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benefitprovidesolder adultsdrugcoverage.WhenthisMedicarebenefitwasintroducedin2006,there
wasacoveragegap—morecommonlyreferredtoas“thedoughnuthole.”Duringtheperiodofthisgapin
theMedicarePartDbenefit,beneficiarieswereresponsiblefor100%ofthecostoftheirmedication.As
aresultofthissuddenincreaseincostfrom25%duringtheinitial benefitperiod to100%,manyolder
adultsabandonedtheirmedicationatthepharmacycounter(Tsengetal.,2009).Follow-onlegislationhas
moved to close the coverage gap, so today it no longer exists: Older adults continue to only be
responsible foramaximumof25%throughtheirbenefituntiltheyreachthecatastrophicperiod,where
they are only responsible for 5% of the cost of their medication (Stefanacci & Spivack, 2010). The
savingsonprescriptiondrugsareevengreaterforolderadultswithlowincomewhoqualifyfor extra
help. These individuals onlypaya little over $2 per prescriptionfor generic medications and $6 for
brandedproducts.Thisexactcopaymentisadjustedannually.
SideEffects
Other reasons for nonadherence to drug treatments includethe unpleasant or inconvenient side effects
accompanyingsomemedications.Drymouth,changeintastesensations,fatigue,orfrequenturinationare
reportedasreasonsforstoppingamedication.Theformofthemedicationandeaseofadministrationare
reasonsaswell.Largetabletsandcapsulesmaybedifficulttoswallow.Swallowingproblemsmaybe
compoundedbyinsufficientfluidbeingtakenwithmedications.Takingseveraloralmedicationsatone
dosing time with too little fluid may result in the medications “getting stuck,” leading to chronic
esophagealirritation.Presbyesophagus(theslowingofesophagealmotilitywithadvancingage)makesit
difficultandfrustratingtoswallowmultiplemedications,anditcanalsoleadtochokingoraspiration.
Manytimes,perceivedsideeffectsarenottrulyrelatedtothemedications,resultinginaninappropriate
discontinuation of a needed therapy. Critical to the management of side effects are education and
communication.Educationrequiresthathealthcareprovidersinformpatientsoftheexpectedsideeffects
oftheir medications. Communicationisrequired toassure thatpatients openly describe their concerns
regarding any and all real and perceived side effects. It is only through effective education and
communicationthatsideeffectsareappropriatelymanaged.
PhysicalandMentalChanges
Functionaldeficits,especiallythoseaffectingthesenses,canalsochallengeadherencetothemedication
regimen.Poorvisionleads to difficultyreadinglabels andconsequentlytakingthewrongpills or too
manyofthesamepills.Arthritichandsandsafetycapscanmakeopeningprescriptionbottlesdifficultand
frustratingforanolderadult.
Theprevalenceofdementia,whichmanifestsinsymptomsofcognitiveimpairmentandpoorshort-term
memoryandrecall,slowlyprogresseswithage,affectingasubstantialpercentageofthoseresidinginthe
community.Theconditionmaybeunrecognizedbythefamilybecausethepatientmayremainseemingly
independentandfunctionaldespitementaldeficits.Thefamilymaybefooledintobelievingthelovedone
is fineuntiltheconditionaffectstheperson’sabilitytomanagebasic,dailyroutines.Unfortunately,the
affectedolderadultisoftenresponsiblefortakinghisorherownmedications.Poormemoryresultsinnot
takingmedicationproperly,forgetting doses,ortakingtoomanydosesofthesamedrug.Approximately
30%ofhospitaladmissionsamongtheolderadultsareattributedtotoxicityfrommedicationsorADRs.
Of prescription medications, almost one third are for those aged 65 and older. While technology,
includingpersonalmechanicalmedicationmanagementsystems,isprovidingawiderangeofsolutionsto
assistin overcoming these challenges, havingengaged caregivers is oftenrequired to overcomethese
issuesinassuringadherencetotherapy.
Self-MedicationIssues
TheuseofOTCdrugsandhomeremediesisanothersignificantissue.Amongcommunitydwellingolder
adults, about as many take nonprescription drugs as take prescription drugs. A review of US data
indicates that the average number of OTC drugs taken daily is around 1.8 (Hanlon, 2001). Of more
concern is the fact that of patients who reported using an OTC medication 58% did not tell their
physicians(Sleath,2001).NSAIDsforexampleareoneofthemostcommonlyusedOTCaccountingfora
significant number of ADRs (Brahma, 2013). Many OTC medications are taken without the medical
provider’s awareness inorder totreatsymptomspatients do notwantto report.Familymembers and
friendsoftenborrowmedicationsbelievedtotreataparticular ailment,againwithoutconsultationwith
theirmedicalprovider.
The use of herbal preparations contributes to ADRs, especially when taken with prescription
medications.Ofthoseoverage65takingherbalpreparations,49%donotdivulgethisinformationtotheir
medicalproviders,compoundingtheriskfordruginteractionsandtoxicity.
ManyOTCmedicationsareproductsthatwereonceavailableonlybyprescription.Now,despitetheir
decreased strength, the use of these medications, which once required medical supervision and
monitoring,presentsapotentialhazardforsideeffects.
The mostcommonOTCmedicationsused bytheolderadultare analgesics, vitamins and minerals,
antacids, andlaxatives. Coughandcold productsandsleepingaids suchas TylenolPMarefrequently
usedbyolderadults.Combiningtheseproductsmayresultinconfusion,changeinmentalstatus,fluidand
electrolyte imbalances, dysrhythmias, and nervousness. Cold medications may worsen hypertension
withoutthepatient’sknowledgeorworsenglucosecontrolinapatientwithdiabetes.
TheolderadultmustbeeducatedtouseOTCdrugssafelyandtodosoonlyafterconsultingwiththe
healthcare provider.Ifanalternativetodruguseis feasible,suchasinitiatingsleephygienepractices
versustakingasleepingpill,thepatientshouldbeencouragedtotrythesemeasuresfirstbecauseoftheir
limitednegativesideeffects.
LIFEEXPECTANCYANDGOALSOFCARE
Appreciating an older adult’s life expectancy and goals of care is critical for determination of when
discontinuationoftreatmentswouldbeappropriate.Toaidinthedeterminationofprognosis,thereisa
calculatoravailabletohealthcareproviders,atwww.ePrognosis.org.
The information on ePrognosis is intended as a rough guide to inform health care providers about
possiblemortalityoutcomes.This informationcanassistinmakinga determinationwhenamedication
suchasastatinmaynolongerbeappropriatebecauseofalimitedlifeexpectancy.Thissituationisunique
to older adults, for in the care of younger adults, discontinuation because of limited effectiveness
secondarytoashortenedlifeexpectancyistypicallynotanissue.Understandingthisdynamicsuchthat
recommendationscanbemadefordiscontinuationisessentialtopreventunnecessaryadverseeventsfrom
occurringaswellasawasteofhealthcareresources.
SPECIALCONSIDERATIONSINLONG-TERMCARE
Advanced age and years of multiple illnesses and mental decline result in frailty and disability.
Transitioning to a long-term care (LTC) facility occurs when an older adult requires assistance with
functionsofdailyliving,suchasbathinganddressing,showscognitiveimpairment,orhasasignificant
nursingneedsuchaswoundcare.Thenationalpercentageofolderadultsinnursinghomesisabout5%,
whichrises to 20% for age85 andolder. Witha wide arrayof physical, psychiatric, neurologic, and
behavioral problems, the LTC resident is the most complex of all older adults. Consequently, the
complexityofprescribingmedicationsforthenursinghomeresidentcanbechallenging.Asaresult,there
is a federal requirement thatall residents of skilled nursing facilities (SNFs) receive a drug regimen
reviewbya consultantpharmacistona monthlybasis.All ofthesepracticesdescribedfor olderadult
residentsofSNFsapplytothoselivinginthecommunityaswell.ThisisespeciallytruegiventhatLTC
needs are increasinglybeingserved inthecommunity. ProgramssuchastheProgramof All-Inclusive
CarefortheElderly(PACE)servicenursinghome–eligibleolderadultsinthecommunity.Additionally,
statesareusinghomeandcommunitywaiverstoprovideLTCservicesoutsideofthenursinghome.This
has forced clinicians to apply LTC practices outside of the nursing home to serve this increasingly
community-basedfrailolderadultpopulation.
FallsandMedication
One ofthe mostserious problems inLTCfacilities are traumatic falls. Approximately halfof nursing
homeresidentsfall annually,sustainingfracturesandsofttissueandotherinjuries.Amongthemultiple
causes of falls are medications, in particular psychotropic agents (e.g., sedatives, hypnotics,
antidepressants,andneuroleptics).Thesemedicationsareusefulfortreatingthedepression,anxiety,and
behavioral problems thatarenotunusual in the LTCresident.However,their use presentsanongoing
treatment challenge. Medication-related falls are often caused by orthostatic hypotension, sedation,
extrapyramidalside effects (EPSs), myopathy, andpupil constriction.Table 5.5 lists drug classes that
leadtoinstability(Hile&Studenski,2007).
Antipsychotics
AntipsychoticsareanongoingmajorconcernfortheCentersforMedicare&MedicaidServices(CMS),
toimprovethequalityofcare forSNFresidents,especiallywhenitcomestorestraintsandwhatthey
considerinappropriatemedications.Again,becauseofthiscontinuousongoingconcernduetotheoveruse
ofpsychotropicmedicationstomanageagitationandotherbehavioralproblemsassociatedwithdementia
—whichgoescontrarytotheU.S.FDAblackboxwarning—CMShasbeenpropelledtoexpandoversight
ontheiruse.CMShasmadeseveralinitiativestodecreasetheuseofantipsychoticmedications,including
statesurvey applicationof unnecessary medicationF-tagsandqualitymeasures specific to this effort,
whichhavehadsuccess.Butinanefforttodecreaseanymedicationthattheyconsidertobeachemical
restraint,CMSislookingtoexpandregulationinthis area.As a result,effective November28,2017,
CMSannouncedseveralregulatorychangesforSNFs,includinganexpandeddefinitionofpsychotropic
medicationsandnewlimitationsontheuseofas-needed(PRN)psychotropicmedicationswithinSNFs.
TABLE5.5
MedicationsThatContributetoFalls
Mechanism ClassesofMedications
Orthostatic
hypotension
Antihypertensives,antianginals,Parkinsoniandrugs,TCAs,andantipsychotics
Sedation,decreased
attention
Benzodiazepines,sedatingantihistamines,narcoticanalgesics,TCAs,SSRIs,antipsychotics,
anticonvulsants,andethanol
Extrapyramidalside
effects
Antipsychotics,metoclopramide,phenothiazinesfornauseasuchasprochlorperazine,and
SSRIs
Myopathy Corticosteroids;colchicine;high-dosestatins,especiallyincombinationwithfibrates;
ethanol;andinterferon
Miosis(pupil
constriction)
Glaucomamedications,especiallypilocarpine
SSRIs,selectiveserotoninreuptakeinhibitors;TCAs,tricyclicantidepressants.
The definition of a psychotropic medication now includes “any drug that affects brain activities
associatedwithmentalprocesses andbehavior” (Centers for Medicare & Medicaid Services, 2017a).
Thesedrugsinclude,butarenotlimitedto,thefollowingdrugcategories:antipsychotic,antidepressant,
antianxiety,hypnotic,aswellasmedicationclassesthatmayaffectbrainactivity.Thisexpandedlistof
psychotropic medications includes CNS agents, mood stabilizers, anticonvulsants, muscle relaxants,
anticholinergicmedications,antihistamines,N-methyl-D-aspartatereceptormodulators,andOTCnatural
orherbalproducts.
Fortheexpandedlistofpsychotropicmedications,CMShasplaced14-daylimitsontheirdurationof
use when prescribed withPRNorders.Extensionof use beyond14 dayscanoccurif the prescribing
practitioner(a)believesitisappropriatetoextendtheorder,(b)documentstheclinicalrationaleforthe
extension,and (c) includesa specific durationofuse. As detailedas theserules are for psychotropic
medications,therulesregardingPRNantipsychoticsspecificallyareevenmoreexplicit.
Forantipsychotics,a14-daylimitationisappliedtoallPRNorders;asaresult,theseordersmaynot
beextendedbeyondthe14-daylimit.Tocontinuetheiruse,aneworderforthePRNantipsychoticmaybe
written if the prescribing practitioner directly examines and assesses the resident and documents the
clinicalrationale.Thisclinicalrationalemustincludethebenefitofthemedicationforthatresident.This
documentationisrequiredevery14daysforaresidentreceivingaPRNantipsychoticwithoutexception,
including hospice patients. As per section F757 in the Manual (Centers for Medicare & Medicaid
Services, 2017b), thecontinued useofthesemedicationsis permittedas long as prescribers heed the
followingguidance:
When a resident is experiencing an acute medical problem or psychiatric emergency (e.g., the
resident’sexpressionoractionposesanimmediaterisktotheresidentorothers),medicationsmay
berequired,asdeliriuminducedpsychosis.Asalways,medicationsshouldonlybeinitiated/usedin
the presence of active clinical symptoms and after nonpharmacological interventions and least
restrictivemeasureshavebeenattempted.
Asaresultoftheseexpandedrules,manySNFswilllikelytrytodiscontinueordersforstandingPRN
antipsychoticmedications.Analternativeapproachistoassureappropriateuse,inwhichtheconsultant
pharmacistcanplayaleadrolewiththeSNFteamtakingthefollowingsteps:
1.Preventinitiationofinappropriateuseofpsychotropicmedicationsinresidents.
2.Taperanddiscontinueinappropriatepsychotropicmedications,toensurethatuseofthemedicationsis
appropriateandthatmonitoringanddocumentationareproperlyconducted.
3. Improve disruptive behaviors while limiting/diminishing the use of psychotropic medications, by
educatingandencouragingprescribersandnursingfacilitystafftoadoptamorestructuredandbroader
approachtothemanagementofbehavioralsymptoms.
Theteamapproachtomanagementofolderadultswithdisruptivebehaviorsshouldemphasizecertain
keyprinciples:
• Individuals who exhibit disruptive behaviors should be thoroughly assessed by a qualified health
professional.
• Theassessmentshouldseekto identify possible underlyingcauses thatmaycontributeto disruptive
behaviors,sothattreatmentcantargettheunderlyingcause.
•Disruptivebehaviorsshouldbeobjectivelyandquantitativelymonitoredbycaregiversorfacilitystaff
anddocumentedonanongoingbasis.
• If thebehaviors do notpresent an immediate and serious threat to thepatient or others, the initial
approach to management should focus on environmental modifications, behavioral interventions,
psychotherapy,orothernonpharmacologicinterventions.
•Whenmedicationlsareindicated,anappropriateagentshouldbeselectedonlyafterconsiderationof
theunderlyingdiagnosisorcondition,effectivenessofthemedication,andriskofsideeffects.
Althoughdevelopedforantipsychoticmedications,thesepracticesshouldbeappliedtoallclassesof
medicationswhenmanagingpharmacotherapyinolderadults.Withallofthesechanges, itisimportant
thatSNFsutilizeresourcessuchasconsultantpharmacistsandmedicalandnursingdirectorstodevelop
andimplementaprocesstomakesurepatientshaveaccesstoappropriatemedications,especiallythose
withlesspotentialforadverseevents.TheBeersCriteria,aconsensus-baseddocumentlistingpotentially
inappropriate medicationsfor useinolderadultsandguidelines forsafe prescribingpractices, canbe
usedasaguidetoassistwiththisselectionprocess.
Anxiolytics
Anxietyisaproblemfrequentlyconfrontedinthenursinghomesetting.Itmaybeprecipitatedbyphysical
causessuchaspain,infection,orchronicillness.Otherstressorsthatcontributetoanxietyincludefatigue
orchange,suchasachangeinadailyroutineorchangeofcaregiver.Anoverlystimulatingenvironment
or expectationsof staffmembers hurryingtheolderresidentthroughdaily routinesmayevokeanxiety.
Initially, nonpharmacologic measures should be used to assess and ameliorate anxiety; prescribing a
medicationtorelieveanxietyshouldbealastchoice.
Severalnonpharmacologic antianxiety treatments maybe beneficial. Theyincludeestablishingdaily
routinesina structuredenvironment,consistentlyprovidingthesamecaregiver forbathingandhygiene
assistance,avoidingoverstimulationfromactivities,limitingsocialvisits,andschedulingquiettimewith
restornaps.
Whenanxiolytic drugsare prescribed, thebenzodiazepinesare oftenchosen for adultsaged65 and
older. Unfortunately, side effects are prevalent, among whichare the discomforts of discontinuing the
therapy. Benzodiazepines can impact cognitive function and psychomotor performance in older adults.
Thepatientmayexperienceincreased agitation,anxiety,andinsomnia.Moreserioussymptomsinclude
tremors,tachycardia,diaphoresis,nausea,vomiting,andalterationsinperception,anterogradeamnesia,
andseizures.Thebenzodiazepineshaveapropensityfordependencebyaccumulatingintheolderbody.
Forthisreason,theyshouldbeprescribedforshortcoursesofupto2weeksatmost.
The older patient receiving benzodiazepine therapy often experiences significant daytime sedation,
dizziness,andsubsequentfalls.Studies indicatethat the “oldest old,” thoseolderthanage85, havea
greaterriskforfallswithbenzodiazepineuse(Hartikainenetal.,2007).Whena benzodiazepinewitha
longhalf-lifeisprescribed, thefall rateis 10-fold greaterthanwhena benzodiazepinewitha shortto
moderatehalflifeisprescribed.Benzodiazepineswithalonghalf-lifeincludediazepamandflurazepam
(Dalmane);benzodiazepineswithashorterhalf-lifeincludelorazepam(Ativan),alprazolam(Xanax),and
oxazepam (Serax). Whena benzodiazepineisprescribed, itshouldhavea shorthalf-life,be for shorttermuse,andbegiveninthelowestdosepossible.
Theselectiveserotoninreuptakeinhibitors(SSRIs),whichtreatdepression,generalanxiety,andpanic
andobsessive–compulsivedisorders,arenowconsideredthebetterchoicefortreatinganxietyinthefrail
olderadultduetotheirfavorablesideeffectprofile(Sheikh&Cassidy,2003).Thereisoftencomorbid
depressionwithanxiety,so anSSRImaytreatbothconditions,suchassertraline(Zoloft)forpanicand
depression.
Analternativeanxiolyticisbuspirone(BuSpar).Itisnonsedatingandhasminimaldruginteractionsand
aslowonsetofaction,of2to3weeks.Forthatreason,itisnotindicatedforacuteanxietybutworks
wellasanadd-ondrug.CautionmustbeusedwithbuspironeinadultswithParkinson’sdiseasebecause
EPSs can occur. For anxiety with underlying depression and insomnia, trazodone (Desyrel) is an
alternative. Because of its sedatingproperties, itpromotes sleep andtreats underlying depressionthat
mayexacerbateanxiety.
Antidepressants
Theprevalenceofdepressionincreaseswithage,asevidencedby25%ofthosewithchronicillnessand
a15%to25%rateofdepressionamongnursinghomeresidents(Bergmanetal.,2009).Olderadultswith
latelifedepressionexhibitmorepsychotic symptoms,delusions, insomnia, andsomatic complaints. In
suchsettings, older adults with depression should be treated because antidepressant treatment usually
improves nutrition and function and decreases symptoms of pain and insomnia. Better choices for
antidepressants are the SSRIs (e.g., paroxetine, fluoxetine [Prozac], sertraline [Zoloft], citalopram
[Celexa],andescitalopram[Lexapro]).SSRIshavetheadvantageofdailydosingandfewersideeffects
thanTCAs,whichwereusedfrequentlybeforetheadventofSSRIs.AlthoughtheTCAsarestillused,
theyareassociatedwithmanysideeffectsthatcanleadtocognitiveimpairmentandfalls.Cardiovascular
effects include hypotension, arrhythmias, and sudden death. Other troublesome side effects include
sedation,drymouth,urinaryretention,anddizzinessfromanticholinergicproperties.
Significant drug interactions and toxicity may occur with SSRI use because these drugs inhibit
oxidative metabolism. Drugs thatmaybe affected bySSRIs includewarfarin,phenytoin,andclass 1C
antiarrhythmics.Studies indicatethatolderadultstakingSSRIshave a greater riskfor fallsthanolder
adultsnottakingantidepressants(Leipzigetal., 1999)andsuggestthathigherdoses ofcombinedCNS
medications,suchasSSRIs,benzodiazepines,andantipsychotics,canleadtocognitivedeclineinolder
adults(Wrightetal.,2009).CommonsideeffectsofSSRIsintheolderadultincludeheadache,nausea,
dry mouth, dizziness, constipation, dyspepsia, diarrhea, asthenia, insomnia, decreased appetite,
tachycardia, andabnormaltaste.Hyponatremiahasbeenincreasinglynotedtooccur inolderadultson
SSRIs.OnwithdrawaloftheSSRI,sodiumlevelsreturntonormalwithindaystoweeks(Kirby&Ames,
2001).Theprescriberneedstobeawareofearlysignsofhyponatremia:lethargy,fatigue,musclecramps,
anorexia,andnausea.
Marijuana
AnanalysisfromdatagatheredintheNationalSurveyonDrugUseandHealth(NSDUH)from2015and
2016showedthatabout9%ofU.S.adultsbetweenages50and64usedmarijuanainthepreviousyear
andabout3%ofpeopleover65usedthedruginthattimeperiod(Han&Palamar,2018;NPR,2018).
There is increasing interest in the use of cannabinoids for disease and symptom management, but
limited information is available regarding their pharmacokinetics and pharmacodynamics to guide
prescribers. Cannabis medicines contain a wide variety of chemical compounds, including the
cannabinoids delta-9-tetrahydrocannabinol (THC), which is psychoactive, and the nonpsychoactive
cannabidiol (CBD). Cannabis use is associated with both pathological and behavioral toxicity and,
accordingly,iscontraindicatedinthecontextofsignificantpsychiatric,cardiovascular,renal,orhepatic
illness. Thepharmacokinetics ofcannabinoidsandtheeffects observeddependontheformulationand
routeofadministration,whichshouldbe tailoredtoindividualpatientrequirements.As bothTHCand
CBDarehepaticallymetabolized,thepotentialexistsforpharmacokineticdruginteractionsviainhibition
or induction of enzymes or transporters. An important example is the CBD-mediated inhibition of
clobazammetabolism.Pharmacodynamicinteractionsmayoccurifcannabis isadministeredwithother
CNS-depressant drugs, andcardiac toxicitymayoccur viaadditive hypertension andtachycardia with
sympathomimetic agents. More vulnerable populations, such as older patients, may benefit from the
potentialsymptomaticandpalliativebenefitsofcannabinoidsbutareatincreasedriskforadverseeffects.
Thelimitedavailabilityofapplicablepharmacokineticandpharmacodynamicinformationhighlightsthe
need toinitiate prescribing cannabis medicines using an“start low and go slow” approach,carefully
observing the patient for desired and adverse effects. Further clinical studies in the actual patient
populations for whomprescribing may be considered are needed, to derive a better understanding of
thesedrugsandenhancesafeandoptimalprescribing.
Therearetwouniqueaspectsinthemanagementofmarijuanathatareuntrueforanyotherdrug.These
involvemanagementofprescribedmedicaluseandself-directedrecreationaluse.Onemajordifference
isthatinthecaseofself-directeduse,informationontheuseanditsquantityandfrequency,whichisoften
notregular,needtobeobtainedfromthepatientasopposedtomedicalclaimsorprescriptiondata.
OtherDisordersandDrugTherapies
Studieshaveshownthat,ingeneral,olderadultsaremorevulnerabletosevereorpersistentpainandthat
the inability to tolerate severe pain increases with age. Further, older adults are far more likely to
experiencepainassociatedwithsurgicalprocedures,suchaskneeandhipreplacements,arthritis,cancer,
andend-of-lifesymptoms.Compoundingtheproblemofpainintheolderadultis thewell-documented
factthatpainintheinstitutionalizedolderadultpopulation,particularlyamongminoritiesandthosewith
dementia,isfarmorelikelytobeundertreated.Accordingtothe2011InstituteofMedicine(IOM)report,
“a study of more than 13,000 people with cancer aged 65 and older discharged from the hospital to
nursinghomesfoundthat,amongthe4,000whowereindailypain,thoseaged85andolderweremore
than1.5timesaslikelytoreceivenoanalgesiathanthoseaged65to74;only13percentofthoseaged85
andolderreceivedopioidmedications,comparedwith38percentofthoseaged65to74”(IOM,2011).
WhilemanydrugprecautionshavebeenineffectsincethepassageoftheComprehensiveDrugAbuse
PreventionandControlActof1970,theyhavenowtakentheformofforcedrestrictions.Someofthese
newrestrictionsareresultinginissuesinmanagingpainforSNFresidents.Forexample,in2011,theU.S.
FDAaskeddrugmanufacturerstolimitthestrengthofacetaminophenincombinationprescriptiondrugsto
325mgpertabletbyJanuary2014,inanattempttoreduceincidencesofpotentiallyfatalliverdamage.
Eventhoughacetaminophenhasbeencommerciallyavailable since1953,itwasnotuntil 2009thatthe
FDA required manufacturers of the OTCdrugTylenolanditsgeneric equivalents to post a black box
warningforliverdamage,dueinlargeparttodeathsattributabletoacetaminophenuseandheavyalcohol
consumption.AccordingtotheFDA,morethanhalfofmanufacturershavevoluntarilycompliedwiththis
request. However, some prescription combination drug products containing more than 325 mg of
acetaminophenperdosageunitremainavailable,promptingtheFDAtoeventuallywithdrawapprovalof
anyprescriptioncombinationdrugproductscontainingmorethan325mgofacetaminophenthatremainon
the market. The result of all of this focus is a limitation on access of higherdose acetaminophen
preparations,andasaresult,appropriateadjustmentsforpatientsreceivingthesetreatmentsmayneedto
occur.Toavoidhepatotoxicity,cautionshouldbetakennottoexceed4,000mgin24hours,especiallyin
patientswithknownliverdisease,alcoholism,ormalnutrition.
The chronic painof degenerative jointdisease unrelieved byacetaminophen canbetreated withan
NSAID. Long-term treatment with NSAIDs, however, can result in GI bleeding, anemia, and renal
insufficiency. Caution should be taken when on highly bound drugs, such as warfarin, digoxin, and
anticonvulsants,becauseincreasedbioavailabilityoccursduetoNSAIDsbeinghighlyproteinbound.The
cyclooxygenase 2 (COX-2) inhibitor celecoxib (Celebrex) is a nontraditional antiinflammatory drug
developedtopreventGIbleedingbynotaffectingplateletaggregationandbleeding.Althoughtheriskof
bleedingwithCOX-2inhibitors maybe lower thanthatwithtraditional NSAIDs,suchasnaproxenor
ibuprofen, it can still occur. Cardiovascular safety issues led to the withdrawal of rofecoxib and
valdecoxibfromthemarketintheUnitedStates.
Neuropathic pain from postherpetic neuralgia or diabetic neuropathy can be treated with mixed
serotoninandnorepinephrineuptakeinhibitors,suchasduloxetine(Cymbalta)andvenlafaxine(Effexor),
withabetterside effectprofilethanolderTCAs.Theanticonvulsantagentsgabapentin(Neurontin)and
carbamazepine(Tegretol)arealsoeffectiveintreatingneuropathicpain.Pregabalin(Lyrica)isindicated
fordiabeticperipheralneuropathy;however,itcancausesomnolenceanddizziness.
TopicalanalgesicscanbeeffectiveinpainmanagementintheLTCsetting.The5%lidocainepatchmay
helpwithneuralgiapain,althoughitisoftenusedofflabelforlocalizedbackpainorarthritis.Thetopical
NSAIDdiclofenac(Flector)isindicatedforchronicpainmanagementwithlesssystemicabsorptionthan
oral NSAIDs(AmericanGeriatricsSociety[AGS]PanelonPharmacologicalManagementofPersistent
PaininOlderPersons,2009).
Other commonly encountered drug-related problems in LTC are urinary incontinence and recurrent
urinarytractinfections(UTIs),evidencedbyconfusionandmentalstatuschanges.Respiratoryinfections
suchasbronchitisandpneumoniaquicklyspreadthroughafacilitybecauseofthecompromisedimmune
stateoffrailresidents.Thus,antibioticuseiscalledonmorefrequentlythanforthecommunity-residing
adult. The frail older patientwith pneumonia maynot have typical signs of illness. For example, the
patientmaynothavea coughor fever.Moreover,thefrail older patientbecomesill more quicklyand
decompensatesrapidlyifuntreated.Dehydration,sepsis,orevendeathmayresult.
Constipationisanotherconcern,andsometimesanobsession,ofolderadults.Inmanyinstances,they
thinktheyneedmedications topromotebowel movements.However, alternatemethodsoftreatingthis
problemmay be judicious,includingincreasingphysicalactivityandconsumptionoffluids, fiber, and
fruit.Oneortwotablespoonsofamixtureofprunejuice,unprocessedbran,andapplesaucetakendailyis
an alternative to stool softeners and laxatives. When assessing constipation, a review of current
medications may yield clues to drug use that contributes to the constipation. For example,
anticholinergics, suchasoxybutynin(Ditropan),used for urinaryincontinence;antidepressants,suchas
theTCAs;andcalciumchannelblockersmayallcauseconstipationinthefrailolderpatient.
In summary, the older resident in LTC is usually the frailest and at greatest risk for complications
relatedtoimproperdrugadministration.Thehealthcareprovidershouldattempttokeepmedicationsata
minimumwiththelowestdosagepossible.Amonthlyorbimonthlyreviewofallmedicationsshouldbe
donetoreviewmedicalnecessity.Apharmacistfromwithinthefacilityorfromthecompanysupplying
thefacilitywithmedicationsshouldroutinelyreviewchartsandwriterecommendationstodecreaseor
stop medications. The suggestions should be evaluated by the health care provider and acted on if
appropriatetoreducepolypharmacy,sideeffects,andcostsfortheresident.
GUIDELINESFORSAFEPRESCRIBING
GuidelinesforsafeprescribingapplynotonlytoresidentsofLTCfacilitiesbuttoallolderadults.The
goal ofprescribingforadultsinLTCshould be topreventadverseevents, falls, andinjuries thatwill
furtherdegradethepatient’sfunction,bothphysicalandmental.Theprovidermustprescribecautiously
andkeepthepatient’ssafetyinmindwhilepromotinghisorhercomfortanddignity(Box5.4).Providers
in LTC need to familiarize themselves with the Beers Criteria. This extensive list of medication
guidelineswascreatedbyaconsensuspanelofnationallyrecognizedexpertsingeriatricsandupdatedin
2019(AGS,2019).
InadditiontotheBeersCriteria,anopportunitytoimproveoutcomescomesfromtheChoosingWisely
initiative. In response to the challenge of improving health care, national organizations representing
medical specialists have asked their members to choose wisely through the identification of tests or
procedures commonly used in their field, whose necessity should be questioned and discussed. The
resultinglist,FiveThingsProvidersandPatientsShouldQuestion,is meanttoencouragediscussionof
theneed—orlackthereof—formanyfrequentlyorderedtestsortreatments.
TheAMDA–TheSocietyforPost-AcuteandLTCMedicinedeveloped5thingstoquestion,whilethe
AGS developed 10. Considering these 15 things, one can identify 5 common themes upon which
cliniciansshouldfocustheirattention.Thesefivecenteronthefollowingcriticalareasformanagementof
pharmacotherapyinolderadults:
Box5.4 GuidelinesforSafePrescribingforOlderAdults
INITIATIONOFTHERAPY
•Reviewtherisksandbenefitsofaddingamedication.Explorenonpharmacologicoptionsfirst.
•Ifpossible,chooseonemedicationthattreatstwocoexistingproblems.
•Alwaysstartwiththelowestdosepossibleandtitrateupslowly.“Startlow,goslowbutgetthere.”
•Chooseadrugwiththefewestdailyrequireddoses(i.e.,dailyortwicedaily).
• Remembertoconsider thecostof the brand name drugandconsider genericequivalents if cost
issueswilldetercompliance.
ONGOINGPHARMACOTHERAPYASSESSMENT
•Scheduleroutinefollow-upexaminationsforthepatientwhohasmultiplechronicillnessesandwho
takesmultiplemedications.
•Reducedosagesordiscontinuemedicationsifpossibletoavoidpolypharmacy.
•Advisepatientstobringallmedications(prescriptionorOTC)toeachofficevisitforreview.
•Documentaccuratelyallcurrentmedicationsanddosages.
• Review medications added by other practitioners and specialists. Inform these professionals of
changesmadebytheprimaryhealthcareprovider.
•Schedulebloodtestsregularlytomonitorlevelsofsuchmedicationsasdiuretics,ACEinhibitors,
antiseizuremedications,anticoagulants,antiarrhythmics,anddigitalis.
PATIENTSUPPORT
•Giveawrittenlistandinstructionstothepatientaftereachofficevisitofthemedicationstobetaken.
•Providethewrittenmedicationinstructionsandchangesinlargeprintintermseasilyunderstoodby
olderadults.
•Explainanddocumentboththegenericandthebrandnameoftheprescribeddrugtoavoidconfusing
thepatient;alsoexplainanddocumenttheimportantreasonforeachmedication.
•Reviewmedicationsandchangesintheregimenwithfamily/caregivers,especiallyforthosecaring
forlovedoneswithcognitiveimpairments.
• Recommend or provide medication planners or weekly/daily dosage containers to improve
complianceandpromotesafemedicationadministration.
1.Dementiaandbehavioralandpsychologicalsymptomsofdementia(BPSD)
2.Screeningandmedicationmanagement
3.Antibioticuse
4.Diabetesmanagement
5.Nutritionalmanagement
ThesefiveareascomefromextensiveworkdonebybothAMDAandAGSandarerefinedherewitha
specialfocustoward thecare ofolder adults.Theresultisfive ChoosingWiselyinitiatives thatwhen
followedwillserveclinicianscaringforolderadultswell.Choosingwiselystartsandoftenendswitha
wiseclinician,onewhounderstandsthatthesefiveinitiativesareastepinthatdirection.
DementiaandBehavioralandPsychologicalSymptomsofDementia
AstartingpointisthemanagementofdementiaandBPSD,forperhapsnothingismorecriticalgiventhe
increasing prevalence of dementia. Several of the AMDA and AGS Choosing Wisely directives are
focused in this area. These include appropriate management of dementia through not prescribing
cholinesterase inhibitorsfordementiawithoutperiodicassessmentforperceived cognitivebenefitsand
adversegastrointestinaleffects.Theimpactofcholinesteraseinhibitorsoninstitutionalization,qualityof
life,andcaregiverburdenis NOTwell established.Clinicians,caregivers,andpatientsshoulddiscuss
cognitive, functional, and behavioral goals of treatment prior to beginning a trial of cholinesterase
inhibitors.Advancecareplanning,patientandcaregivereducationaboutdementia,dietandexercise,and
nonpharmacologicapproachestobehavioralissuesareintegraltothecareofpatientswithdementiaand
should be included in the treatment plan in addition to any consideration of a trial of cholinesterase
inhibitors. If goals of treatment are not attained after a reasonable trial (e.g., 12 weeks), then
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