Strategies to Decrease Medication Errors in Elderly. Abeer Zeitoun, Pharm. D Certified in Medication Safety, MCPHS

Transcription

1 Strategies to Decrease Medication Errors in Elderly Abeer Zeitoun, Pharm. D Certified in Medication Safety, MCPHS

2 Road Map..Outline 1. Introduction A. Definitions B. Geriatrics: High risk population C. Magnitude of the problem D. The Need.. 2. Strategy 1: Guidance for Evaluating the use of medications in Elderly A. Beer s criteria B. START/STOPP criteria 4. Other strategies: A. Prescribing Cascade B. Medication Therapy Management C. Remember these are Geriatrics 5. Recommendations and Conclusion

3 Definitions Geriatric: Any person aged 65 and older High risk population: Specific group or subgroup that is more likely to be exposed, or is more sensitive to a certain substance than the general population. J Am Geriatr Soc April ; 60(4):

4 Why Geriatrics Are Considered High-Risk? Physiological Changes Polypharmacy Mental Function Changes Multiple Diseases Pharmacokinetics Changes Decreased Compliance

5 Magnitude of Problem >65yo 81% take >=1 prescription/day 29% take >=5 prescriptions/day 50% take >=5 medications/day (Rx, OTC, supplements) Each year about 1/3 experience a serious averse drug event (ADE) The elderly account for about 25% of emergency department visits due to adverse drug events. And about 50% of hospitalizations due to adverse drug events are in the elderly. Qato, D et al. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA 2008;300(24):

6 Adverse Drug Event (ADE) An injury resulting from the use of a drug or lack of an intended drug. Includes the following: Side effects (SEs) or adverse effects Adverse drug reactions (ADRs) Medication errors (MEs) JAMA. 1997;277:

7 Magnitude of Problem 1/3 of hospital admissions in elderly involve ADE Many in those > 80 year old Mostly due to unintentional overdose Budnitz DS, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365:

8 Magnitude of Problem Commonly implicated Warfarin 33%, Insulins 14%, Aspirin, Plavix 13%, Oral hypoglycemics 11% Budnitz DS, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365:

9 Risk Factors for ADE 5 medications 12 doses/day Dementia Depression Female gender Low body weight or BMI<22 Multiple chronic conditions Self-care CrCl <50ml/min Recent hospitalization Multiple pharmacies Multiple prescribers Prior ADE Regular use of alcohol Sleep, anxiety Low Vision Age 85 year old

10 THE NEED. A list of potentially inappropriate medications, their therapeutic alternatives, and medications to consider initiating in the elderly had to be created

11 The Need.. Key Guidance for Evaluating Medication Therapy Not really an attempt at making a hit list of medications to avoid in the elderly Intention to inform thoughtful prescribing decisions The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4): Gallagher PF, et al. Prevention of potentially inappropriate prescribing for elderly patients:a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 2011;89: PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist.s Letter/Prescriber.s Letter. September

12 Guidance for Evaluating Medications in Geriatric I. BEERS Criteria II. STOP/START Criteria 12

13 Guidance for Evaluating Medications in Geriatric I. Beers Criteria 13

14 Beers Criteria: Purpose Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Commonly called the Beers List It is a guideline for healthcare professionals to help improve the safety of prescribing medications for older adults It emphasizes avoiding medications, which reduces the problems of: 1. High risk benefit ratio 2. Polypharmacy 3. Drug interactions 4. Adverse drug reactions J Am Geriatr Soc April ; 60(4) 14

15 Beers Criteria: Purpose- Cnt d First published in 1991, revised 1997, 2003, 2012 Old criteria Medications that should be avoided in those 65 years 2012 criteria Medications that are potentially inappropriate J Am Geriatr Soc April ; 60(4) 15

16 Beers Criteria: Content 53 medications/drug classes 3 Groups: 1. Potentially inappropriate in all older people Ex: first generation antihistamine Due to their anticholinergic SE 2. Potentially inappropriate in older people with certain diseases Ex. CHF elderly to avoid NSAID 3. Drugs to be used with caution in older people EX. PRASUGREL increased risk of bleeding J Am Geriatr Soc April ; 60(4) 16

17 Beers Criteria: Content

18 Guidance: Beers Criteria /clinical_practice/clinical_guidelines_recommendations/2012

19 Beers Criteria: Problems- Cnt d 1. Focused on US prescriber 2. Unstructured 3. Not used ROUTINLY IN clinical practice 4. Lack of efficacy data in relation to: ADE prevention Cost reduction 5. Lack of significant association between Beers IP drugs and risk of ADE s 6. Do not include several important instances of IP 7. Criteria do not take into account prescribing omission errors J Am Geriatr Soc April ; 60(4) 19 *IP: Inappropriate prescribing

20 Beers Criteria: Problems J Am Geriatr Soc April ; 60(4) 20

21 Guidance for Evaluating Medications in Geriatric II. START/STOPP Criteria 21

22 STOPP and START: Purpose First published in 2008 STOPP (Screening Tool of Older Persons potentially inappropriate Prescriptions) Prescriptions that are potentially inappropriate in persons aged 65 START (Screening Tool to Alert doctors to Right Treatment) Medication that should be considered for people aged 65 where no contraindication exist O Mahony & Gallagher, Age & Ageing,

23 Guidance: STOPP Criteria Screening Tool of Potentially Problematic Prescribing Uses 65 indicators related to drug-drug and drug-disease interactions and therapeutic duplication Lists 65 risky drug interactions with diseases or other drugs Systems-based analysis (Ex. Avoid tricyclics with glaucoma, BPH, dementia, but not neuropathic pain) (Ex. Not to use NSAIDS without PPI or H2 blocker in patient with history of ulcers/gi bleeding)

24 Guidance: START Criteria Screening Tool to Alert doctors to the Right Treatment START incorporates 22 evidence-based indicators of common prescribing omissions. Suggested therapy 22 situations (Ex. Warfarin for atrial fibrillation) (Ex. ACE inhibitors for heart failure) (Ex. Metformin for diabetes)

25 How might STOPP/START be better than the Beers criteria Gallagher et al s shows: Significant improvement in medical appropriateness and underutilization of medications. However, the study was not powered to evaluate outcomes like falls or adverse drug events. With a list of medical conditions and an accurate med history, applying STOPP/START takes a median of 3 minutes, making it an option for both inpatient and outpatient settings. Yonsei Med J 55(5): ,

26 STOPP/START: Content

27 Analgesics and Antiinflammatory 27 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

28 Analgesics and Antiinflammatory- Cnt d 28 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

29 Cardiovascular 29 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

30 Cardiovascular- Cnt d 30 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

31 Cardiovascular- Cnt d 31 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

32 CNS 32 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

33 CNS- Cnt d 33 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

34 Endocrine 34 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

35 Gastrointestinal 35 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

36 Gastrointestinal Cnt d 36 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

37 Respiratory 37 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

38 Urinary Tract 38 PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011.

39 Implementation of START/STOPP and Medications Modification Start the use of Acetaminophen 650mg po PRN for pain instead of NSAID Start the use of DMARD (azathioprine) instead of NSAID for chronic treatment of rheumatoid arthritis Start Diet therapy including fibers and fluid for constipation in conjunction with CCB Start the use of shorter acting BDZ instead of the long acting: lorazepam 39

40 Implementation of START/STOPP and Medications Modification Start the use of PPI for GERD treatment and for GI protection: Nexium 20mg PO daily Switch from metoclopramide use to ondansetron 4mg PO daily for nausea treatment Continue use of allopurinol for gout treatment Continue the use of acenocoumarol (warfarin) for prevention of stroke in Afib 40

41 Guidance: Patient Handout

42 Road Map..Outline 1. Introduction A. Definitions B. Geriatrics: High risk population C. Magnitude of the problem D. The Need.. 2. Strategy 1: Guidance for Evaluating the use of medications in Elderly A. Beer s criteria B. START/STOPP criteria 4. Other strategies: A. Prescribing Cascade B. Medication Therapy Management C. Remember these are Geriatrics 5. Recommendations and Conclusion

43 Guidance: 1. Prescribing Cascade A prescribing cascade develops when an adverse drug event is misinterpreted as a new medical condition and additional drug therapy is then prescribed. Polypharmacy increases the possibility of prescribing cascades. Rochon P A, Gurwitz J H BMJ 1997;315:

44 Guidance: 1. Prescribing Cascade Rheumatoid Arthritis NSAID Worsen Hypertension CCB Leg swelling Chronic constipation Diuretic Laxative/stool softener Gout Allopurinol

45 Guidance: 2. Medication Therapy Management (MTM) Collect patient-specific information Obtain a complete medication history Match up indications for all medications Develop a list of medication-related problems Create a plan to resolve

46 Guidance: 3. Being a Geriatric Absorption, Distribution, Metabolism, Excretion Polypharmacy Geriatric Syndrome

47 Guidance: 3. Geriatric Syndrome Cognition impairment Urinary incontinence Falls Depression Osteoporosis Insomnia Constipation Dizziness

48 Guidance: 3. Geriatric Syndrome Always consider a new symptom as a possible side effect Evaluate need of existing medications Evaluate need for new medication Consider non-pharmaceutical treatment Use lowest possible dose Consider best options of needed medication

49 What Should Be Done 49

50 Prescribing Appropriately Consider risk vs. benefit Avoid therapeutic duplication Use simplest regimen possible Use least expensive alternative Use 1 medication to treat 2 conditions Adjust doses for renal and hepatic impairment Consider drug-drug and drug-disease interactions Avoid prescribing to treat side effect of another drug Determine therapeutic endpoints and plan for assessment 50 Gillespie, LD, Robertson, MC, Gillspie, WH, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No: CD DOI:

51 Preventing Polypharmacy Review medications regularly and each time a new medication started or dose is changed Maintain accurate medication records (include vitamins, OTCs, and herbals) Gillespie, LD, Robertson, MC, Gillspie, WH, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No: CD DOI: 51

52 Remember to check Medication Appropriateness Index Indication for medication? Medication effective for condition? Correct dose? Correct directions/ are they practical? Drug/drug interactions? Drug/disease interactions? Duplication of therapy? Duration of therapy appropriate? Least expensive alternative for similar outcomes? Hanlon JT, Schmader KE, Samsa GP. A method for assessing drug therapy appropriateness. J Clin Epidemiol

53 Tips To Improve Patient Safety in Elderly Patient Information Update current medications Verify allergies and reactions Use patient-specific identifiers Highlight clinical diagnoses and conditions Drug information Establish guidelines Maintain drug references Identify high-alert medications 53 Scheffer AC, Schuurmans MJ, Van Dijk N, Van Der Hoof T. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and ageing 2008; 37:

54 Tips To Improve Patient Safety in Elderly Communication Share information Improve handwriting Avoid problematic abbreviations Be aware of similar drug names Require that orders be read back Consider using electronic systems Labeling and storage Separate problematic drugs Control access to medications Keep the storage area well organized 54 Scheffer AC, Schuurmans MJ, Van Dijk N, Van Der Hoof T. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and ageing 2008; 37:

55 Tips To Improve Patient Safety in Elderly Patient education Evaluate patients medical literacy Do not rush medication counseling Culture change Make it easy to learn from errors Assess your practice s performance Look for system changes that will help prevent future errors 55 Scheffer AC, Schuurmans MJ, Van Dijk N, Van Der Hoof T. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and ageing 2008; 37:

56 References American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49: PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September Medication Use in Older Patients: Better Policy Could Encourage Better Practice. Jerry Avorn. JAMA. 2010;304(14):1606. Inappropriate Prescribing and Adverse Drug Events in Older People. Hamilton et.al. BMC Geriatrics 2009, 9:5 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Christine M. Campanelli. J Am Geriatr Soc April ; 60(4): Qato, D et al. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA 2008;300(24): Gallagher PF, et al. Prevention of potentially inappropriate prescribing for elderly patients:a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 2011;89:

57 References Cnt d American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association, Neto AS, Nassar AP Jr, Cardoso SO, Manetta JA, Pereira VG, Esposito DC, et al. Delirium Screening in Critically ill patients: a Systematic Review and meta analysis. Crit Care Med. June 2012; 40(6): Catic AG. Identification and management of in-hospital drug-induced delirium in older patients. Drugs Aging 2011;28(9): Shekelle P et al. Falls prevention interventions in the Medicare population. RAND report and evidence based recommendations. Baltimore, United States Department of Health, Scheffer AC, Schuurmans MJ, Van Dijk N, Van Der Hoof T. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and ageing 2008; 37: Gillespie, LD, Robertson, MC, Gillspie, WH, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No: CD DOI: / CD pub3. Yonsei Med J 55(5): ,

58 Thank you..