Prevent Unnecessary Medication Use with D2UM

MDSCarePlanBuilder.com
Meeting Professional
Standards of Practice
Debbie Ohl RN, NHA, M.Msc., Ph.D
Ohl & Associates
Consultant and Educator

What are
Unnecessary Medications?
 Excessive doses
 Excessive duration
 Without adequate monitoring
 Without adequate indications for use
 Presence of adverse consequences
indicating dose should be reduced or
discontinued.

Question
In your own words, what
do you consider to be
unnecessary drugs?

UNNECESSARY MEDS ARE
D2UM
DOSE, DURATION, USE, & MONITORING
ARE NOT IN PLACE

Regulatory Interrelationships
• Unnecessary Drug Use
• Antipsychotic Drugs
• Medication Errors
• Drug Regimen Review
• Comprehensive assessment
• Care planning
• Professional standards of practice

There are 5 questions to consider to prevent
connecting these F-tags to one another
1. Do the target symptoms warrant
medications?
2. Are non-pharmacological interventions in
place and relevant?
3. Is medication appropriate to manage the
symptoms or condition?
4. Do the intended or actual benefits justify
the risk of use?
5. Is there a system in place to insure these
criteria are adhered to?

Key Terms
Linked to Unnecessary Med Use
1. ADE: Adverse Drug Effect
2. ADR: Adverse Drug Reaction
3. Poly-pharmacy
4. Predictability
5. Medication Errors
6. Beers List
7. Immediate Jeopardy
8. Professional standards of practice

Defining Key Terms
ADVERSE DRUG EFFECT:
Basket term that captures med
errors and ADR’s.
• ADEs can have different
outcomes: worsening of existing
condition, or lack of expected
improvement.
• Statistically: 2 ADE’s /100 residents
More than half of adverse drug
events may be preventable.
ADVERSE DRUG REACTION:
• Any unintended response to a drug
that is Harmful / noxious in doses
for diagnosis, prophylaxis, or
therapy.
• High risk med categories:
Psycho tropics, analgesics,
anticoagulants, antibiotics,
cardiovascular

Key Terms cont’
• Polypharmacy : lots of meds
• Predicatblitiy: primary concern
• MEDICATION ERRORS
Any preventable event that can
cause or lead to inappropriate
medication use or patient harm
while the medication is in control of
the health professional.
DAMP: mistakes are related to
dispensing, administering, or
monitoring , prescribing,
5 errors / 100 residents
• BEERS LIST: medication with high
risk side effects that outweigh
benefits of use; meds that are
inappropriate at any dose; specific
meds used at low with caution.
• Immediate Jeopardy: scope
H I L K L
• STANDARDS of PRACTICE:
The various practice regulations in
each State, and commonly
accepted health standards
established by national
organizations, boards and councils.

Failure to protect from undue adverse med
consequences or failure to provide med as prescribed.
1. Administration of medication to an individual with a
known history of allergic reaction to that medication.
2. Lack of monitoring and identification of potential serious
drug interaction, side effects and adverse reactions.
3. Administration of contraindicated medications.
4. Pattern of repeated medication errors without
intervention.
5. Lack of timely and appropriate monitoring required for
drug titration.

Degree of the
Problem
Isolated Pattern Wide-
spread
Immediate
Jeopardy J K L
Actual
Harm G H I
Potential for
Harm D E F
No harm
likely A B C
From a
citation
perspective,
what are the
potential
scope and
severity of
slide 10
failures
and why?

Adverse Drug Events
• Pharmacodynamics:
drugs with similar or
opposing effects
• Pharmacokinetics:
what the body does to
a drug
AD ME
• Absorption
• Distribution
• Metabolism
• Elimination

Pharmacokinetics: ADME
What the body does to a drug
• ABSORPTION: bowel surface
decreases with age and gastric
juices increase.
• DISTRIBUTION: Total body
water decreases 10 to 15%
with aging. Results in possible
higher blood concentrations of
some water-soluble drugs;
• Body weight that is body fat
increases from 18 to 36% in
men and from 33 to 45% in
women. Result is fat soluble
drugs take longer to eliminate.
• METABOLISM: liver mass and
blood flow decrease = harder
to breakdown and eliminate
• ELIMINATION: renal mass
and blood flow decrease =
reduced elimination of drug.

Preventable Adverse Drug Effects
Occur at Ordering
 Wrong drug choice
 Failure to consider drug interactions
 Transcription errors
Occur at Monitoring
 Failure to order specific monitoring needs
 Delayed response or failure to respond to signs &
symptoms of toxicity or lab evidence of toxicity

An adverse drug reaction is any unexpected,
unintended, undesired, or excessive response to a
drug that requires
• Discontinuing the drug (therapeutic or diagnostic)
• Changing the drug therapy
• Modifying the dose (except for minor dosage adjustments)
• Necessitates admission to a hospital
• Prolongs the stay in a health care facility
• Necessitates supportive treatment
• Significantly complicates diagnosis
• Negatively affects prognosis
• Results in temporary or permanent harm, disability, or death

ADE Drugs in Elderly
• Analgesics
– Opioid
– NSAIDS
 Anti-psychotics
 Anti-coagulants
 Anti-histamines
 Anti-convulsants
 Cardiovascular
 Diabetic medications
– Insulins
– Oral agents
JAMA 2006; 296:1858-1866; AGS 2004;52:1349-1354; NEJM 2003;348:1556-64

Surveyor Assessment
1. Indications / reasons for use.
2. Effectiveness, dose.
3. Monitoring: drug regimen, response to
irregularities.
4. Duplication of drug therapy.
5. Presence of Adverse Drug Events
6. Weight history of note.
7. Hydration / intake records of note.

Surveyors assessing for
1. Indications / reasons for use: Assessment and rationale
2. Effectiveness, dose: Baseline, dose range, expected outcome and
time line to see it.
3. Monitoring: drug regimen, response to irregularities: MUST
ESTABILISH BASELINE, Gatekeepers are: direct care, charge
nurse, physician, pharmacist.
4. Duplication of drug therapy: same class, similar side effects.
5. Presence of Adverse Drug Events: predictable v. unpredictable
6. Weight history of note: gain or loss, anorexia, dysphagia /
swallowing problems.
7. Hydration / intake records of note: evaluation of change in
hydration, fluid, electrolyte balance.

Regulator’s Looking For:
• Comprehensive Assessment
Condition, risk, needs, behaviors
• Quality of Care
Lethargy, sedation, bowel problems, sleep disturbance, increased pain
• ADL decline
NEW or rapid decline; decline in function or tolerance
• Urinary Incontinence
Change in function or status
• Mental and Psychosocial function
Change in behavior, depression, mood, agitation, restlessness, confusion, delirium
• Physician Services and Visits
• Medical Director
Procedures in place to resolve concerns
• Pharmacy Services
Medical Regimen Review

Predictability
Reactions can be immediate as in anaphylaxis, but generally
requires 5 days of treatment, most show by 12 weeks
PREDICTABLE
• Usually dose dependent.
• Most identified prior to
marketing.
• Can be due to
concomitment disease,
drug/drug, and food/drug
interactions.
• Rarely life threatening
but can produce
significant disability.
UNPREDICTABLE
• Usually not an extension
of the known drug
properties.
• Generally independent of
dose and route of
administration.
• Includes idiosyncratic
reactions, immunologic or
allergic reactions.
• Tend to concentrate in
liver, kidneys, and
nervous system.

Types of Adverse Drug Reactions
1. Drug / Drug Interactions
2. Drug / Nutrient Interactions
3. Allergic Reactions / Hypersensitivity
4. Drug Toxicity
5. Idiosyncratic Reaction
6. Complications
7. DRUG / DISEASE INTERACTIONS

Prevalence of ADR-related Hospitalizations
ranges from 5% to 35%. ADEs are estimated to cost the health care
system $75 billion to $85 billion annually.
• Drug / Drug Interactions: PHARMACOKINETICS AND DYNAMICS
40% elderly at risk
• Drug / Nutrient Interactions:
• Allergic Reactions / Hypersensitivity
• Drug Toxicity: concurrent use of different drugs with same toxicity
side effects
• Idiosyncratic Reaction
• Complications
• DRUG / DISEASE INTERACTIONS: exacerbation of the disease by
the drug (i.e. anti-cholinergic are the most common cause:
glaucoma, BPH, ALTZ, dry eye)

Minimizing Occurrence
• Understand
pharmacokinetic and
pharmacodynamics.
• Monitor drugs with narrow
therapeutic range.
• Avoid polypharmacy.
• Know, convey, and
document baseline
status.
• The pharmacist is the
primary gatekeeper:
Monthly or more often
(worsening status first 30 days).
• MRR (medication
record review) is
designed to:
– Prevent
– Identify
– Report
– Resolve MRP’s

Factors that Produce/ Contribute to
Inappropriate Drug Use
1. Under use of medications
2. Over use of medications
3. Poly pharmacy
4. Excessive dose or duration
5. Lack of assessment
6. Lack of monitoring
7. Lack of recognition of ADR’s
8. Lack of adherence to drug therapy

Assessing a Possible ADR
1. Review the current medications in use for
associations with symptoms or condition
change.
2. Assess other possible causes for signs and
symptoms.
3. Validate the drug ordered is the drug given.
4. Verify that the onset of the event was AFTER
drug administration initiated.
5. Determine the time interval between the
beginning of drug treatment and the onset of
the event.

Safeguards
Prevention of Adverse Drug Reactions
1. Consider any new symptom as a possible ADE before
requesting/ administering new medication for the
symptom.
2. Monitor medication orders for wrong drug choices (high-
risk inappropriate medications, drug–disease and drug–
drug interactions), wrong dosages, or admin errors.
3. Improve prescribing practices by documenting:
+ indication for initiation of new drug therapy
+ maintaining a current medication list
+ documenting response to therapy.

Polypharmacy
• Concomitant use of multiple drugs, done by
simply drug counting.
• Administration of more medications than is
clinically-indicated.
• 34% of all drugs prescribed in the United States
are considered unnecessary.
References:
Stewarb RB. Polypharmacy in elderly: a fair accompli? DICP 1990; 24; 321-323. Montamat SC,
Cusack B. Overcome the problems with polypharmacy and drug misuse. Clin Geriatr Med 1992; 8:
143-158. LeSage J. Polypharmacy in the geriatric patient. Nurs Clin North Am 1991; 26: 273-287.

Possible Impacts of Polypharmacy
• Adverse drug reactions
• Drug-drug interactions
• Medication errors made up of non-
compliance
• Link to 5% of hospital admission

Preventing Polypharmacy
Gather information
• Determine all medications being used.
• Identify meds by generic name & drug class.
• Identify the clinical indication of each
medication.
• Know the side effect profile of each
medication.
• Identify risk factors for an adverse drug
reaction.

Resident Medication Profile
Medications
(brand and
generic)
Drug
Class
Clinical
indication
Common
Side
Effects
Expected
Response

Preventing Polypharmacy
Eliminate, Substitute and Simplify
• Eliminate medication with no therapeutic benefit.
• Eliminate medication with no clinical indication.
• Substitute a safer medication.
• Avoid treating an adverse drug reaction with a
drug.
• Use a single drug with an infrequent dosing
schedule.

Medication Errors
Any preventable event that may cause or
lead to inappropriate medication use or
patient harm while the medication is in
control of the health professional.

Pharmaceutical Process Where Drug
Errors are Most Likely to Occur
• Prescribing
• Transcribing
• Dispensing
• Administering

Process
Causative Problems
& Reasons For Potential Solutions
Prescribing
Transcribing
Dispensing
Administering

Psychoactive Medications
THINK
• Why are you using them?
• Consider:
– Interpretive guidelines criteria for use
– Potential benefits
– Potential adverse effects
– Impact on other health conditions

Causes of
Behavior Disturbances
• Altered cognition
• Altered emotions
• Mood disturbances
• Physical illness
• Drug toxicity

Behavioral Disturbance Prompting
PA Med Use
Aggression
• Is it offensive or defensive?
• Stimulus internal or external?

Cognitive Compromise
• Amnesia
• Aphasia
• Apraxia
• Agnosia

ALTERED MENTAL STATUS
Delirium
• Acute confusion that
is reversible.
Dementia
Decline in multiple
cognitive functions:
Orientation
Attention
memory
language
occurring in clear
consciousness.

Mood Disturbances
1. Emotionally Labile
2. Pathological Emotions
3. Catastrophic Reactions

Treatment Principles
Psychoactive Medications
1. Rule out and/or stabilize
medical problems
2. Check critical lab work
3. Create a list of behavior
disturbances that need
to be improved.
4. Augment therapy if
needed.
5. Set realistic goals
6. Establish routine
7. Provide physical clues
8. Talk before touch
9. 1 step commands
10. Allow adequate time for
medications trial
11. Specify and quantify
improvement

Behavior Questions
1. What is the behavior;
how long does it lasts?
2. Are psychoactive
medications used?
3. Is behavior creating care
resistance or is care
creating behavior
problem?
4. What do you believe are
the potential causes or
contributors to the
behavior problem?
5. Can the behavior be
easily altered?
6. If not, why not?
7. Has the use of
medication been
considered?
8. Have you evaluated the
triggered RAPs and
triggered Quality
Indicators?

Questions for Behavior & PA Meds
 What are the
symptoms?
 What is the
frequency?
 What is the
severity?
 What is the ease
of alterability?
If easily altered
• Are they receiving psychoactive
meds?
• How long?
• Are side effects present?
• Is a reduction program needed or
underway?
If not easily altered
• Have physical causes been ruled
out?
• Might there be drug interactions
creating the problem? How do you
know?
• Are they receiving Psych meds? How
long? Has behavior improved? If not,
why not? What now?

Questions for Depression & PA Meds
 What are the symptoms ?
 If you don’t think these
symptoms are mood
related, why?
 How have you come to
this decision?
 How pervasive?
 How serious?
 How easily altered?
 Are psychoactive, anti-
anxiety, hypnotics in use?
 If easily altered & receiving
antidepressant are they a
candidate for reduction?
• If NOT easily altered and
receiving antidepressant
how long has med been
given?
 If NOT easily altered and
NOT receiving
antidepressant are they a
candidate?

Antipsychotic Meds
Can you justify use?
High Risk: Cognitive Impairment
Criteria: Harm to self or others; symptoms
so distressing impacts ability to function
Low Risk: major mental illness, psychosis,
schizophrenia, manic depression
Criteria: Supporting Diagnosis

Anti-Anxiety Med Questions
 Is this a resident demand or clinical need?
 What attempts have been made to address this?
 Is there a risk plan in place?
 Are there adverse effects that can be tied to other
problems?
 Is it clinically indicated? If so what are risks, concerns?
 Is documentation in place?

Beers Criteria
Anticholinergic Medications
Drug classes
• Tricyclic antidepressants
• Antihistamines
• Antispasmodics and
muscle relaxants
Adverse Effects
• Urinary retention
• Constipation
• Confusion, delirium,
behavior changes
• Exacerbation of
dementia

Beers Criteria
Antihypertensives
Principle
• Select agents which
act peripherally and
are not highly
lipophilic
Preferred
• ACE inhibitors, ARBs,
CC blockers, atenolol
Avoid
• Agents which act
centrally or are highly
lipophilic
– Methyldopa, clonidine,
propranolol
– Short-acting nifedepine

Beers Criteria
Antianxiety/ Sedative Agents
Principle
• •Select short-acting
agents, without active
metabolites
• Lowest possible dose
• Shortest possible time
• Evaluate need for therapy
frequently
Preferred
• Lorazepam, Triazolam,
Zolpidem, Zopiclone
Avoid
• Diazepam,
• Chlordiazepoxide

Beers Criteria
Antipsychotics
Principle
• Use least sedating agents
• Minimal anticholinergic
effects
Preferred
• Atypical antipsychotics
– Risperidone,
- Olanzapine
- Ziprasidone
- Quetiapine,
- Aripiprazole
Avoid
• Chlorpromazine
• Perphenazine

Beers Criteria
Antidepressants
Principles
• Use least sedating agents
• Minimal cardiotoxicity
• Minimal anticholinergic S/E
Preferred
• SSRIs (Except Fluoxetine)
• SNRI, NRTIs or adrenergic
blockers
• Venlafaxine, Duloxetine or
mirtazapine
• nortriptyline
Avoid
• Amitriptyline
• Imipramine

Minimize Unnecessary Drug Use
• Drug protocols
• Quality assurance
• Communication
• Initial and ongoing
assessment
• Care Plan
development and
implementation
• Gait keeper
• Staff training:
 meds used, dose
ranges, side effects,
potential complications
 implication of cognitive
compromise
 catastrophic
responses leading to
unnecessary med
orders.

Assessment Tools for Benchmarking Behavior
• Behavior Pathology in Alzheimer's Disease Rating
Scale (BEHAVE-AD), Measures agitation/anxiety,
psychosis, aggression, depression, and activity
disturbance.
• Cohen-Mansfield Agitation Inventory (CMAI), a
questionnaire evaluating agitation.
• Clinical Global Impressions (CGI), a rating system
used to evaluate the overall and severity of clinical
change in a patient with various diseases affecting the
brain.
• Functional Assessment Staging (FAST), a diagnosis
tool for determining the stage of dementia

Assessment Tools for Benchmarking Behavior Cont’
• AIMS abnormal involuntary movements
associated with antipsychotic drugs.
• NPI neuropsychiatric inventory assessment of
psychopathology for dementia and other neuro-
psychiatric disorders.
• CAM: screens for overall cognitive impairment.

REASONS FOR MEDICATION USE
• Cure acute illness
• Arrest or slow disease process.
• Decrease or eliminate symptoms.
• Prevent a disease or symptom.
• Therapeutic or enabling for a resident
with chronic mental or physical problems.
The FUNDAMENTAL ISSUES to be addressed in
the CMS guidelines is the lack of clear,
solid clinical rational for use of the specific medication identified.

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Prevent Unnecessary Medication Use with D2UM

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