Reducing Polypharmacy: With a Focus on Older Adults

Sandra Dorr

Western Carolina University

I. Problem or Issue

As the population of the United States increases, so do the number of older adults treated for chronic illness and the number of medications prescribed. It is estimated that older adults, those 65 years and older, consume 40% of all prescription medications (Rocchiccioli, Sanford, & Caplinger, 2007). This problem is compounded when multiple physicians are treating a patient or multiple pharmacies are used. A survey of community based older adults revealed that 50% used 5 or more prescription and over-the-counter medications per week. Twelve percent of those surveyed used 10 or more (Edlund, 2007). Each year, thousands of older adults are admitted to the hospital with illnesses directly related to medications (Rocchiccioli et al, 2007). With the increase in the number of medications prescribed for older adults, the health care practitioners must be aware of the number of medications their patients are taking and how pharmacokinetics and pharmacodynamics can both be affected by the aging process.

Pharmacokinetics

Pharmacokinetics is defined as how the body handles a drug (Reddy, 2006). Reddy, in the article “Prescribing in older people”, cites several pharmacokinetics changes that occur in older adults, the first and most important is the decrease in renal clearance. With decreased renal clearance less of the drug is excreted and the medication accumulates in the body (Reddy, 2006). The kidneys loose mass starting at the age of 30 resulting in approximately a 23 percent reduction by the age of 80. Most of the functional loss is in the renal cortex reducing the glomerular filtration rate (Dingwall, 2007). A second pharmacokinetic change cited by Reddy is a decline in liver function. This is especially a problem in frail elders because of the possibility of increased plasma concentration of the medication. The author recommends for this population that medication doses be prescribed at low levels and titrated up gradually (Reddy, 2006). Factors that affect drug metabolism in the liver are a loss of liver mass, reduced hepatic blood flow and decreased enzyme activity (Dingwall, 2007). Lastly, Reddy cautions that there are changes in the gastrointestinal tract (GI). Changes in the GI tract that effect absorption of medications includes an increase in the gastric pH, changes in gastric emptying and intestinal motility, and changes to the surface area of absorption and the blood flow at the site of absorption (Dingwall, 2007).

Pharmacodynamics

Pharmacodynamics is defined as what a drug does to the person (Reddy, 2006).

Sensitivity to medication is altered in older adults. The person may be over sensitive, resulting in exaggeration of the normal effects of a drug, or under sensitive, resulting in the medication not reaching the desired effect (Dingwall, 2007).

Adverse drug reactions (ADR) are any harmful or unwanted effects caused by a drug taken as instructed in its regular dosage (Reddy, 2006). Certain medications are more likely to cause an adverse drug reaction in an older adult. Examples of ADRs are:

· Hypnotics, with long half-lives, may cause drowsiness, unsteadiness, confusion and slurred speech. This can increase the possibility of falls (Reddy, 2006)

· Non-steroidal anti-inflammatory drugs (NSAIDs) can increase the possibility of a GI bleed, heart failure and impaired renal function (Reddy, 2006).

· Digoxin is likely to cause toxicity in the very elderly, especially when there is impaired renal function (Reddy, 2006).

· Anticoagulants such as warfarin, have a narrow therapeutic index and should only be prescribed if the patient has a thorough understanding of the medication’s purpose, risks, dose schedule and the importance of regular blood test (Reddy, 2006).

Increased risk of falls can be directly related to an older adults medication use. In the article, “The impact of medication on falls”, Nazarko states that every year 1.57 million older people fall three or more times and that falls are a major health issue that lead to death and disability. Any drug that causes sedation, confusion, hypotension or dehydration may increase the risk of falls (Nazarko, 2005).

Drug interactions increase as a person ages and are compounded when a person has multiple physicians. Persons with multi-pathologies may have drugs prescribed by different practitioners. There is a risk that some clinicians will prescribe independently of others, increasing the potential for adverse drug reactions and interactions (Dingwall, 2007). The use of over-the-counter (OTC) medication and complementary and alternative medication (CAM) can also cause drug interactions. Because people are now being encouraged to manage common illness without a visit to a physician, by using OTC medication, practitioners are not always informed of their use. CAM used in conjunction with prescription medication may induce potential herb-drug interactions (Dingwall, 2007).

Due to the number of problems and interactions that medications can cause in older adults, as a result of changes in pharmacokinetics and pharmacodynamics, it is important that healthcare practitioner be aware of the possibility of polypharmacy in their patients. Polypharmacy is defined as an undesirable state caused by the use of duplicative medications, drug interactions, and a disregard for pharmacokinetic and pharmacodynamic principles (Rocchiccioli et al, 2007). Polymedicine is defined as multiple medications, prescribed appropriately for older adults to treat co-morbid conditions (Rocchiccioli et al, 2007).

One of the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) patient safety goals is that health care providers will ensure that there is an accurate and complete reconciliation of medications across the continuum of care. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions (JCAHO, 2007). Since this JCAHO goal was enacted, hospitals across the United States have developed policies around Medication Reconciliation. A patient’s home list of medications is reconciled on admission, on transfer within the hospital, after surgery/procedures, and on discharge. This medication list is to be reviewed by the physician at all times of transition in the care of the patient. A physician’s review and knowledge of a patient’s medications is imperative for the delivery of quality care, but the physician may not be the most knowledgeable health care provider to identify adverse drug interactions, eliminate unnecessary medications and assess if the lowest possible effective dose is being prescribed. A pharmacist review of a patient’s medical record and medication list can more accurately prevent polypharmacy.

II. Statement of Problem

As the population of the United States ages, the number of person’s over the age of 65 will continue to increase. With the increasing aged population, one would expect to have a greater number of patients with co-morbidities and multiple medications prescribed. These factors result in an increase in the incidence of polypharmacy. The healthcare practitioner will need to perform a thorough review of a patient’s medication list to prevent polypharmacy. An in-depth understanding of pharmacokinetics and pharmacodynamics, as they relate to the geriatric patient, is essential to ensure that patients receive a therapeutic dose and at the same time avoid dangerous drug interactions and adverse effects.

III. Proposed Plan of Action

Systemic changes

Currently when a patient is admitted to the ACF a complete and accurate list of home medications, both prescription and OTC are documented as part of the Medication Reconciliation process. Although this medication list is collected and compiled there is not a process in place to ensure that the medications are truly evaluated as appropriate for the patient. A controlled plan needs to be in place that ensures that a patient’s medications are evaluated for appropriateness and that this evaluation is conducted consistently on all patients at risk for polypharmacy.

Stakeholders

The stakeholder that I identify most with is the nursing staff. The advantage of being a nurse is that I am able to see how the Medication Reconciliation process works from start to finish and how important this practice is to the well-being of the patient. I understand the process of patient diagnosis, the prescribing of medications by the physician, and how medications are dispensed by a licensed pharmacist. A disadvantage of being a nurse and identifying most closely with this group of stakeholders is I may lack of complete and thorough understanding of why certain medications are prescribed for specific disease processes. Not being involved in the financial and budgetary process of the hospital, I may have an incomplete understanding of the financial expenditure of hiring additional staff members dedicated solely to evaluating the patient’s medication list and medical record in an effect to decrease polypharmacy. As a nurse, I believe that it would be important to have a multi-disciplinary team involved in initiating any proposal to decrease polypharmacy to ensure that all stakeholders are able to provide input into a workable solution to this problem.

Other Solutions

In Dingwalls article, “Medication issues for nursing older people”, she states that her aim and intended learning outcome is to raise awareness about professional responsibility and accountability in medication issues that impact on older people. Nurses must recognize their responsibilities in regard to the safe administration of medicines and challenge poor drug administration practices (Dingwall, 2007). Part of the staff nurses’ role as a patient advocate is to question physician orders that he/she believes are unsafe. Articles such as Dingwall’s help increase the staff nurses’ base knowledge of pharmacodynamics and pharmacokinetics as they related to older adults, but the staff nurse is by no means an expert. One way in which nursing can improve the care that is provided to older adults is by developing a Geriatric Resource Nurse (GRN) program based on the Nurses Improving Care to Health-system Elders (NICHE) model. Such a program identifies and trains nurses on the unit to become unit-based resources in geriatric best practice. These programs are often lead by Geriatric Nurse Practitioners (Henry & Henry, 2006). Although a

GRN program is important to improving the nursing care of elderly patients, I do not believe that a staff nurse is the most knowledgeable health care provider to consistently identify polypharmacy.

Nurse Practitioners are being used to help decrease polypharmacy. In the book Transformational eldercare from the inside out, Jocelyn M. Porquez, a certified family nurse practitioner and psychiatric clinical nurse specialist, works with elderly patients with a “vision for healing holistically and embracing an integrated biopsychosocial-spirtiual model for health and well-being”. Porquez stated that part of her role is “to serve as a pharmaceutical referee for patients and their specialists” (Henry et al, 2007). Nurse Practitioners specializing in Geriatrics bring a wealth of knowledge to the clinical setting and are qualified to reviewing patient charts and recommend changes to physicians. Nurse Practitioners that function in a role such as Porquez often have multiple responsibilities to the ACF and the patients being treated on the nursing unit. I do not believe that a Nurse Practitioner with multiple job responsibilities would be able to consistently identify polypharmacy and act as a consultant for all patients admitted to the ACF taking five or more medications. I also do not believe that a Nurse Practitioner is the most knowledgeable health care provider to identify polypharmacy.

Described above are alternative solutions to help decrease polypharmacy, all of which could have some success. A pharmacist review of a patient’s medical record and medication list would more accurately and consistently prevent polypharmacy in all patients admitted to an ACF taking five or more medications.

Recommended Solution

A pharmacist has the expert knowledge of pharmacokinetic and pharmacodynamic principles to more accurately identify polypharmacy and make recommendations for change to the physician. A Pharmacist Consult would be initiated by the admitting nurse at the time of hospital admission when the Medication Reconciliation process identifies a patient meeting the criteria of having five or more medications, both prescription and over-the-counter. Older adults will most likely comprise a large majority of these patients. A physician’s order will not be necessary to initiate a Pharmacist Consult. The pharmacist would review the patient’s medication list and medical record, making recommendations to the Primary Physician and any Consulting Physicians of changes that, if made, could decrease polypharmacy. Recommendations that could be made by the pharmacist include the elimination of duplicate medications, increasing of a drug’s dose to a therapeutic level, decreasing a medication dose that may be too large for an older adult based on the patient’s disease process, and substituting a medication that is less likely to cause an ADR in older adults. The pharmacist would follow the patient throughout the hospitalization and would be assigned to the nursing unit or several nursing units. The pharmacist would stay on the nursing unit/units throughout his/her shift reviewing patient medical records, consulting with physicians, nurses, and other interdisciplinary team members to ensure a thorough understanding of the patient’s diagnosis and treatment plan. The advantage of decentralization of pharmacist is the fostering of interdisciplinary relationships and interactions. The disadvantage is the increased cost to the ACF to hire more pharmacists.

Beneficiaries

There are many beneficiaries of this proposed plan, but foremost the patient would benefit. The patient’s medication list would be thoroughly reviewed and evaluated ensuring that a therapeutic dose of medications is ordered, that medications are evaluated for drug to drug interactions and drug to herb interactions, and that duplicate medications are not prescribed. The patient would benefit by not paying for unnecessary medications.

The patient’s insurer would benefit. If polypharmacy was decreased, the likelihood of future hospitalizations due to an ADR would be decrease, thus decreasing insurance cost. The elimination of unnecessary medications would also benefit the insurance company by decreasing cost.

Physicians and hospitals would benefit if ADR are avoided, because re-hospitalization of patients will be decreased. Patient falls should decline as a result of decreased ADR, consequently helping hospitals to stay in compliance with JCAHO standards. Staying in compliance with JCAHO standards benefits not only the hospital, but the entire hospital staff.

Losers

A loser in this proposed plan would be drug companies. A decrease in the number of prescriptions written for the average older adult will ultimately affect the drug companies’ profits. The hospital will lose profit with the initial hiring and training of new Staff Pharmacists. This initial financial loss would be off set by increased patient safety and a decrease in probability of litigation resulting from patient falls or other poor patient outcome due to overmedicating and ADR.

IV. Implementation and Evaluation Strategy

The proposed plan to use a Staff Pharmacist as a means to decrease polypharmacy would be implemented with the following action steps.

Action Steps

1. An interdisciplinary team would be formed to discuss and plan the implementation process. This Implementation Team would include a Physician, a Pharmacist, a Manager or other person that is in the position to evaluate and change policy, a Geriatric Nurse Practitioner (if available) and a staff nurse. The Team would be open to the possibility of adding more members if expertise was needed from a discipline not included in the original team. It would be important for hospital leadership to promote team building between the members.
2. The Implementation Team would evaluate if there are institutional policies or processes needing change or adaptation.
3. The implementation of this change would first be trialed on a single medical/surgical unit before being introduced to the entire facility.
4. The unit’s nursing staff would be educated about the trial.
5. Physicians that routinely admit patients to the trial unit would be educated about the trial.
6. A Pharmacist would be assigned to the unit and educated concerning the trial.
7. When a new patient is admitted to the nursing unit, the Medication
   Reconciliation process would be initiated.
8. If a patient is identified as having five or more medications, a Pharmacist Consult would be requested by the admitting nurse through an electronic ordering computer system. This system will allow for the tracking of Pharmacist Consults.
9. A Pharmacist Consult would not require a physician’s order.
10. The Pharmacist would go to the patient’s chart and review the medication list, laboratory results, height, weight and diagnosis. Based on the Pharmacist review of the patient’s chart, he/she would be able to make recommendations to the Physician/s for changes in the medication regiment or dosage if any are required.
11. During the trial period data will be collected from the patient’s medical record by Clinical Improvement, a department comprised of registered nurses who collect and analysis data with the intention of identifying areas that need improvement and enacting change.
12. The trial period should be for a minimum of three months. During which time the Implementation Team will meet weekly to monitor the progress of the trial.
13. If the trial is successful, the process will “roll-out” to the entire facility incrementally.

Goals

The primary goal of this change is to decrease polypharmacy. The intent of the change would be for the patient to be discharged from the hospital on medications that are appropriately dosed, that are not duplicated, and do not interact with other medications ordered.

The secondary goal would be to increase communication between the healthcare team members: the Primary Physician, the Secondary Specialist, the Pharmacist, and the Nursing Staff.

Criteria and Effectiveness

The Implementation Team will know that the use of a Pharmacist Consult to reduce polypharmacy was successful if the data collected during the trial shows that:

• There was a significant change in the medications ordered at the time of discharge in relation to the medications ordered on admission.
• If after a Pharmacist Consult was requested, that the recommendations for change were followed by the Physician/s.
• If there was a significant decrease in the number of falls or other poor patient outcomes due to overmedicating and ADR related to medication.

Framework for analysis

Clinical Improvement will collect data from all patient charts that have received a Pharmacist Consult during the three month trial period. The following data will be collected retrospectively from the discharge chart.

• The number of Pharmacist Consults requested.
• The name, frequency, and dose of all the medications that the patient has been taking prior to hospital admission. This information can be obtained from the Medication Reconciliation sheet completed on admission
• The name, frequency, and dose of all medications prescribed by the physician on admission.
• If a recommendation for change is made to the Primary Physician
• If the Pharmacist’s recommendations were followed by the physician.
• The name, frequency, and dose of all medications that the patient is prescribed at discharge.

The data will be analyzed to see if there was:

· A change in the number of medications from admission to discharge.

· A significant number of recommendations made by the Pharmacist on consult. The recommendations will be placed in the following categories:

o Eliminating a duplicate medication.

o Increasing a dose that is not therapeutic.

o Decreasing a dose that is too large for the older adult.

o Substituting of a medication that is less likely to cause an ADR in an older adult.

V. Policy Implications

There are several policy and process changes that would need to be made to support a Pharmacist Consult. A form would need to be created for the pharmacist to document their consultation and recommendations. This form would be development by the Implementation Team and approved by the Form’s Committee, a committee that reviews all forms prior to use. The Pharmacist Consult Documentation Sheet would include a place for the physician’s signature to indicate that the consult was reviewed and taken into consideration by the physician.

A second policy change would be the ability of the nursing staff to initiate a Pharmacist Consult without a physician’s order. This policy change would need to be approved by the Medical Executive Committee, a committee made up of physician leaders representing different medical disciplines. A representative from the Implementation Team would present the request to the Medical Executive Committee, explaining the benefits of this policy change. Once approval is obtained, the Implementation Team would need to submit a request to Information Technology for the Pharmacist Consult to be added into the computerized ordering system.

Once the Implementation Team has a process for documenting the Pharmacist Consult and approval that the initiation of the consult be nurse driven the process would need to be presented to the appropriate Nursing Shared Governance Councils. The Implementation Team would first present the proposal to the Leadership Council, whose members are Nurse Managers representing the different nursing units and practice areas. This council would make recommendations for change based on their expertise and make decision regarding the trial location and the process for hospital wide “roll-out”. The Implementation Team’s second presentation would be to the Clinical Practice Council, whose members are Registered Nurses representing all practice areas in the hospital. The Clinical Practice Council would make recommendations for changes to the process based on their knowledge of how nursing is practiced at the bedside and how the policy changes will affect that practice. After approval is gained from the Leadership and Clinical Practice Councils the Implementation Team would present the process and associated policy changes to the Education Council. The Education Council is comprised of Staff Development Clinicians and staff nurses. The council would make recommendations to the Implementation Team on how the nursing staff should be educated about the policy changes.

VI. Executive Summary

In this Case Study I have identified that polypharmacy is an ongoing problem that affects as much as 50 percent of older adults, age 65 and older. With the increasing population of older adults in the United Sates healthcare providers should expect to see a greater number of patients with co-morbidities requiring multiple medications to improve and maintain the older adult’s quality of life. Polypharmacy is especially a problem for older adults because of pharmacokinetic and pharmacodynamic changes that occur with aging. It is essential that the healthcare practitioner perform a thorough review of the patient’s medication list and medical record to prevent polypharmacy.

I have looked at a number of solutions with the goal of decreasing polypharmacy. One solution is the development of a Geriatric Resource Nurse program that trains staff nurses to become unit-based resources in geriatric best practice. These nurses would be educated in the most common pharmacokinetics and pharmacodynamic changes that occur with aging and would act as a patient advocate by questioning inappropriate physician orders in an effort to decrease polypharmacy. A second solution is the use of a Geriatric Nurse Practitioner whose multifaceted role would include the reviewing of patient medical records and medication list to recommend changes to physician if polypharmacy is identified. A third solution and the one that I propose will be the most successful is to use a staff pharmacist as a means of decreasing polypharmacy.

A pharmacist has the expert knowledge of pharmacokinetic and pharmacodynamic principles to more accurately identify polypharmacy. The pharmacist would have the dedicated task of evaluating the patient’s medication regimen and medical record and recommending changes to the physician. The pharmacist would be part of the unit’s interdisciplinary team, following the patient throughout his/her hospitalization. This proposed solution would be trialed on a single medical/surgical unit, evaluated for effectiveness, and implemented throughout the hospital after appropriate changes are made to the process. Before the trial is started an Implementation Team will be formed to discuss policy changes, plan how the changes will be implemented, plan staff education, and oversee the implementation process. During the trial, the process will be monitored for strengths and weaknesses. At the end of the trial, the process will be evaluated and changes made if needed. If successful, the process will “rolls-out” to the rest of the nursing units.

Data will be collected and analyzed during the trial to show that the proposed solution is effective in reducing polypharmacy. The Implementation Team will know that the use of a Pharmacist Consult to reduce polypharmacy was successful if the data showed that there was a change in the medications ordered at discharge from those ordered at admission, if the pharmacist recommendations were applied by the physician, and if there was a decrease in the number of poor patient outcomes related to an adverse drug reaction.

References

Dingwall, L., (2007). Medication issues for nursing older people. Nursing Older

People. P25-29.

Edlund, B., (2007). Pharmacotherapy in Older Adults: A Clinician’s Challenge.

Journal of Gerontological Nursing. p.3-4.

Henry, J.D., & Henry, L.G., (2007). Transformational eldercare from the inside

out. Silver Springs, MD: Nursebooks.org.

Joint Commission on Accreditation of Healthcare Organizations’. (2007).

Retrieved October 19, 2007 from http://www.jointcommission.org/Sentinel

Events/SentinelEventAlert/sea_35.htm

Nazarko, L., (2005). The impact of medications on falls. Nursing & Residential Care. p. 208-211.

Reddy, B., (2006). Prescribing in older people. Nurse Prescribing. p. 378-381.

Rocchiccioli, J.T., Sanford, J., Caplinger, B., (2007). Polymedicine and aging: Enhancing older adult care through Advanced Practitioners. Journal of Gerontological Nursing. p. 19-24