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MEDICATION REVIEW:

Keep Your Eye on This QI: Residents Taking 9 or More Meds

Published on Sun May 24, 2009

4 ways to keep adverse drug reactions at bay.

Ensuring medications help rather than cause harm can be tricky when caring for nursing home residents with multiple co-morbidities. That's why a resident triggering on the QI for use of nine or more different medications definitely needs review.

Run the numbers: "If a person takes nine or more meds, he's statistically 100 percent certain to have an adverse drug reaction," cautions Russell Jenkins, MD, an internist and a board member of the Institute for Safe Medication Practices.

Thus, the QI provides a safety net or threshold for detecting residents in potential jeopardy; however, facilities should monitor residents' meds and related outcomes in real time.Experts suggest these key strategies.

1. Review medications at admission and periodically. The clinician should ask if there's a good reason for not stopping each medication,advised MatthewWayne, MD,CMD, in a presentation at the March 2009 American Medical Directors Association meeting. And even if the drugs all have appropriate indications, look to see "whether the aggregate of the medications is causing nausea or drug-drug interactions," advises Harold Bob, MD, CMD, a nursing home and hospice administrator in Baltimore. Medication-related nausea or gastrointestinal distress can lead to appetite loss -- a key factor in triggering a downward spiral, Bob cautions. That's especially true for people with dementia, he adds.

2. Focus on 'high alert'medications. Pay special attention to whether residents really need what's known as "high alert" medications. By definition, those medications pose a higher risk of patient harm if an error occurs, says Jenkins. The list includes anticoagulants, antipsychotics, diuretics, and anti-epileptics.

Tip: "Ask whether an elderly patient really needs to be on warfarin or low molecular weight heparin," Jenkins suggests. He reports seeing patients who remain on a blood thinner for inappropriate lengths of time because no-one thought to take the person off it. For example, the patient may have started taking heparin to help prevent deep-vein thrombosis due to hip surgery, he says. "Yet the prophylaxis has a limited time period for clinical effectiveness -- usually three months."

You may also find a resident is on a medication due to an exacerbation of congestive heart failure or seizures that long ago resolved, he adds.

3. Prune the PRNs. When "pruning"or trimming potentially inappropriate medications, look closely at PRN medication use, advises Susan Scanland, APRN, MSN, a geropsychiatric nurse practitioner in Clarks Summit, Pa.

Also make sure PRN medication orders don't get carried on forever. To prevent that from happening, Jenkins' practice used to write PRN orders with an automatic stop order when a nursing home resident doesn't  receive the PRN in two months. "That's a good rule because if a patient doesn't need a PRN for two months but then suddenly does, you'd want to know what's going on," adds Jenkins.

4. Follow the evidence for treating psych and behavioral problems. For example, less meds may sometimes be better in treating residents with psychiatric illnesses. One study funded by the National Institutes of Health found that adding an antidepressant on top of a mood stabilizer to treat depression in people with bipolar disorder had as much effect as a sugar pill (New England Journal of Medicine, March 28, 2007).

In other cases, the right combination of medications can stave off the need for additional psychoactive meds. Research shows that antidepressant therapy to treat depression to remission, and dementia medication (cholinesterase inhibitor plus Namenda starting in the middle stages of Alzheimer's) can decrease the need for antipsychotics or antianxiety agents, says Scanland.

If the facility uses antipsychotics off label to treat dementia-related behavioral symptoms, make sure to monitor whether the medication is helping a particular resident.

Residents treated with antipsychotics not only don't improve but are often worse after the first year of treatment, according to research by the New York Association of Homes & Services for the Aging, says Christie Teigland, PhD, one of the researchers. "So, the [medications] don't work in most cases. Behavioral approaches do work and they work much faster."

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