a7 rapid fire: implementing medication reconciliation across the continuum - k. white
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To Med Rec and Beyond: Addressing Polypharmacy in the Long-Term Care SettingDr. Keith WhiteClinical lead, medication reconciliation
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Polypharmacy in Long-term Care
A Growing Concernpolypharmacy /poly·phar·ma·cy/ (-fahr´mah-se). 1. administration of many drugs together. 2. administration of excessive medication.
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PolyPharmacy: What We Know
• Average number of meds in LTC = 9• Range of 0 to 55!!!!!
• Affects Quality of Life & Resident Safety• Decreases in:
• Global health• Cognitive function
• Increases in:• Transfers to acute care• Risk of falls
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Adverse Drug Events
• Drug Interactions• Warfarin and antibiotics, PPI’s
• Aricept (donepezil) and anticholinergics• Falls• Delirium• Extra Pyramidal Symptoms (EPS)• Diarrhea
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How Did We Get Here?
• Treating symptoms and numbers• Treating side effects with another pill• Telephone or Faxed based medicine• Lack of evidence for “Chemoprevention”• Discharge from acute care
• No information or explanation provided for medication changes/additions
• Lack of awareness of medications that are anticholinergics
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Medication Reviews for LTC
• Occur every 6 months• Why aren’t they working?
• MRP (most responsible physician) often not present
• Faxed Med Review becomes a scan, rather than an active review
• Easier to start or continue a drug than to stop it• Fear that an adverse event will be correlated
with stopping a medication• Pharmacist lacks authority to makes changes
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Drugs of Concern• Drugs associated with:
• Confusional states • Antipsychotics, Antidepressants, Opioid Analgesics,
Hypnotics• Falls
• Antipsychotics, antidepressants (tricyclics), hypnotics, antihypertensives, hypoglycemics, anticonvulsants, antiparkinson meds, antihistamines
• Bleeding • Warfarin, Antiplatelet Meds
• Indications not or no longer present • Statins, PPIs, Analgesics, Osteoporosis meds,
Antihypertensives, Antianginals, Antipsychotics, Antidepressants
• Significant anticholinergic effects • Antidepressants (tricyclics), Antihistamines
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“Hidden” Anticholinergics•Benadryl (diphenhydramine)•Gravol (dimenhydrinate)•Flexeril (cyclobenzaprine)•Ditropan (oxybutynin)•Cogentin (benztropine)
•Side Effects•Atxia..loss of coordination •Decreased mucus production in the nose and throat; consequent dry, sore throat •Xerostomia or dry-mouth with possible acceleration of dental caries •Cessation of perspiration; consequent decreased epidermal thermal dissipation leading to warm, blotchy, or red skin •Increased body temperature •Pupil dilation (mydriasis); consequent sensitivity to bright light (photophobia) •Loss of accommodation (loss of focusing ability, blurred vision — cycloplegia) •Double-vision (diplopia) •Increased heart rate (tachycardia) •Tendency to be easily startled •Urinary retention •Diminished bowel movement, sometimes ileus - (decreases motility via the vagus nerve) •Increased intraocular pressure; dangerous for people with narrow-angle glaucoma •Shaking
Possible effects in the central nervous system resemble those associated with delirium, and may include:•Confusion •Disorientation •Agitation
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And The List Goes On…..• Euphoria or dysphoria • Respiratory depression • Memory problems[3] • Inability to concentrate • Wandering thoughts; inability to sustain a train of thought • Incoherent speech • Wakeful myoclonic jerking • Unusual sensitivity to sudden sounds • Illogical thinking • Photophobia • Visual disturbances
• Periodic flashes of light • Periodic changes in visual field • Visual snow • Restricted or "tunnel vision"
• Visual, auditory, or other sensory hallucinations[3] • Warping or waving of surfaces and edges • Textured surfaces • "Dancing" lines; "spiders", insects; form constants • Lifelike objects indistinguishable from reality • Hallucinated presence of people not actually there
• Rarely: seizures, coma, and death • Orthostatic hypotension (sudden dropping of systolic blood pressure when standing up suddenly) and significantly
increased risk of falls in the elderly population.[4]
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What Else Do We Know?• Studies show 50% of meds can be stopped
with resultant improvement in global health and cognitive function
• Only 2% of meds need to be restarted due to recurrence of indication
• Physicians, pharmacists, nursing, and family need a solid platform from which to make decisions
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What Is The Right Balance?
• Level of intervention updates important
• Hidden Costs to Nursing/LPN resources
• Important to ask family “What would (resident) want?” rather than
“What do you want?”• Must consider benefit to harm concept
• NNT vs NNH (www.thennt.com)
• Garfinkel algorithm
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“Take one of these out every four hours.”
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DRAFT 23-04-08Medication Rationalization with LTC Residents
14
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Fijate!• When weaning meds, we must be aware of
withdrawal or discontinuation syndromes and not confuse them with recurrence of symptoms
• This process will require close collaboration between physician, pharmacists, nursing and family• Circle of care
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What are we doing in BC?
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What are we doing in BC?• Med Rec at Admission to Long-term Care• Shared Care Committee: Joint BCMA/MoH
Committee• Polypharmacy in Long-term Care Working
Group• Polypharmacy Reduction Initiative prototype
in several geographic areas• Our aim is to provide sites with a solid process to
implement a Polypharmacy Reduction process tailored to their particular needs
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Polypharmacy Reduction Initiative• We are, or will be prototyping a Polypharmacy
Reduction initiative in several geographic areas.
Abbotsford West Kootenay Boundary
Prince George White Rock/SurreyChilliwack South IslandSouth Okanagan
• Each area is different and has, or will soon have various levels of “Enhanced Residential Care Physician” teams
• These teams are essentially created by collaboration between HA’s and Divisions of Family Practice
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QUESTIONS?
“One of the first duties of the physician is to educate the masses not to take medicine.”
Sir William Osler 1849-1919