Issues in Medication Management
Even the simple case of Mrs. Waters highlights several issues in medication management. Be aware of the importance of the following factors that impact assessment and medication management of the older ED patient.
Click on the factors below to learn more.
Physiology of Aging
- Decreased renal function and thus limited ability to clear most drugs.
- Amlodipine is renally excreted (10% unchanged) so its effect is going to be magnified especially in someone with an already increased volume of distribution (peripheral edema).
- Decreased liver function – Calcium Channel Blockers are metabolized by the liver.
- Decreased cardiac function – especially decreased cardiac output.
Generally speaking the decreased physiologic reserve that characterizes normal aging is relevant in all of these cases.
Polypharmacy
Important Note
In the case of Mrs. Waters there are a limited number of medications. So we need to consider not just the number of medications, but other important factors:
- ACE Inhibitors are probably not appropriate in a person with impaired renal function as she ages.
- Amlodipine can increase peripheral edema which is already on her problem list.
In the case of Mr. Martini with his LONG medication list, the possibility of a significant and dangerous drug-drug interaction is very high. Extreme care must be taken in adding or changing a medication in such a high-risk situation. But many of those risks can be mitigated with high-quality communication.
Polymorbidity of Aging
- Cognitive impairment impairs ability to manage new medication/changes. (To learn more about cognitive impairment in the older ED patient, visit the module on Cognitive Impairment.)
- Already impaired cardiac function.
- Already impaired kidney function.
To learn more about atypical presentations in the older ED patient, visit the module on Atypical Presentations.
Communication
- Write things down clearly – getting full understanding from the patient herself is going to be difficult since this involves learning a new task.
- Involve principal care giver(s) – e.g. written communication back to LTCH or in this case to her care-giver such as a family member.
- Send communication to her family doctor – e.g. fax the chart.
- Provide home care referral for a visiting RN or pharmacist to do a medication check.
- Suggest getting her medication in a blister pack from the pharmacist – it is very difficult for a cognitively impaired person to manage multiple medications.
- Use simple language and be consistent – doctorspeak complicates our communication. All patients – not just the elderly – have difficulty with our persistent use of two different words (one generic, one commercial) to refer to the same thing. Find out what the patient calls the medication — “the little blue pill” “my water pill” “furosemide” “lasix” — and then stick with that term.
Discussion: Issues in Medication Management
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GENERAL LANGUAGE
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keeping a list of common drug interactions should be required to have in order to prevent these types of situations.
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Ohk
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Wow
pharmacy consult
this is a great tool to use when available
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Good points
excellent resource
This is helpful
communication is so important
Good points
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good
Always a good idea to consult pharmacy!
polypharmacy is rampant
Every medicine has a side effect or interaction. check them
great
great
polypharmacy
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great
medication management plan are a good way to
like the idea of asking the patient “what they call the pill’
Love the idea of asking the patient what they call the pill…”little blue pill” and refer to the medication as that to ensure clarity in making changes.
very good point
great points
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Pharmacist, always consult them is not sure or lacking knowledge.
great
very useful info
Valuable insights
very important when it comes to medication management
agreed, pt needs to understand instructions
Great ideas
great ideas!
good ideas
very informative
yes
communication is key
Case managers are excellent resources to assist the elderly in managing their care at home. Often rushed PCPs can not spend the time needed to address complicated management issues and deal with the necessary communication processes that are required. This will only get worse with an ever-expanding geriatric population.
team collaboration
Include the pharmacist. Dosage changes needs to communicated to pharmacy so they are included on the record instead of patient being told to “just take half a pill”.
Find out what the patient calls the medication — “the little blue pill” “my water pill” “furosemide” “lasix” — and then stick with that term.
Great Recommendation
ensure understanding
Elderly cannot be expected to understand drug interactions. Therefore it is for Healthcare Professionals to be hypervigelent
The med interaction modules in EHRs in theory should help this but due to alarm fatigue often ends up not helping at all.
being sure patient and care givers understand discharge
good points
interesting
Blister packs are great. However when medication changes are made the blister pack has to be redone or some other compensation made. For instance changing doses of furosemide in heart failure according to patient weight means that daily doses may change and this is difficult with prepacked blister packs. Add in some cognitive impairment and its easy to see why we see patients repeatedly with overdiuresis or worsening heart failure.
Need to consider more how patients call medications, take medications, keep track of medications, and also to keep the main healthcare provider in the loop
Patients with five or more medications are at high risk for drug interactons
multiple strategies must be applied for medication management plan of elderly with drug interaction check. If available a home care referral should be done by a visiting RN to do a medication check and medication administration should be performed under constant supervision or by caregiver.
yes
collaboration with circle of care is important
Faxing the prescription to the pharmacy can be a big help to the elderly population with poor social support
All good recommendations
We need to see more emphasis on DEPRESCRIBING!
Good recommendations. Consider also, a closer relationship with local pharmacist, home care nurse, family or live in care giver, or LTC facility in order to communicate changes to all responsible parties to avoid confusion or inappropriate medicating.
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Pharmacists are underutilized in cases of polypharmacy in our practice setting.
Polypharmacy can also be reduced by attempting non-pharmacological adjuncts to manage symptoms
I agree with the above. Including pharmacy to review medications
The RN visit through CCAC is a good idea too, thanks for bringing that up, as it was not the first thing I thought of.
key factors
beware of long medications lists
undoubtedly!
is there an app for that
I use google
Mhmm, that’s right.
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great
Empiric antibiotics.
My practice is exclusively care of the elderly. I do assess and restore in hospital and frequently admit patients in their 80’s and 90’s on >15 medications. I have a discussion with them on the first day about reducing unnecessary medications during their stay. Polypharmacy is out of control. What frail 90 year old with dementia is getting benefit from their Lipitor 80 mg? I cannot imagine the interactions and side effects possible with so many medications.
Thank you RhondaC! I couldn’t agree more…
Rx files app is very handy, there is also RX files for the elderly i think it was published 2015
yeah, but requires a paid subscription
Great information
its necessary to check interacts whit other drugs to abort de secondary effect
educate patients and make time drug list
do list and choose the necessary medicamenteos
The real need of medications has to be assessed.
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Collaboration wit client/carers/other care providers in the client circle is the key!
great
dose changes need to be monitored
key points are to communicate and thoroughly investigate the persons
Dose changes and new medications need to be reconciled with current medications for interactions.
Patient oriented,team care givers should always be the way to manage patient care.
Written instructions are great as long as the patient is able to read it and understand. Many older people are visually impaired and can’t read the instructions on the bottle so it is important to inform a care giver of the change. Arrange for a dosette to be used or better yet blister packs can be helpful in helping a patient manage medications.
handy advice
I find that written instruction on discharge summary is helpful and increases compliance
pharmacy apps like epocrates include an drug interaction function.
at our LTC facility when we order certain drugs, there is an automatic alert informing us of the patient’s last documented creat-clearance and suggested doses based on this.
When I am concerned or unsure about possible drug-drug interaction or requirement for renal dose adjustment, I request pharmacy consult.
Include the pharmacist. Dosage changes needs to communicated to pharmacy so they are included on the record instead of patient being told to “just take half a pill”.