Medication Management Across the Continuum
Transcript of Medication Management Across the Continuum
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!
416-217-3820x2560
Please advocate for the medication safety needs of our older adults