Review of Current Literature 4/2/18 POLYPHARMACY IN ASSISTED LIVING EVIDENCE BASED APPROACH

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1 POLYPHARMACY IN ASSISTED LIVING A Evidence Based Approach to Management of Medication Regimen Complexity By Burton Korer, MSN, RN-BC, CPHQ EVIDENCE BASED APPROACH Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. Titler MG. The Evidence for Evidence-Based Practice Implementation. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 7.Available from: BACKGROUND BACKGROUND Review of Current Literature Improvements in quality and access to healthcare in the United States has increased life expectancy and contributed to the growth in numbers of people living with chronic conditions. Individuals aged 65 years and older are now 13% of the U.S. population and account for a disproportionate one-third of spending on outpatient prescription drugs (Greenleaf Brown, 2016). Many elderly adults require treatment with multiple medications to meet their complex needs resulting in the prescribing of long-term therapies, many times involving multiple prescribers. 1

2 BACKGROUND BACKGROUND As the number of prescribers or pharmacies increases so does the risk of medication-related problems (Golchin, Frank, Vince, Isham, & Meropol, 2015). For residents of assisted living communities, medication adherence may no longer pose the same risk as compared to community-dwelling seniors. However duplicate therapy, contraindicated drug combinations, and unnecessary medications may still be associated with a higher risk of adverse drug events (Lalic et al., 2016). A healthcare quality approach to management of medication regimen complexity may improve functional outcomes, and decrease the use of healthcare resources among residents of assisted living communities. Define polypharmacy Identify risks of polypharmacy OBJECTIVES Identify contributing factors to polypharmacy Determine theoretical approach/quality improvement approach to polypharmacy/medication regimen complexity Identify opportunities for assisted living nurse, and best practices for assisted living community DEFINING POLYPHARMACY The ability to define polypharmacy is complex due to the prevalence of multi-morbidity among individuals age 65 years and older, and new clinical guidelines that may encourage prescribers to treat single chronic diseases with multiple medications (Sirois et al., 2017). The association between increased number of medications and adverse events has promoted the practice of defining polypharmacy by the number of active medications for an individual. Lalic et al (2016) found the most common number of active medications to be considered polypharmacy as 5 or more in community and outpatient, and 9 or more in residential care settings (Lalic et al., 2016). 2

3 DEFINING POLYPHARMACY WORKING DESCRIPTION But this strict definition by numbers offers no consideration of the positive outcomes that may attributed to the increased number of active medications. A revised approach to defining polypharmacy should distinguish between thoughtful consideration of medicine combinations, versus unthoughtful prescribing which is an ad hoc process made worse when multiple prescribers are involved (Dunning, 2017). The key to avoiding polypharmacy in older adults isn t a set number of medications and trying to stay below it, but rather using the right medications at the right doses and for the shortest possible duration on a case-by-case basis (Montgomery R. Smith & Kautz, 2018). RISKS FROM POLYPHARMACY ADVERSE DRUG EVENTS Medications for chronic conditions may improve health when taken individually. But when administered in certain combinations, can contribute to adverse events and increase mortality and morbidity (Montgomery R. Smith & Kautz, 2018). In the United States, 35.8% of older adults are prescribed 5 or more medications. Of these individuals, 15% are taking medications in combinations that pose some risk of a major drugto-drug interaction (Guharoy, 2017). Individuals taking five medications have a 58% risk of an adverse event, and increases to 82% for individuals taking seven or more medications (Alpert & Gatlin, 2015). Medications most often associated with adverse drug events are anticoagulants, opioids, and diabetic agents (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2014). RISKS OF POLYPHARMACY GERIATRIC SYNDROME Multiple medications in combination with physiological changes common in the elderly can dramatically increase the risk of an adverse drug event (Greenleaf Brown, 2016). When they occur, an adverse drug event may be overlooked or misinterpreted as some other condition based upon a resident s nonspecific complaints or complaints that mimic other conditions (Montgomery R. Smith & Kautz, 2018). Common complaints of aging that may actually be medication related are confusion, fatigue, dizziness, depression, nervousness, and incontinence. Geriatric syndromes and decreasing functional outcomes may occur from a failure to identify and intervene on adverse drug events. 3

4 RISKS OF POLYPHARMACY FALL RISK RISKS OF POLYPHARMACY PRESCRIBING CASCADE The risk of patient falls increases dramatically with the number of medications prescribed (Alpert & Gatlin, 2015). Medication most closely implicated with an increase of fall are diuretics, benzodiazepines, and anticholinergics. When a medication prescription is changed or a new medication added to the regimen, close monitoring of the residents response must occur. Medication related complaints that are overlooked or misinterpreted may contribute to prescribing cascade. A prescribing cascade occurs when a new medication is prescribed to counter signs or symptoms of an existing but unrecognized adverse drug event (Guharoy, 2017). RISKS OF POLYPHARMACY PREVALENCE Non-adherence Higher healthcare costs In a review of Medicare patient in 2011, 22% of SNF residents were determined to have had an adverse event. Medication related events were 37%, resident care events were 37%, and events related to infections were 26%. (Department of Health and Human Services, Office of Inspector General [OIG], 2014) 4

5 PREVALENCE PREVALENCE PREVALENCE NURSES ROLE IN CONFRONTING POLYPHARMACY Of the adverse and temporary harm events attributed to medication, 66% were determined to be preventable (OIG, 2014). Nurses have a unique opportunity to identify problems related to polypharmacy (Greenleaf Brown, 2016, p. 408). 5

6 NURSES ROLE IN CONFRONTING POLYPHARMACY What is the best approach? Regulatory/compliance? Policies & Procedure, Regulations Nursing Practice/Theory? Research to Practice Healthcare Quality? Process improvement and better outcomes Outcomes Value - Satisfaction NURSES ROLE IN CONFRONTING POLYPHARMACY What is the best approach? Healthcare Quality Process improvement and better outcomes Outcomes - Value Satisfaction IHITriple Aim METHOD/THEORY/APPROACH DONABEDIAN MODEL Donabedian (1966) noted, all evaluations of the quality of care can be classified in terms of one of three measures: structure, process, or outcome. Structure refers to characteristics of the individuals who provide care and of the settings where the care is delivered. Process is the series of events that takes place during the delivery of care. Appropriateness, skill (proficiency), timeliness of care. Outcome measures capture whether healthcare goals are achieved. 6

7 Structure? POLYPHARMACY PREVENTION Process? Outcome The right medications at the right doses and for the shortest possible duration on a case-by-case basis A BALANCED APPROACH TO SURVEILLANCE AND PREVENTION On a case by case basis A patient centered approach to accommodate the individual needs of each resident/family A BALANCED APPROACH TO SURVEILLANCE AND PREVENTION SELECT DETERMINANTS OF PREVENTABLE ADVERSE DRUG EVENTS Observation/assessment of abrupt changes in mental, physical, or emotional state of elderly individuals may be associated with medications. When noticed, these changes should be communicated to the prescriber for evaluation (Greenleaf Brown, 2016). Adherence and compliance to the prescribed regimen should be investigated to aid the prescriber in considering appropriate adjustment to therapy. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention. Washington, DC:. 7

8 SELECT DETERMINANTS OF PREVENTABLE ADVERSE DRUG EVENTS PROXIMATE FACTORS OF PREVENTABLE ADVERSE DRUG EVENTS Patient Polypharmacy Medication incorrectly or inappropriately prescribed Reduced hepatic and/or renal metabolism Inappropriate monitoring Age Miscommunication between providers Cognitive decline Failure to follow policy Physical frailty Staff inexperience or new work setting Medical and/or psychiatric comorbidities Order illegible Multiple providers Prescribed high-risk mediations (anticoagulants, diabetes agents, opioids) Provider SURVEILLANCE SURVEILLANCE Adverse Drug Event Triggers (CMS) Risk factors related to medication(s) Triggers: Signs and Symptoms Triggers: Clinical Interventions 8

9 INTERACT POLYPHARMACY ENCOUNTERED When polypharmacy is encountered, deprescribing is initiated. DEPRESCRIBING DEPRESCRIBING De-prescribing, the process of tapering, withdrawing, discontinuing, or stopping medications, is important in reducing polypharmacy, adverse drug effects, inappropriate or ineffective medication use, and cost (Liu, 2014, p. 136). An important component of geriatric care is the discontinuation of unnecessary or harmful medications. However, the many factors to consider when stopping any medication may be very time consuming for prescribers, especially when residents and families resist discontinuing medications that may be perceived as withholding care (Liu, 2014). Many prescribers express reluctance to discontinue or change therapies prescribed by other clinicians. 9

10 DEPRESCRIBING DEPRESCRIBING The long term prognosis for some residents may be difficult to predict and obscure the ongoing need for certain medications. Potential harm or adverse events may result when certain medications are discontinued. Several protocols exist to help guide a clinician in deprescribing medications. A step-wise approach is generally accepted as the best approach. Clinicians should first evaluate how effective the medication has been, discuss observations/findings with the patient and nursing staff, evaluate whether the medication is of benefit or high-risk, and then determine whether or not the medication should be discontinued (Liu, 2014, p. 137). DEPRESCRIBING DEPRESCRIBING Clinicians must also determine the cause of falls, confusion and lethargy by discerning between drug-toxicity and possible urinary tract infections (Liu, 2014). And patient s with less life expectancy (< 12 months) should be treated more conservatively with medications. The benefits and risks of even common drugs must be considered for discontinuation when clinical uncertainty exists. In a randomized controlled trial of aspirin for use in primary prevention, 120 individuals treated for 6 years prevented 1 case of cardiovascular disease, while 73 participants experienced a non-trivial bleed (Hilmer, Gnjidic, & Le Couteur, 2012). 10

11 DEPRESCRIBING POLYPHARMACY PREVENTION Structure Prescribers Medication Reconciliation erx (CPOE) Pharmacy Policies Electronic Health Record Family Process Care delivery Surveillance Risk factors Triggers: s/s Triggers: interventions Evaluation algorithm Documentation/retrievable data Deprescribing Outcome The right medications at the right doses and for the shortest possible duration on a case-by-case basis STRUCTURE Prescribers Prescribers practice in a manner to minimize medication regimen complexity, deprescribing (hospice/palliative) Medication Reconciliation Upon move-in and at each transition of care, reconciliation of regimen between multiple providers erx (CPOE) Clinical decision support enabled Pharmacy Coordinated approach to minimization of complex medication regimen (reports, education, dispensing review) Policies STRUCTURE Medication reconciliation process, care delivery, and surveillance Electronic Health Record Dashboard and reporting of critical data Family Participation and engagement in support of decreased medication regimen complexity 11

12 Care delivery Adherence to prescribed therapy Surveillance PROCESS Risk factors (risk stratification- diagnosis, high risk meds (Beers criteria), # active meds, medication combinations Triggers: s/s abnormal vitals, deteriorating vitals, cognitive changes, behaviors (restlessness/somnolence, diet/elimination Triggers: interventions prescriber new Rx or changes, acute care transfer Falls Evaluation algorithm (guided observation, documentation, and prescriber communication Documentation/retrievable data PROCESS EHR designed for necessary data collection with real time dashboard alerts/reporting Deprescribing Prescribers in agreement with approach and provided proper resident specific monitoring and evaluation OUTCOME Outcomes measures # of active meds by resident % of residents with high risk factors/meds # of falls # acute care transfers Adherence with prescribed regimen Behaviors Hypoglycemic episodes Satisfaction OUTCOME Resident/family/prescriber/health plan/referral source/employee/ownership Operational efficiencies 12

13 SUMMARY/CONCLUSION REFERENCE The right medications at the right doses and for the shortest possible duration on a case-by-case basis Alpert, P. T., & Gatlin, T. (2015, November/December). Polypharmacy in older adults. Home Healthcare Now, 23(10), Department of Health and Human Services, Office of Inspector General. (2014). Adverse events in skilled nursing facilities: national incidence among Medicare beneficiaries. Washington, DC:. Dunning, T. (2017). Medicines and older people: polypharmacy. adherence and safety. International Diabetes Nursing, 14, Golchin, N., Frank, S. H., Vince, A., Isham, L., & Meropol, S. B. (2015, April-June). Polypharmacy in the elderly. Journal of Research in Pharmacy Practice, 4(2), Gray, I. A., Gray, L. C., Martin, J. H., Pillans, P. I., & Mitchell, C. A. (2013). Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evidence Based Medicine, 18(4), REFERENCE REFERENCE Greenleaf Brown, L. (2016, November-December). Untangling polypharmacy in older adults. Medsurg Nursing, 25(6), Guharoy, R. (2017, September 1). Polypharmacy: America's other drug problem. American Journal of Health-System Pharmacists, 74(17), Hilmer, S. N., Gnjidic, D., & Le Couteur, D. G. (2012). Thinking through the medication listappropriate prescribing and deprescribing in robust and frail older patients. Australian Family Physician, 41(12), Komiya, H., Umegaki, H., Asai, A., Kanda, S., Maeda, K., Shimojima, T.,... Kuzuya, M. (2018). Factors associated with polypharmacy in elderly home-care patients. Geriatric Gerontology International, 18, Lalic, S., Jamsen, K. M., Wimmer, B. C., Tan, E. C., Hilmer, S. N., Robson, L.,... Bell, J. S. (2016). Polypharmacy and medication regimen complexity as factors associated with staff informant rated quality of life in residents of aged care facilities: a cross-sectional study. European Journal of Clinical Pharmacology, 72, Liu, L. M. (2014). Deprescribing: an approach to reducing polypharmacy in nursing home residents. The Journal for Nurse Practitioners, 10(2), Montgomery R. Smith, D., & Kautz, D. D. (2018). Protect older adults from polypharmacy hazards. Nursing2018, 48(2), Scott, I. A., Gray, L. C., Martin, J. H., Pillans, P. I., & Mitchell, C. A. (2013). Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evidence Based Medicine, 18(4), Sirois, C., Laroche, M., Guenette, L., Kroger, E., Cooper, D., & Emond, V. (2017). Polypharmacy in multimorbid older adults: protocol for a systematic review. Systematic Reviews, 6(104). U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention. Washington, DC:. 13

14 CONTACT Burton Korer, MSN, RN-BC, CPHQ 14