Medication Reviews within Care Homes. Catherine Armstrong
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1 Medication Reviews within Care Homes Catherine Armstrong
2 What is a Medication Review? A structured, critical examination of a patient s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medicationrelated problems and reducing waste Task Force on Medicines Partnership and the National Collaborative Medicines Management Services Programme (2002). Room for Review. A guide to medication review: the agenda for patients, practitioners and managers
3 What is different within a Care Home setting? Structured, critical examination Agreement with patient Optimise impact of medicines Minimise medication-related problems Reduce waste PLUS Access to additional information
4 Additional points to remember: All ill! Frail, dependent, multiple comorbidities Short life expectancy quality rather than quantity May not be fit for (or may not cooperate with) further investigation Often simple interventions can make a difference Initial assessment and management may be time consuming, but reaps rewards later both for patient and doctor
5 Polypharmacy
6 Structured approach For all medications need to consider: Is it still indicated? Is the method of administration still the best Can the patient manage the formulation? Does the patient have any swallowing difficulties? Are there any drug interactions Based on assessment of patient Specific drugs for consideration...
7 Medicines for Chronic Diseases Is it still appropriate to prevent chronic disease? Difficult decision, do not make in isolation Side effects statins, aspirin Complications warfarin if patient has increased risk of falls 14-43% of care home residents on statins
8 Antipsychotics Is it still required? Document continued need Reassess behaviour regularly Side effects Parkinsonism 24% of care home residents on antipsychotics
9 Sedatives Is sedation needed? Review continued need regularly Document continued need Increases risk of falls Use appropriate dose Try to only use 1 sedative agent
10 Diuretics Review why started originally Audit across 5 care homes 62% of patients should have stopped Is there still a need? Dehydration risk watch fluid intake Hypotension increased risk of falls
11 Antihypertensives Check BP regularly Postural hypotension increased risk of falls
12 Antidepressants Is it still needed? NB depression often undertreated in care homes SSRIs increase risk of GI bleed Safest SSRI in CVD sertraline Side effects Low sodium Postural hypotension Sedation
13 Analgesia Is it still needed? May need to increase NSAIDs lowest effective dose for shortest time Avoid tramadol Consider topical agents
14 Osteoporosis Assess mobility and risk of fracture If bed-bound, what is the likelihood of a fall / fracture? Side effects GI worse with alendronate (PPI?) Decreased appetite Consider renal function Give calcium & vitamin D 3 if mobile consider formulation
15 Others Anti-dementia drugs Check continued benefit Nutritional supplements Is supplementation still needed Food fortification / assistance with eating Weight loss may be part of disease progression Drugs for urinary incontinence Can cause increased confusion Eye drops Poor vision and macular degeneration can lead to falls
16 Standard vision
17 6/24 vision
18 Macular degeneration
19 Case 1 Peter aged 84 Retired teacher Recent discharge from hospital with back pain following a fall Osteoporosis and L2 fracture Admitted to residential care Low mood (wife died 4 months ago) Low sodium Low vitamin D (IM injection and Zolendronic acid infusion in hospital) Previous constipation now overflow diarrhoea Residual urine on bladder scan PMH vertigo and arthritis
20 Medicines Citalopram 20mg 1 m Clopidogrel 75mg 1 m Naproxen 250mg 1 bd Ranitidine 150mg 1 bd Betahistine 8mg 1 tds Codeine 30mg 1 tds Movicol 1-2 daily (refusing due to diarrhoea) Senna 7.5mg 2 n Finasteride 5mg 1 m Alimenazine 20mg 1 n
21 Structured approach For all medications need to consider: Is it still indicated? Is the method of administration still the best Can the patient manage the formulation? Does the patient have any swallowing difficulties? Are there any drug interactions Based on assessment of patient Specific drugs for consideration
22 Medicines Citalopram 20mg 1 m Clopidogrel 75mg 1 m Naproxen 250mg 1 bd Ranitidine 150mg 1 bd Betahistine 8mg 1 tds Codeine 30mg 1 tds Movicol 1-2 daily (refusing due to diarrhoea) Senna 7.5mg 2 n Finasteride 5mg 1 m Alimenazine 20mg 1 n Chronic disease medicines Antipsychotics Sedatives Diuretics Antihypertensives
23 Medicines Citalopram 20mg 1 m Naproxen 250mg 1 bd Ranitidine 150mg 1 bd Betahistine 8mg 1 tds Codeine 30mg 1 tds Movicol 1-2 daily (refusing due to diarrhoea) Senna 7.5mg 2 n Finasteride 5mg 1 m ADD calcium and vitamin D 3 caplet Antidepressants Analgesia Osteoporosis
24 Medicines Mirtazapine 15mg (increase if necessary, review regularly, stop once mood improved) Ranitidine 150mg 1 bd Betahistine 8mg 1 tds Movicol 1-2 daily (refusing due to diarrhoea) Senna 7.5mg 2 n Finasteride 5mg 1 m Calcium and vitamin D 3 2 daily General medicines are they all still needed? Swallowing difficulties Drug interactions Paracetamol 2 qds PRN Piroxicam gel PRN
25 Medicines Citalopram 20mg 1 m Clopidogrel 75mg 1 m Naproxen 250mg 1 bd Ranitidine 150mg 1 bd Betahistine 8mg 1 tds Codeine 30mg 1 tds Movicol 1-2 daily (refusing due to diarrhoea) Senna 7.5mg 2 n Finasteride 5mg 1 m Alimenazine 20mg 1 n Mirtazapine 15mg (increase if necessary, review regularly, stop once mood improved) Calcium and vitamin D 3 2 daily Paracetamol 2 qds PRN Piroxicam gel PRN Annual zolendronic acid infusion
26 Case 2 Frances aged 75 Has been in residential care for 7 months Referred for urgent assessment to local elderly care assessment centre Sudden change in function?tia History of: Vascular dementia Atrial fibrillation TIA Hypertension Breast cancer
27 History from carer Fell 1 month ago Complained of bad back Previously mobile with little assistance now needs 2 people to transfer Incontinent of urine Constipated Little interaction with others
28 Observations / Investigations New crush fractures in lumbar spine Poor swallow reflex No significant CV changes no TIA
29 Medications Losartan 25mg 1 m Simvastatin 10mg 1 n Warfarin as per INR result Mirtazapine 30mg 1 n Amisupiride 100mg 1 n Atenolol 50mg 1 n Paracetamol 250mg/5ml 20ml qds
30 Medications Losartan 25mg 1 m Simvastatin 10mg 1 n Warfarin as per INR result Mirtazapine 30mg 1 n Amisupiride 100mg 1 n Atenolol 50mg 1 n Paracetamol 250mg/5ml 20ml qds ADD Aspirin disp 75mg 1 m Chronic disease medicines Antipsychotics Sedatives
31 Medications Losartan 25mg 1 m Mirtazapine 30mg 1 n Amisulpiride (reducing to stop) Atenolol 50mg 1 n Paracetamol 250mg/5ml 20ml qds Diuretics Antihypertensives Aspirin disp 75mg 1 m
32 Medications Losartan 25mg 1 m Mirtazapine 30mg 1 n Amisulpiride (reducing to stop) Atenolol 50mg 1 n Paracetamol 250mg/5ml 20ml qds Aspirin disp 75mg 1 m ADD alendronate 70mg/100ml 1 weekly Antidepressants Analgesia Osteoporosis ADD calcium and vitamin D 3 sachets
33 Medications Losartan 25mg 1 m Mirtazapine 30mg 1 n Amisulpiride (reducing to stop) Atenolol 50mg 1 n Paracetamol 250mg/5ml 20ml qds Aspirin disp 75mg 1 m Alendronate 70mg/100ml 1 weekly Calcium and vitamin D 3 sachets General medicines are they all still needed? Swallowing difficulties Drug interactions
34 Medicines Losartan 25mg 1 m Simvastatin 10mg 1 n Warfarin as per INR result Mirtazapine 30mg 1 n Amisupiride 100mg 1 n Atenolol 50mg 1 n Paracetamol 250mg/5ml 20ml qds Losartan 25mg 1 m Mirtazapine 30mg 1 n (orodispersible) Amisulpiride (reducing to stop) Atenolol 25mg/ml 10ml m Paracetamol 250mg/5ml 20ml qds Aspirin disp 75mg 1 m Alendronate 70mg/100ml 1 weekly Calcium and vitamin D 3 sachets
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