Antihistamines• Antispasmodics and

muscle relaxants

Adverse Effects• Urinary retention

• Constipation

• Confusion, delirium, behavior changes

• Exacerbation of dementia


Beers Criteria Antihypertensives

Principle• Select agents which

act peripherally and are not highly lipophilic

Preferred• ACE inhibitors, ARBs,

CC blockers, atenolol

Avoid• Agents which act

centrally or are highly lipophilic– Methyldopa, clonidine,

propranolol– Short-acting nifedepine


Beers Criteria Antianxiety/ Sedative Agents

Principle• •Select short-acting

agents, without activemetabolites

• Lowest possible dose• Shortest possible time• Evaluate need for therapy

frequently

Preferred• Lorazepam, Triazolam,

Zolpidem, Zopiclone

Avoid• Diazepam, • Chlordiazepoxide


Beers Criteria Antipsychotics

Principle• Use least sedating agents• Minimal anticholinergic

effectsPreferred

• Atypical antipsychotics– Risperidone,- Olanzapine- Ziprasidone- Quetiapine,- Aripiprazole

Avoid• Chlorpromazine• Perphenazine


Beers Criteria Antidepressants

Principles• Use least sedating agents• Minimal cardiotoxicity• Minimal anticholinergic S/E

Preferred• SSRIs (Except Fluoxetine)• SNRI, NRTIs or adrenergic

blockers• Venlafaxine, Duloxetine or

mirtazapine• nortriptyline

Avoid• Amitriptyline• Imipramine


Minimize Unnecessary Drug Use

• Drug protocols • Quality assurance• Communication• Initial and ongoing

assessment • Care Plan

development and implementation

• Gait keeper

• Staff training: meds used, dose

ranges, side effects, potential complications

implication of cognitive compromise

catastrophic responses leading to unnecessary med orders.


Assessment Tools for Benchmarking Behavior

• Behavior Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), Measures agitation/anxiety, psychosis, aggression, depression, and activity disturbance.

• Cohen-Mansfield Agitation Inventory (CMAI), a questionnaire evaluating agitation.

• Clinical Global Impressions (CGI), a rating system used to evaluate the overall and severity of clinical change in a patient with various diseases affecting the brain.

• Functional Assessment Staging (FAST), a diagnosis tool for determining the stage of dementia


Assessment Tools for Benchmarking Behavior Cont’

• AIMS abnormal involuntary movements associated with antipsychotic drugs.

• NPI neuropsychiatric inventory assessment of psychopathology for dementia and other neuro-psychiatric disorders.

• CAM: screens for overall cognitive impairment.


REASONS FOR MEDICATION USE

• Cure acute illness• Arrest or slow disease process.• Decrease or eliminate symptoms.• Prevent a disease or symptom.• Therapeutic or enabling for a resident with chronic mental or physical problems.

The FUNDAMENTAL ISSUES to be addressed in

the CMS guidelines is the lack of clear,

solid clinical rational for use of the specific medication identified.

Purchase the digital download


Best PracticeBehavior Management

Psychoactive Drugs, Physical Restraints,

unnec med use 2010

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