Medication Management

Across the Continuum

Chris Fan-Lun, Geriatrics Pharmacist

Through the Looking Glass: Alice’s Adventures

Continue across the Continuum of Care…

Thursday, June 27, 2013

Adverse Drug Event

“any injury caused by the drug and any

harm associated with the use of drug”

• at normal dosage and/or due to overdose

• discontinuation or interruption of drug therapy

Nebeker JR, Barach P, Samore MH. Ann Intern Med 2004; 140:795-801.

Adverse Drug Events (ADEs)

• Most common type of iatrogenic injury

• Predictors – Polypharmacy

– LOS > 14 days

– > 4 active medical problems

• 70-80% ADEs in the elderly are dose related

• Most errors occur at the ordering and monitoring

stages

Carbonin P, Pahor M, Bernabei R et al. J Am Geriatr Soc 1991;39:1093-9

Pharmacokinetics in the Elderly

Aging Physiology and

Pharmacology Parameter Relevance

Hematopoiesis - response under

stress

Chemotherapy

Body composition - lean mass,

adipose, albumin

Drug distribution

Increased drug available to receptor

Liver - mass and flow Hepatic drug metabolism (Phase I)

Kidney - GFR, blood flow, tubular

function

Renal drug clearance

CNS - weight,volume of brain sensitivity to depressant drugs

CNS side effects exagerated

Halter JB, Ouslander JB, Tinetti MB, Studenski S, High KP, Asthana S. ed.

Hazzards’s Geriatric Medicine and Gerontology, 6th ed.

Budnitz DS, Lovegrove MC, Shehab N et al. N Eng J Med 2011;365(21):2002-2012.

Medication Reconciliation

1. Compare

2. Clarify

3. Communicate

4. Reconcile

Imagine…

You come into the hospital wearing…

• a red shirt,

• blue shoes,

• a black belt

• and size 32 grey pants

A Medication Reconciliation Allegory

Mark Kearney, Pharmacist, Queensway Carleton Hospital

You leave the hospital…

• wearing a red dress,

• a blue shirt,

• no belt…

• and a size 32 grey thong!

What Happened?

• Medication error Ordered a grey thong instead of grey pants

Forgot to reorder your belt

• Documentation error Blue a better colour for you so

substituted in place of red shirt

but nobody was told

• No error Everyone told you that you had the

legs for a dress so we replaced your pants

This small white pill is what I munch

at breakfast and right after lunch.

I take the pill that’s kelly green

before each meal and in between.

These loganberry-colored pills

I take for early morning chills.

I take the pill with zebra stripes

to cure my early evening gripes.

These orange-tinted ones, of course,

I take to cure my charley horse.

I take three blues at half past eight

to slow my exhalation rate.

On alternate nights at nine p.m.

I swallow pinkies. Four of them.

The reds, which make my eyebrows strong, I eat like popcorn all day long.

The speckled browns are what I keep beside my bed to help me sleep.

This long flat one is what I take if I should die before I wake.

Polypharmacy by Dr Seuss

Medication Side Effects

hyperthermia

dry mouth

urinary retention

constipation

flushing

blurred vision

delirium

unsteadiness

drowsiness

dizziness

falls

confusion

depression

urinary incontinence

fatigue

malaise

insomnia Anticholinergics

sedatives

antihypertensives

analgesics

statins

AchEI’s

antidepressants anticonvulsants antipsychotics

Review & Rationalize

Medications • Determine therapeutic endpoints and plan for

assessment

• “Deprescribe” agents whenever possible

• Avoid prescribing to treat side effect of another drug

• Start with a low dose and titrate slowly

• Use simplest regimen possible

• Avoid starting 2 agents at the same time

• Reach therapeutic dose before switching or adding agents

• Consider non-pharmacologic options

Updating Medication Lists

• Medication/Immunization Record

Up-to-date medication list with you at

all times

• Multiple Patient Profiles

Easy access to your and your loved

one’s health information

• Dose/Refill Reminder

Reminds you to take your medications

on time and when they need to be

refilled

• Email Information

Keep your healthcare team, family etc.

up-to-date by sending them information

directly

knowledgeisthebestmedicine.org

Summary • Adverse Drug Events - common, serious,

and potentially preventable

• Identify polypharmacy

• Aging is a continuum

– Prescribing must be dynamic

• Tailor therapy

– Monitor for therapeutic/adverse effects

– Re-evaluate medications for chronic illness

Summary

• Incorporate safety processes

– Clear communication

• Eg. Med reconciliation, updated med lists

– Medication review regularly

– Optimize

– Perform “Drugectomy” when indicated

– Consider medication adherence tools

Agenda

1.Home visit for medication review

2.Medication-specific services in the community

3.Safe self-management of medications

Transition to care at home

Home Medication Review

*responsiveness

Community pharmacist

- MedsCheck

Rapid Response Nursing -

CCAC

CCAC Pharmacist

Primary Care - Reconciliation

Medication support in the community – team approach Primary Care – applying geriatric lens to prescribing and working with a patient’s support network to maximize adherence

Organization systems: weekly pill boxes, “blister packs”, bubble packs, services from community pharmacy

Personal Support Workers (PSW) – support ADL, no direct administration

Registered Nurses and Registered Practical Nurses – teaching role, administration, Rapid Response Nursing

Occupational Therapists – facilitate patient to perform daily tasks safely

CCAC pharmacy – focus on homebound older adults and linking with primary care

Compliance Packaging CONSIDERATIONS

Cost

Teaching

Vision/Dexterity

Mid-cycle changes

Compliance Packaging should not facilitate polypharmacy – it should facilitate adherence to the simplest medication regime possible

Safe Self-Management of Medications Keeping an up to date medication list

Medication Administration-type record in the home

Reviewing medication concerns with primary care

Patient should have only 1 pharmacy filling all the medications

Always get advice prior to using over the counter remedies, home based remedies

Summary

Home Visit Medication Reviews are important for older adults taking multiple medications

Medication Reconciliation is important when transitioning between care environments

Safe medication management involves the whole team

Thank you!

norm.umali@toronto.ccac-ont.ca

416-217-3820x2560

Please advocate for the medication safety needs of our older adults