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5 - Adverse Drug Events, Polypharmacy, and Medication Management |
117
3. Patient with significant cardiac history and DM without assessment or treatment for
hyperlipidemia.
Plan:
1. Discontinue famotidine, diltiazem, digoxin, warfarin, vitamin C, and vitamin E due to
lack of a current indication for use.
2. Reduce dose of ASA to 81 mg to reduce the risk of gastrointestinal bleeding.
3.
Titrate metoprolol and lisinopril for a blood pressure goal of <140/90 mmHg.
4.
Re-evaluate need for hydrochlorothiazide in addition to two other antihypertensive
agents as they may be less effective in patients with reduced renal function (i.e.,
<30 mL/min).
5.
Re-evaluate need for KCl in light of increasing lisinopril dose and possible discontinu-
ation of hydrochlorothiazide.
6.
Re-evaluate need for multivitamin. If the patient is eating a well-balanced diet, these
supplements may be discontinued with little risk but with the benefit of a decreased
pill burden.
7.
Change from ibuprofen to acetaminophen for headaches, as ibuprofen may worsen
HTN, renal function, and risk of PUD with aspirin.
8. Order cholesterol panel and evaluate patient for statin therapy.
9.
Refer to geriatric evaluation and management clinic pharmacist for medication
therapy monitoring as an outpatient.
Rationale:
1. This patient is a classic example of polypharmacy, evidenced by unnecessary drug
use, because several of his prescribed and OTC medications have no currently
active medical indication. In addition, multiple drugs were prescribed at less than
maximum doses for treatment of hypertension, increasing the pill burden and risk
for drug-related problems. The digoxin dose is higher than recommended by the
Beers’ criteria for an older adult, and the addition of diltiazem at the last office visit
likely further elevated the digoxin serum concentration. Digoxin toxicity was further
increased by the high serum potassium level, which was a result of potassium
supplementation along with use of an ACEI.
2. Furthermore, another form of suboptimal drug use may be present in the underuse of
a cholesterol-lowering medication, which is likely in this patient with a long history of
cardiovascular disease.
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| Fundamentals of Geriatric Pharmacotherapy
C S
Older adults often need multiple medications to
treat their conditions. Due to complex medica-
tion regimens, suboptimal drug use is prevalent.
Pharmacists are crucial in detecting suboptimal
prescribing and ADEs and in the use of MTM to
provide the most effective care for patients.
S-A Q
1. What are important factors when evaluating
a medication for an older adult?
2. TJ is an 88-yo male who was treated for a
major depressive episode for the past year.
He is no longer depressed, and his medi-
cation was abruptly discontinued. He starts
to experience vertigo, malaise, fatigue, and
alteration in sensations. What drug-related
problem is TJ experiencing?
3. What are some examples of suboptimal
drug use?
4.
What evaluations may be used to determine
unnecessary medication use?
5.
What tools use implicit criteria to deter-
mine medication appropriateness for older
adults?
R
1. Qato DM, Alexander GC, Conti RM, et al. Use of
prescription and over-the-counter medications and
dietary supplements among older adults in the United
States. JAMA. 2008;300:2867–2878.
2. Dwyer LL, Han B, Woodwell DA, et al. Polypharmacy
in nursing home residents in the United States: results
of the 2004 National Nursing Home Survey. Am J
Geriatr Pharmacother. 2010;8:63–72.
3. Spinewine A, Schmader KE, Barber N, et al. Appro-
priate prescribing in elderly people: How can it be
measured and optimized? Lancet. 2007;370:173–184.
Clinical Pearls
• Transitions in care are crucial periods in which drug therapy may be changed; medica-
tion reconciliation is needed to prevent ADEs. Often, agents are added when a patient
is in the hospital but the drug may not be needed long term. Also, chronic medications
are sometimes changed due to formulary restrictions. Some good examples are proton
pump inhibitors and H
2
blockers, which are frequently added with hospitalization or
changed to the formulary product. At discharge, medication reconciliation that incorpo-
rates steps to identify these changes will reduce the risk for a patient to return home
with duplicate therapy (i.e., taking both the medication used in the hospital and the
chronic medication used at home), unnecessary drug therapy (i.e., an acid suppressant
to prevent stress ulcers that is no longer indicated), or expensive medication not cov-
ered by the patient’s Medicare Part D formulary (i.e., prescription proton pump inhibitor
instead of an OTC product).
•
Information about OTC agents and herbal products are necessary pieces of information
for a complete medication history. To obtain this information, ask questions about what
the patient uses to treat complaints he or she has. For example,What do you take when
you get a headache? This helps prompt the patient to think about all of the OTC agents
he or she uses daily.
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5 - Adverse Drug Events, Polypharmacy, and Medication Management |
119
4. Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary
drug use in frail older people at hospital discharge. J
Am Geriatr Soc. 2005 Sep;53(9):1518–1523.
5.
Steinman MA, Landefeld CS, Rosenthal GE, et al.
Polypharmacy and prescribing quality in older people.
J Am Geriatr Soc. 2006 Oct;54(10):1516–1523.
6.
Rossi MI, Young A, Maher R, et al. Polypharmacy
and health beliefs in older outpatients. Am J Geriatr
Pharmacother. 2007;5(4):317–323.
7.
Tjia J, Velten SJ, Parsons C, et al. Studies to reduce
unnecessary medication use in frail older adults: a
systematic review. Drugs Aging. 2013;30(5):285–307.
8.
Dimitrov MS, Airaksinen MS, Kivelä SL, et al.
Comparison of prescribing criteria to evaluate the
appropriateness of drug treatment in individuals aged
65 and older: a systematic review. J Am Geriatr Soc.
2011;59:1521–1530.
9. O’Connor MN, Gallagher P, O’Mahony D. Inappro-
priate prescribing. Drugs Aging. 2012;29:437–452.
10. Hanlon JT, Schmader KE. e Medication Appropri-
ateness Index at 20: where it started, where it has been,
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900. PMCID:PMC3831621.
11. Beers MH, Ouslander JG, Rollingher I, et al. Explicit
criteria for determining inappropriate medication
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1991;151:1825–1832.
12. American Geriatrics Society 2012 Beers Criteria
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high-risk medications for older veterans: 2004–2006.
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15. Quato DM, Trivedi AN. Receipt of high-risk medica-
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to potentially harmful drug-disease interactions in
a national cohort of older veterans: who is at risk?
J Am Geriatr Soc. 2011;59:1673–1678. PMCID:
PMC3390785.
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guidelines for oral dosing of primarily renally
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2009;57:335–340. PMCID: PMC2640432.
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Hanlon JT, Schmader KE, Samsa GP, et al. A method
for assessing drug therapy appropriateness. J Clin
Epidemiol. 1992;45:1045–1051.
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Hanlon JT, Artz MB, Pieper CF, et al. Inappropriate
medication use among frail elderly inpatients. Ann
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the frail elderly. Am J Med. 2004;116:394–401.
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25. Shrank WH, Polinski JM, Avorn J. Quality indicators
for medication use in vulnerable elders. J Am Geriatr
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Cooper JW. Probable adverse drug reactions in a rural
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30. Gurwitz JH, Field TS, Avorn J, et al. Incidence and
preventability of adverse drug events in nursing homes.
Am J Med. 2000 Aug 1;109(2):87–94.
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36.
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drug reactions in a population of hospitalized very
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Adverse drug reactions in elderly hospitalized patients:
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related to drug withdrawal in nursing home residents.
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inappropriate prescribing and adverse drug withdrawal
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events after discontinuing medications in elderly
outpatients. Arch Intern Med. 1997;157:2205–2210.
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macy in a general surgical unit and consequences of
drug withdrawal. Br J Clin Pharm. 2000;49:353–362.
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peutic failure related hospitalization in the frail elderly.
Drugs Aging. 2006;23:579–586.
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Marcum ZA, Amuan ME, Pugh MJV, et al.
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bution of drug related problems to hospital admission
in the elderly. J Nutr Health Aging. 2010;14:477–482.
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6
P
H C
LINDSEY DAYER and LISA C. HUTCHISON
L O
1. Contrast the terms palliative care, comfort care, and hospice care.
2. Describe the goals of care in the dying geriatric patient.
3. Assess common symptoms in the dying geriatric patient.
4. Design a drug therapy plan to manage a geriatric patient at different stages of dying.
5.
Discuss grief and bereavement.
K T D
COMFORT CARE: Palliative care that is provided once a patient has decided to forego curative, aggressive
interventions.
HOSPICE: A system to provide pain and other symptom management, which also includes psychological and
spiritual aid, to terminally ill patients with a prognosis of 6 months or less.
PALLIATIVE CARE: The active, total care of patients whose disease is not responsive to curative treatment.
PROPORTIONATE PALLIATIVE SEDATION: Increasing sedation with the goal of controlling symptoms intrac-
table to other management modalities.
SPIRITUALITY: The search for meaning and purpose in life and in the present moment.
TERMINAL SECRETIONS: Oral secretions that accumulate in the last days or hours of life as a patient loses
the ability to swallow. When air passes through the accumulated secretions, a gurgling or rattling sound is
heard, frequently called the “death rattle.”
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| Fundamentals of Geriatric Pharmacotherapy
I
D
espite efforts for more than 30 years, signif-
icant misconceptions persist about death
and dying as they relate to older adults and to
the healthcare system. Older adults frequently
express anxiety regarding the process of dying
but prove generally accepting of death itself.
This anxiety most likely stems from concerns that
death will be characterized by pain, suffering,
loss of independence, and loneliness. Many
patients in this situation fear that they will no
longer receive the necessary symptom control
because the healthcare system is geared toward
treatments that cure. Compared to community-
dwelling older adults, individuals in long-term
care institutions express more fear, perhaps
arising from higher levels of dependence on
others, lower self-esteem, and loss of purpose
in life.
1
In general, the youngest old are similar
to younger adults in their approach to death and
dying. The oldest old begin to face death differ-
ently, perhaps because of increased frailty and
dependence. This chapter will review end-of-
life concerns, the hospice model of care, and
specific pharmacologic and nonpharmaco-
logic issues associated with the end of life and
bereavement.
D D
Many people, including healthcare profes-
sionals, are not aware of what to expect as a
patient progresses through the months prior to
death, or within the last days or hours of life.
Although millions of people die each year in the
United States, mostly from chronic illness, this
gap in knowledge stubbornly persists. Reduced
mortality rates and changes in where one dies
(e.g., hospital, nursing home) have removed
the average American from exposure to the
process. Patients and family members are torn
between fear of what is to come and a desire to
understand it. Information about illness and its
progression that also includes guidance about
symptoms to expect and how to manage them
proves helpful in allaying these fears.
2
Pain,
depression, and anxiety are usually observed
early on for patients at the end of life, whereas
other symptoms (fatigue, anorexia) develop later.
But an individual’s death and dying involve expe-
riences beyond the physical and psychosocial.
3
Therefore, the models of care and support to aid
in achieving a “good” death must address spiri-
tual experiences as well as life closure, death
preparation, and grief.
Discussing end-of-life issues with patients
and family is thought to help reduce death
anxiety.
1
However, healthcare providers find this
to be challenging, and few providers receive
adequate training to feel comfortable addressing
treatment decisions, future symptoms, and pref-
erences for death. Simply knowing how to start
the discussion offers a place to begin learning
about treatment of the dying patient.
Exploring fears and dispelling myths is a
good first step toward reassurance. For example,
a patient may assume that the process of death
will be similar to that observed in someone
else. Family members may have concerns over
whether they are capable of meeting the needs
of their loved one if he or she prefers to die at
home. Patients need to be given information
about these issues as well as the time to eval-
uate treatment decisions and determine prefer-
ences. If possible, it is best to have discussions
about death and dying over several visits, to
encourage patients to develop a trusting rela-
tionship with their healthcare provider.
4
Pharmacists are not the typical healthcare
professionals who identify a patient’s wishes
regarding the overall dying process. However,
whether the pharmacist is dispensing medi-
cations, performing rounds within a hospital,
consulting in a nursing home, or practicing
in hospice or palliative care settings, he or
she will have the opportunity to assess and
counsel dying patients. A careful approach that
recognizes the process of death is warranted,
because missteps could hinder progress in
helping a patient cope and adapt to the situation.
Providing pharmaceutical care to this population
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6 - Palliative and Hospice Care |
125
requires the pharmacist to understand spiritual
considerations as well as social and community
influences on an individual patient. The ability to
identify and assess symptoms of a palliative care
patient with regard to the patient’s emotional,
mental, and social state aids in making the best
treatment decisions. The pharmacist has an inte-
gral role in discussing symptom management
and pharmacotherapy with the patient.
5
It is helpful to understand cultural differ-
ences in the approach to death and healthcare
decision making associated with the end of life
in order to place a patient’s desires for symptom
control and pain relief in context. Table 6-1
identifies several cultural groups and how older
adults from them frequently approach healthcare
decision making, as well as common difficul-
ties encountered by healthcare professionals.
6
However, each cultural group is composed of
people from a wide range of backgrounds, and
an individual may be a member of a cultural
group but hold different attitudes and beliefs.
Although it is helpful to understand ethnic
patterns in general, the pharmacist must identify
the desires of the individual patient, which may
not follow those patterns.
E--L C
End-of-life care can be a confusing term because
multiple definitions, components, and systems
of delivery exist. The term initially referred to
healthcare that is provided in the final days or
hours of life but has been expanded to include
care for any patient with an illness or condi-
tion that is progressive and incurable. Palliative
care, comfort care, and hospice are compo-
nents of end-of-life care. Palliative care strives to
reduce symptoms and anxiety associated with a
disease to ensure the best achievable quality of
life as the disease progresses. It is intended to
encourage patients to live actively while neither
hastening nor postponing the time to death. As
such, palliative care can be offered to individuals
living with a complex, chronic disease whether
or not they are expected to recover. Palliative
care that is provided when a patient has decided
to forego curative, aggressive interventions is
termed comfort care. Although both palliative
and comfort care aim at symptom relief, pallia-
tive care does not indicate that potentially cura-
tive treatments have been stopped.
Table 6-1. Common Cultural Differences in Healthcare and End-of-Life Decision Making
Cultural Group Communication About
Healthcare Decisions
End-of-Life Decisions
African American Family usually involved
Fictive kin (individuals not related by
blood or marriage) also consulted
Aggressive therapies usually favored
Resistant to DNR orders
Clergy support welcomed
Native American Close and distant relatives involved
Considered rude to interrupt
Pauses to assure speaker is finished
Avoid life expectancy predictions; considered
self-fulfilling
Desire for unfettered struggle with death
Desire to stay in homeland
Desire to remain hopeful, positive
Asian Indian Emphasis on interconnectedness
Family and friends consulted
Prefer to die at home
May have important rituals with dead body
Chinese American Decisions made by family
Older men take primary role
Critically ill patients prefer hospitalization
Speaking about death considered bad luck
Preference for physician to make decisions
Latin American Family takes priority
Focus on present, not future
May only make decision in family
group setting
Family, physician, and religion influences
Aggressive treatment usually favored
DNR, do not resuscitate.
For additional information, see reference 6.
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| Fundamentals of Geriatric Pharmacotherapy
Hospice care as a distinct modern concept
originated in Great Britain as a system to provide
pain management and other symptom relief
that also includes psychological and spiritual
aid for terminally ill cancer patients.
7
However,
patients with any terminal disease will benefit.
Typical non-cancer diagnoses are end-stage
organ disease (e.g., dementia, congestive heart
failure [CHF], chronic obstructive pulmonary
disease [COPD]), and unspecified debility. In the
United States, hospice care is a program paid
for by Medicare Part A, Medicaid, and private
insurance for beneficiaries with a prognosis of
6 months or less. More than 42% of hospice
patients receive care at home, 24% receive care
in a nursing home or residential facility, and 26%
receive care at an inpatient hospice facility.
8
An
interprofessional team of physicians, nurses,
pharmacists, social workers, chaplains, home
aides, and volunteers provide needed care for
the patient and education and bereavement
counseling to family and friends.
KEY POINT:
Hospice is not a place.
Palliative and hospice care can be provided
in any setting: home, assisted living
facility, nursing home, or hospital.
More than 80% of patients enrolled in a
hospice service are insured by Medicare, which
began its hospice coverage in 1982.
8
Services
provided include management of pain and other
symptoms; assistance with nonmedical aspects
of dying; drugs related to the hospice diag-
nosis; supplies and equipment; and education,
bereavement care, and counseling to survivors.
Eligible Medicare beneficiaries who choose
to enroll in the Medicare Hospice Benefit may
revert back to Medicare if they prefer. There are
no copayments for hospice benefits under Medi-
care, unlike other Medicare benefits. Hospice
providers are paid a per diem amount, and the
hospice provider, in turn, pays the hospital, phar-
macy, and interprofessional staff. Hospice bene-
fits are important for patients who wish to die
at home. However, there are limits to how long
hospice will provide paid caregivers, so families
must sometimes weigh benefits between Medi-
care Hospice Benefit and Medicaid or other
insurance.
In the past, hospice did not pay for medi-
cations unrelated to the hospice diagnosis,
nursing home residential costs, or any curative
treatments. If a patient needed those items, he
or she would pay out of pocket, through other
insurance (e.g., Medicaid for nursing home
costs), or convert out of the Medicare Hospice
Benefit back to original Medicare or Medicare
Advantage. However, due to potential overpay-
ments and fraud between the hospice benefit
and Medicare Part D coverage, regulations were
changed so that any prescriptions submitted
through Medicare Part D for a beneficiary
enrolled in hospice would be denied coverage,
requiring the hospice provider to ensure they had
not already covered the cost. This was meant
to remove ambiguity and reduce overlapping
expenditures, reported as $33 million in 2009.
9,10
This change may delay receipt of medications
that were previously covered by Medicare Part D
while current coverage is being confirmed.
C N
I P C
In developed countries, most end-stage chronic
illness occurs in individuals over age 65, and
death from these illnesses is preceded by phys-
ical and functional disability. Caring for elderly
patients with chronic disease is medically and
ethically challenging, and hospice and palliative
care is especially useful. The first issue in pallia-
tive and hospice care is for a patient and his or
her physician to discuss the end of life, so the
patient can make better decisions about care.
Having these forthright discussions should not
make a patient sad, worried, or terrified.
11
A stan-
dard list of questions may be helpful to initiate
discussion:
https://t.me/medicina_free
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