Unnecesary Medication Use in Long Term Care Facilites


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Meds are a key component in the clinical process.
The guidelines are intended to insure medication use is of value and necessary. T
Significant emphasis is placed on preventing and recognizing adverse drug reactions ASAP.
Consequently, surveyors will expect to see:
Rationale for use, Parameters for monitoring
Prompt recognition and evaluation of new onset problems and conditions worsening
Consideration for dose reduction and discontinuance as appropriate.

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  • Meds are a key component in the clinical process. The guidelines are intended to insure medication use is of value and necessary. T Significant emphasis is placed on preventing and recognizing adverse drug reactions ASAP. Consequently, surveyors will expect to see: Rationale for use Parameters for monitoring Prompt recognition and evaluation of new onset problems and conditions worsening Consideration for dose reduction and discontinuance as appropriate.
  • Excessive doses : given at one time or over a period of time Excessive duration : longer than required or needed Without adequate monitoring : not paying attention to changes or outcomes occurring Without adequate indications for use : failure to establish rationale for use Presence of adverse consequences indicating dose should be reduced or discontinued : Failure to recognize change and / or take action as indicated or needed.
  • In your facility what might you consider as unnecessary and why? UNNECESSARY MEDS ARE D 2 UM
  • DOSE, DURATION, USE, and MONITORING are not in place
  • There are 5 questions to consider to prevent connecting these tags to one another Do the target symptoms warrant medications? Are non-pharmacological interventions in place and relevant? Is medication appropriate to manage the symptoms or condition? Do the intended or actual benefits justify the risk of use? Is there a system in place and to insure these processes are adhered to?
  • 1. ADVERSE DRUG EFFECT: collective b asket term that captures med errors and ADR’s. Statistically: 2 ADE’s /100 residents More than half of adverse drug events may be preventable. ADEs can have different outcomes: worsening of existing condition, or lack of expected improvement. 2. 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 3. Polypharmacy : lots of meds 4. Predicatblitiy: primary concern 5. 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 prescribing , dispensing, administering, or monitoring drug. 5 errors / 100 residents 6. 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 dose meds used with caution. 7. Immediate Jeopardy: H I L K L 8. STANDARDS of PRACTICE: include the various practice regulations in each State, and commonly accepted health standards established by national organizations, boards and councils.
  • Group exercise: From a citation perspective, what are the potential scope and severity of these and why?
  • Pharmacodynamics : The response of the body to the drug ; It is the time course and effect of the drugs on cellular and organ function. With aging there is increased sensitivity R/I > ADR’s and toxcity. Problems tend to occur when two or more drugs together can “add up” to increase effect, magnify or inhibit the effect of the other med. Pharmacokinetics : 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. BOTTOM LINE : Long Term and Maintenance therapy requires dose adjusted reviews especially with acute illness and dehydration.
  • 35% of older persons experience ADEs and almost half of these are preventable. 5 med errors for every100 residents 14% of hip fractures are related to PA med 100 ADE’s for every 100 residents An adverse drug reaction is any unexpected, unintended, undesired, or excessive response to a drug that: Requires discontinuing the drug (therapeutic or diagnostic) Requires changing the drug therapy Requires modifying the dose (except for minor dosage adjustments) Necessitates admission to a hospital Prolongs stay in a health care facility Necessitates supportive treatment Significantly complicates diagnosis Negatively affects prognosis Results in temporary or permanent harm, disability, or death System issues at the facility are a key concern of regulators which gives as pause to determine how Preventable Adverse Drug Effects come about. Occur at Ordering Wrong drug choice PA v. pain med Failure to consider drug interactions pharm v diet Transcription errors Nsg, md, pharm Occurr at Monitoring Failure to order specific monitoring needs: blood test md, pharm, nsg Delayed response or failure to respond to signs & symptoms of toxicity or lab evidence of toxicity: NF system issues, oversight, FU day to day, and qa DRUG CLASSES OF CONCERN; Diuretics, ANTI’s, Hypnotics
  • Start low and go slow. Monitor for potential side effects i.e. mental status changes
  • 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, 4 gatekeepers: direct care, charge nurse, physician, pharmacist 4. Duplication of drug therapy: same class, similar side effects 5. Presence of Adverse Drug Events: predictable verses 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
  • Comprehensive Assessment Based on assessment of 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, increased confusion, delirium Physician Services: Medical Director: Procedures in place to resolve concerns Pharmacy Services:Medical Regimen Review
  • Use as a key to keep surveyors on track and as response criteria on 2567’s . Reactions can be immediate as in anaphylaxis, but generally requires 5 days of treatment, most show by 12 weeks
  • 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 toxcity side effects Idiosyncratic Reaction Complications DRUG / DISEASE INTERACTIONS: exacerbation of the disease by the drug (i.e. anti-cholinergic are the MOSY common cause: glaucoma, BPH, ALTZ, dry eye
  • 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
  • 1. Underuse of medications Untreated indications . The patient has a medical problem that requires drug therapy but is not receiving a drug for that indication. Subtherapeutic dosage . The patient has a medical problem that is being treated with too little of the correct medication. 2 . Overuse of medications Drug use without indication . The patient is taking a medication for no medically valid indication. Overdosage . The patient has a medical problem that is being treated with too much of the correct medication. 3. Use of inappropriate medications Improper drug selection . The patient has a drug indication but is taking the wrong drug, or is taking a drug that is not the most appropriate for the special needs of the patient. 4. Adverse drug reactions, including drug interactions Adverse drug reactions . The patient has a medical problem that is the result of an adverse drug reaction or adverse effect. Drug interactions. The patient has a medical problem that is the result of a drug-drug, drug-food, or drug-laboratory test interaction. 5. Lack of assessment 6. Lack of monitoring 7. Lack of recognition of ADR’s 8. Lack of adherence to drug therapy (patient noncompliance) Failure to receive medication. The patient has a medical problem that is the result of not receiving a medication due to economic, psychological, sociological, or pharmaceutical reasons.
  • Review the current medications : CALL PHARMACIST and ask!. 2. Assess other possible causes for signs and symptoms: PMS/E 3. Validate the drug ordered is the drug given: ck drug, dose, freq against MAR and order 4. Verify that the onset of the event was AFTER drug administration initiated. 5d-12wk 5.Determine the time interval between the beginning of drug treatment and the onset of the event. Does it fit with pharmocdynamics?
  • AVOID the prescribing cascade (example in context).
  • What medications does the resident really need and why?
  • Know and report the meds/dosages resident is taking when requesting orders.
  • Go to next slide for group exercise
  • CMS suspect the drugs, which come with warnings of serious side effects and require careful monitoring, are being overused for people with behavior problems, especially in facilities without the staff or training to first try to calm residents by other means. CAUSES AND CURES: Policies, procedures, protocols Education IDT Team involvement Monitoring: assessment, POC interventions, implementation, effectiveness Created most used meds cheat sheet facts Quick recognition monitoring system
  • The Beers criteria list identifies medications with High risk side effects outweighing any benefit the medication may have at any dose, for any indication Medications to be used with caution at certain doses and for specific indications
  • Altered cognition : Delirium, dementia, catastrophic reactions/task failure, schizophrenia, and mental illness/retardation. Altered emotions: There are different types of depression. Reactive, the most common; Affective, a recurrent mood disorder; Symptomatic/Secondary, related to neurological disease. Disturbances of mood: Emotional labiality precipitated by thoughts, and/or circumstances; or pathological, related to disease processes such as multiple sclerosis or strokes. Physical Illness altering level of consciousness, infection, pain or disfigurement can create behavioral disturbances. The key question: Is the behavior change consistent with physical illness? Drug toxicity: Is the behavior drug induced? Can you make a correlation with drug use and onset of behavior? Don’t be fooled by a lab test that indicates drug is within therapeutic range. Drug toxicity can be present in the elderly despite “normal” lab reports.
  • Aggression offensive = ASSUALTIVE defensive = RESISTIVE Stimulus internal = delusion / hallucination external = environment, light, noise, certain people
  • Amnesia: inability to learn new information. Aphasia: Difficult comprehension; unable to follow instructions; unable to participate in conversation; unable to express need. Apraxia: Loss of ability to do learned motor skills Agnosia: Loss of ability to recognize objects
  • Is there supporting criteria for the drug category being used? If so, Is behavior a threat, distressing or harmful to self or others?
  • Are they high risk Cognitively impaired, psychotic, manic depressive Are they low risk? What are the symptoms? Verbal abuse, physical; abuse, socially inappropriate What is the frequency? What is the severity? What is the ease of alterability?
  • If easily altered and receiving antidepressant are they a candidate for reduction? If not, why not? If so, what is the plan and what are the potential risk? If NOT easily altered and receiving antidepressant how long has med been given? Is there a need to adjustment or change? If not, why? If NOT easily altered and NOT receiving antidepressant are they a candidate? If not why not and what are the risk and concerns? What is the plan for managing?
  • Continued Use? Drug Reduction attempted? If contraindicated record clearly demonstrates why. Are symptoms easily altered? If so, consider length of use & possible reduction program. If not , how long on med? Has there been any improvement? If not new drug is higher dose indicated OR reassess cause factors? Are other psychoactives in use? Has ADR presence / potential investigated?
  • If Use is PRN Is it given pro-actively to facilitate treatment or calm in anticipation of predicable reaction? Is there a care plan in place for this? Is effectiveness noted? Is med used in response to behavior outburst or mood problem? Could that outburst have been anticipated and dealt with non-medically and/or proactively with medication? Is care plan in place? Is there documentation of need and interventions tried prior to administration? Is effectiveness noted? Is there monitoring for adverse effects?
  • Staff training on implication of cognitive loss & CATASTROPHIC RESPONSES. Sensitizing staff to resident perspective. Quality assurance oversight. Drug usage Relationship of functional status to drug use Accuracy of assessment Effectiveness of care plan Staff comprehension of cognitive loss, mood and behavior problems. Develop drug protocols. Effective communication with physician. Accurate assessment and ongoing evaluation. Consistent implementation of the care plan.
  • Unnecesary Medication Use in Long Term Care Facilites

    1. 1. Meeting Professional Standards of Practice DebbieOhl.com Unnecessary Medication Use Debbie Ohl RN, NHA, M.Msc. Ohl & Associates Consultant and Educator MDSCAREPLANBUILDER.com THINKTHETHOUGHTS.com
    2. 2. What are Unnecessary Medications? <ul><li>Excessive doses </li></ul><ul><li>Excessive duration </li></ul><ul><li>Without adequate monitoring </li></ul><ul><li>Without adequate indications for use </li></ul><ul><li>Presence of adverse consequences indicating dose should be reduced or discontinued. </li></ul>DebbieOhl.com
    3. 3. Question <ul><li>In your own words, what do you consider to be unnecessary drugs? </li></ul>DebbieOhl.com
    4. 4. UNNECESSARY MEDS ARE D 2 UM DebbieOhl.com
    5. 5. Regulatory Interrelationships <ul><li>Unnecessary Drug Use </li></ul><ul><li>Antipsychotic Drugs </li></ul><ul><li>Medication Errors </li></ul><ul><li>Drug Regimen Review </li></ul><ul><li>Comprehensive assessment </li></ul><ul><li>Care planning </li></ul><ul><li>Professional standards of practice </li></ul>DebbieOhl.com
    6. 6. <ul><li>Do the target symptoms warrant medications? </li></ul><ul><li>Are non-pharmacological interventions in place and relevant? </li></ul><ul><li>Is medication appropriate to manage the symptoms or condition? </li></ul><ul><li>Do the intended or actual benefits justify the risk of use? </li></ul><ul><li>Is there a system in place to insure these criteria are adhered to? </li></ul>DebbieOhl.com
    7. 7. Key Terms Linked to Unnecessary Med Use <ul><li>ADE : Adverse Drug Effect </li></ul><ul><li>ADR : Adverse Drug Reaction </li></ul><ul><li>Poly-pharmacy </li></ul><ul><li>Predictability </li></ul><ul><li>Medication Errors </li></ul><ul><li>Beers List </li></ul><ul><li>Immediate Jeopardy </li></ul><ul><li>Professional standards of practice </li></ul>DebbieOhl.com
    8. 8. Failure to protect from undue adverse medication consequences and/or failure to provide medications as prescribed. <ul><li>Administration of medication to an individual with a known history of allergic reaction to that medication. </li></ul><ul><li>Lack of monitoring and identification of potential serious drug interaction, side effects and adverse reactions. </li></ul><ul><li>Administration of contraindicated medications. </li></ul><ul><li>Pattern of repeated medication errors without intervention. </li></ul><ul><li>Lack of timely and appropriate monitoring required for drug titration. </li></ul>DebbieOhl.com
    9. 9. DebbieOhl.com 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
    10. 10. Adverse Drug Events <ul><li>Pharmacodynamics : drugs with similar or opposing effects </li></ul><ul><li>Pharmacokinetics : what the body does to a drug </li></ul><ul><li>AD ME </li></ul><ul><li>Absorption </li></ul><ul><li>Distribution </li></ul><ul><li>Metabolism </li></ul><ul><li>Elimination </li></ul>DebbieOhl.com
    11. 11. Preventable Adverse Drug Effects <ul><ul><li>Occur at Ordering </li></ul></ul><ul><ul><li>Wrong drug choice </li></ul></ul><ul><ul><li>Failure to consider drug interactions </li></ul></ul><ul><ul><li>Transcription errors </li></ul></ul><ul><ul><li>Occur at Monitoring </li></ul></ul><ul><ul><li>Failure to order specific monitoring needs </li></ul></ul><ul><ul><li>Delayed response or failure to respond to signs & </li></ul></ul><ul><ul><li> symptoms of toxicity or lab evidence of toxicity </li></ul></ul>DebbieOhl.com
    12. 12. ADE Drugs in Elderly <ul><li>Analgesics </li></ul><ul><ul><li>– Opioid </li></ul></ul><ul><ul><li>– NSAIDS </li></ul></ul><ul><li>Anti-psychotics </li></ul><ul><li>Anti-coagulants </li></ul><ul><li>Anti-histamines </li></ul><ul><li>Anti-convulsants </li></ul><ul><li>Cardiovascular </li></ul><ul><li>Diabetic medications </li></ul><ul><ul><li>– Insulins </li></ul></ul><ul><ul><li>– Oral agents </li></ul></ul>DebbieOhl.com JAMA 2006; 296:1858-1866; AGS 2004;52:1349-1354; NEJM 2003;348:1556-64
    13. 13. Surveyor Assessment <ul><li>Indications / reasons for use. </li></ul><ul><li>Effectiveness, dose. </li></ul><ul><li>Monitoring: drug regimen, response to irregularities. </li></ul><ul><li>Duplication of drug therapy. </li></ul><ul><li>Presence of Adverse Drug Events </li></ul><ul><li>Weight history of note. </li></ul><ul><li>Hydration / intake records of note. </li></ul>DebbieOhl.com
    14. 14. Regulator’s Looking For: <ul><li>Comprehensive Assessment </li></ul><ul><li>Quality of Care </li></ul><ul><li>ADL decline </li></ul><ul><li>Urinary Incontinence’ </li></ul><ul><li>Mental and Psychosocial function </li></ul><ul><li>Physician Services and Visits </li></ul><ul><li>Medical Director </li></ul><ul><li>Pharmacy Services </li></ul><ul><ul><li>Medical Regimen Review </li></ul></ul>DebbieOhl.com
    15. 15. Predictability <ul><li>PREDICTABLE </li></ul><ul><li>Usually dose dependent. </li></ul><ul><li>Most identified prior to marketing. </li></ul><ul><li>Can be due to concomitment disease, drug/drug, and food/drug interactions. </li></ul><ul><li>Rarely life threatening but can produce significant disability. </li></ul><ul><li>UN PREDICTABLE </li></ul><ul><li>Usually not an extension of the known drug properties. </li></ul><ul><li>Generally independent of dose and route of administration. </li></ul><ul><li>Includes idiosyncratic reactions, immunologic or allergic reactions. </li></ul><ul><li>Tend to concentrate in certain body systems: liver, kidneys, and nervous system. </li></ul>DebbieOhl.com
    16. 16. Types of Adverse Drug Reactions <ul><li>Drug / Drug Interactions </li></ul><ul><li>Drug / Nutrient Interactions </li></ul><ul><li>Allergic Reactions / Hypersensitivity </li></ul><ul><li>Drug Toxicity </li></ul><ul><li>Idiosyncratic Reaction </li></ul><ul><li>Complications </li></ul><ul><li>DRUG / DISEASE INTERACTIONS </li></ul>DebbieOhl.com
    17. 17. Minimizing Occurrence <ul><li>Understand pharmacokinetic and pharmacodynamics. </li></ul><ul><li>Monitor drugs with narrow therapeutic range. </li></ul><ul><li>Avoid polypharmacy. </li></ul><ul><li>Know, convey, and document baseline status. </li></ul>DebbieOhl.com
    18. 18. Factors that Produce/ Contribute to Inappropriate Drug Use <ul><li>Under use of medications </li></ul><ul><li>Over use of medications </li></ul><ul><li>Poly pharmacy </li></ul><ul><li>Excessive dose or duration </li></ul><ul><li>Lack of assessment </li></ul><ul><li>Lack of monitoring </li></ul><ul><li>Lack of recognition of ADR’s </li></ul><ul><li>Lack of adherence to drug therapy </li></ul>DebbieOhl.com
    19. 19. Assessing a Possible ADR <ul><li>Review the current medications in use for associations with symptoms or condition change. </li></ul><ul><li>Assess other possible causes for signs and symptoms. </li></ul><ul><li>Validate the drug ordered is the drug given. </li></ul><ul><li>Verify that the onset of the event was AFTER </li></ul><ul><li>drug administration initiated. </li></ul><ul><li>5. Determine the time interval between the beginning of drug treatment and the onset of the event. </li></ul>DebbieOhl.com
    20. 20. Safeguards Prevention of Adverse Drug Reactions <ul><li>Consider any new symptom as a possible ADE before requesting/ administering new medication for the symptom. </li></ul><ul><li>Monitor medication orders for wrong drug choices (high-risk inappropriate medications, drug–disease and drug–drug interactions), wrong dosages, or admin errors. </li></ul><ul><li>Improve prescribing practices by documenting: </li></ul><ul><li>+ indication for initiation of new drug therapy </li></ul><ul><li>+ maintaining a current medication list </li></ul><ul><li>+ documenting response to therapy. </li></ul>DebbieOhl.com
    21. 21. Polypharmacy <ul><li>Concomitant use of multiple drugs, done by simply drug counting. </li></ul><ul><li>Administration of more medications than is </li></ul><ul><li>clinically-indicated. </li></ul><ul><li>34% of all drugs prescribed in the United States are considered unnecessary. </li></ul>DebbieOhl.com 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 .
    22. 22. Possible Impacts of Polypharmacy <ul><li>Adverse drug reactions </li></ul><ul><li>Drug-drug interactions </li></ul><ul><li>Medication errors made up of non-compliance </li></ul><ul><li>Link to 5% of hospital admission </li></ul>DebbieOhl.com
    23. 23. Preventing Polypharmacy Gather information <ul><li>Determine all medications being used. </li></ul><ul><li>Identify meds by generic name & drug class. </li></ul><ul><li>Identify the clinical indication of each medication. </li></ul><ul><li>Know the side effect profile of each medication. </li></ul><ul><li>Identify risk factors for an adverse drug reaction. </li></ul>DebbieOhl.com
    24. 24. DebbieOhl.com Resident Medication Profile Medications (brand and generic) Drug Class Clinical indication Common Side Effects Expected Response
    25. 25. Preventing Polypharmacy Eliminate, Substitute and Simplify <ul><li>Eliminate medication with no therapeutic benefit. </li></ul><ul><li>Eliminate medication with no clinical indication. </li></ul><ul><li>Substitute a safer medication. </li></ul><ul><li>Avoid treating an adverse drug reaction with a drug. </li></ul><ul><li>Use a single drug with an infrequent dosing schedule. </li></ul>DebbieOhl.com
    26. 26. Medication Errors <ul><li>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. </li></ul>DebbieOhl.com
    27. 27. Pharmaceutical Process Where Drug Errors are Most Likely to Occur <ul><li>Prescribing </li></ul><ul><li>Transcribing </li></ul><ul><li>Dispensing </li></ul><ul><li>Administering </li></ul>DebbieOhl.com
    28. 28. DebbieOhl.com Process Causative Problems & Reasons For Potential Solutions Prescribing Transcribing Dispensing Administering
    29. 29. Citations for violations of drug-misuse rules have increased by nearly 40% since 2004, according to CMS. DebbieOhl.com
    30. 30. beers DebbieOhl.com
    31. 31. Psychoactive Medications THINK <ul><li>Why are you using them? </li></ul><ul><li>Consider: </li></ul><ul><ul><li>Interpretive guidelines criteria for use </li></ul></ul><ul><ul><li>Potential benefits </li></ul></ul><ul><ul><li>Potential adverse effects </li></ul></ul><ul><ul><li>Impact on other health conditions </li></ul></ul>DebbieOhl.com
    32. 32. Causes of Behavior Disturbances <ul><li>Altered cognition </li></ul><ul><li>Altered emotions </li></ul><ul><li>Mood disturbances </li></ul><ul><li>Physical illness </li></ul><ul><li>Drug toxicity </li></ul>DebbieOhl.com
    33. 33. Behavioral Disturbance Prompting PA Med Use <ul><li>Aggression </li></ul><ul><li>Is it offensive or defensive? </li></ul><ul><li>Stimulus internal or external? </li></ul>DebbieOhl.com
    34. 34. Cognitive Compromise <ul><li>Amnesia </li></ul><ul><li>Aphasia </li></ul><ul><li>Apraxia </li></ul><ul><li>Agnosia </li></ul>DebbieOhl.com
    35. 35. ALTERED MENTAL STATUS <ul><li>Delirium </li></ul><ul><li>Acute confusion that is reversible. </li></ul><ul><li>Dementia </li></ul><ul><li>Decline in multiple cognitive functions: </li></ul><ul><ul><ul><li>Orientation </li></ul></ul></ul><ul><ul><ul><li>Attention </li></ul></ul></ul><ul><ul><ul><li>memory </li></ul></ul></ul><ul><ul><ul><li>language </li></ul></ul></ul><ul><li>occurring in clear consciousness. </li></ul>DebbieOhl.com
    36. 36. DebbieOhl.com 1. Emotionally Labile 2. Pathological Emotions 3. Catastrophic Reactions Mood Disturbances
    37. 37. Treatment Principles Psychoactive Medications <ul><li>Rule out and/or stabilize medical problems </li></ul><ul><li>Check critical lab work </li></ul><ul><li>Create a list of behavior disturbances that need to be improved. </li></ul><ul><li>Augment therapy if needed. </li></ul><ul><li>Set realistic goals </li></ul><ul><li>Establish routine </li></ul><ul><li>Provide physical clues </li></ul><ul><li>Talk before touch </li></ul><ul><li>1 step commands </li></ul><ul><li>Allow adequate time for medications trial </li></ul><ul><li>Specify and quantify improvement </li></ul>DebbieOhl.com
    38. 38. Behavior Questions <ul><li>What is the behavior; how long does it lasts? </li></ul><ul><li>Are psychoactive medications used? </li></ul><ul><li>Is behavior creating care resistance or is care creating behavior problem? </li></ul><ul><li>What do you believe are the potential causes or contributors to the behavior problem? </li></ul><ul><li>Can the behavior be easily altered? </li></ul><ul><li>If not, why not? </li></ul><ul><li>Has the use of medication been considered? </li></ul><ul><li>Have you evaluated the triggered RAPs and triggered Quality Indicators? </li></ul>DebbieOhl.com
    39. 39. Questions for Behavior & PA Meds <ul><li>What are the symptoms? </li></ul><ul><li>What is the frequency? </li></ul><ul><li>What is the severity? </li></ul><ul><li>What is the ease of alterability? </li></ul><ul><li>If easily altered </li></ul><ul><li>Are they receiving psychoactive meds? </li></ul><ul><li>How long? </li></ul><ul><li>Are side effects present? </li></ul><ul><li>Is a reduction program needed or underway? </li></ul><ul><li>If not easily altered </li></ul><ul><li>Have physical causes been ruled out? </li></ul><ul><li>Might there be drug interactions creating the problem? How do you know? </li></ul><ul><li>Are they receiving Psych meds? How long? Has behavior improved? If not, why not? What now? </li></ul>DebbieOhl.com
    40. 40. Questions for Depression & PA Meds <ul><li>What are the symptoms ? </li></ul><ul><li>If you don’t think these symptoms are mood related, why? </li></ul><ul><li>How have you come to this decision? </li></ul><ul><li>How pervasive? </li></ul><ul><li>How serious? </li></ul><ul><li>How easily altered? </li></ul><ul><li>Are psychoactive, anti-anxiety, hypnotics in use? </li></ul><ul><li>If easily altered & receiving antidepressant are they a candidate for reduction? </li></ul><ul><li>If NOT easily altered and receiving antidepressant </li></ul><ul><li>how long has med been given? </li></ul><ul><li>If NOT easily altered and NOT receiving antidepressant are they a candidate? </li></ul>DebbieOhl.com
    41. 41. Antipsychotic Meds Can you justify use? <ul><li>High Risk : Cognitive Impairment </li></ul><ul><li>Criteria : Harm to self or others; symptoms so distressing impacts ability to function </li></ul><ul><li>Low Risk: major mental illness, psychosis, schizophrenia, manic depression </li></ul><ul><li>Criteria : Supporting Diagnosis </li></ul>DebbieOhl.com
    42. 42. Anti-Anxiety Med Questions <ul><li>Is this a resident demand or clinical need? </li></ul><ul><li>What attempts have been made to address this? </li></ul><ul><li>Is there a risk plan in place? </li></ul><ul><li>Are there adverse effects that can be tied to other problems? </li></ul><ul><li>Is it clinically indicated? If so what are risks, concerns? </li></ul><ul><li>Is documentation in place? </li></ul>DebbieOhl.com
    43. 43. Beers Criteria Anticholinergic Medications <ul><li>Drug classes </li></ul><ul><li>Tricyclic antidepressants </li></ul><ul><li>Antihistamines </li></ul><ul><li>Antispasmodics and muscle relaxants </li></ul><ul><li>Adverse Effects </li></ul><ul><ul><li>• Urinary retention </li></ul></ul><ul><ul><li>• Constipation </li></ul></ul><ul><ul><li>• Confusion, delirium, behavior changes </li></ul></ul><ul><ul><li>• Exacerbation of dementia </li></ul></ul>DebbieOhl.com
    44. 44. Beers Criteria Antihypertensives <ul><li>Principle </li></ul><ul><li>Select agents which act peripherally and are not highly lipophilic </li></ul><ul><li>Preferred </li></ul><ul><li>ACE inhibitors, ARBs, CC blockers, atenolol </li></ul><ul><li>Avoid </li></ul><ul><li>Agents which act centrally or are highly lipophilic </li></ul><ul><ul><li>Methyldopa, clonidine, propranolol </li></ul></ul><ul><ul><li>Short-acting nifedepine </li></ul></ul>DebbieOhl.com
    45. 45. Beers Criteria Antianxiety/ Sedative Agents <ul><li>Principle </li></ul><ul><li>• Select short-acting agents, without active </li></ul><ul><li>metabolites </li></ul><ul><li>Lowest possible dose </li></ul><ul><li>Shortest possible time </li></ul><ul><li>Evaluate need for therapy frequently </li></ul><ul><li>Preferred </li></ul><ul><li>Lorazepam, Triazolam, Zolpidem, Zopiclone </li></ul><ul><li>Avoid </li></ul><ul><li>Diazepam, </li></ul><ul><li>Chlordiazepoxide </li></ul>DebbieOhl.com
    46. 46. Beers Criteria Antipsychotics <ul><li>Principle </li></ul><ul><li>Use least sedating agents </li></ul><ul><li>Minimal anticholinergic effects </li></ul><ul><li>Preferred </li></ul><ul><li>Atypical antipsychotics </li></ul><ul><li>– Risperidone, </li></ul><ul><li>- Olanzapine </li></ul><ul><li>- Ziprasidone </li></ul><ul><li>- Quetiapine, </li></ul><ul><li>- Aripiprazole </li></ul><ul><li>Avoid </li></ul><ul><li>Chlorpromazine </li></ul><ul><li>Perphenazine </li></ul>DebbieOhl.com
    47. 47. Beers Criteria Antidepressants <ul><li>Principles </li></ul><ul><li>Use least sedating agents </li></ul><ul><li>Minimal cardiotoxicity </li></ul><ul><li>Minimal anticholinergic S/E </li></ul><ul><li>Preferred </li></ul><ul><li>SSRIs (Except Fluoxetine) </li></ul><ul><li>SNRI, NRTIs or adrenergic blockers </li></ul><ul><li>Venlafaxine, Duloxetine or mirtazapine </li></ul><ul><li>nortriptyline </li></ul><ul><li>Avoid </li></ul><ul><li>Amitriptyline </li></ul><ul><li>Imipramine </li></ul>DebbieOhl.com
    48. 48. Minimize Unnecessary Drug Use <ul><li>Drug protocols </li></ul><ul><li>Quality assurance </li></ul><ul><li>Communication </li></ul><ul><li>Initial and ongoing assessment </li></ul><ul><li>Care Plan development and implementation </li></ul><ul><li>Gait keeper </li></ul><ul><li>Staff training: </li></ul><ul><ul><li>meds used, dose ranges, side effects, potential complications </li></ul></ul><ul><ul><li>implication of cognitive compromise </li></ul></ul><ul><ul><li>catastrophic responses leading to unnecessary med orders. </li></ul></ul>DebbieOhl.com
    49. 49. Assessment Tools for Benchmarking Behavior <ul><li>Behavior Pathology in Alzheimer's Disease Rating Scale ( BEHAVE-AD), M easures agitation/anxiety, psychosis, aggression, depression, and activity disturbance. </li></ul><ul><li>Cohen-Mansfield Agitation Inventory (CMAI), a questionnaire evaluating agitation. </li></ul><ul><li>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. </li></ul><ul><li>Functional Assessment Staging (FAST), a diagnosis tool for determining the stage of dementia </li></ul>DebbieOhl.com
    50. 50. Assessment Tools for Benchmarking Behavior Cont’ <ul><li>Mini-Mental State Examination (MMSE ), used to evaluate cognition. </li></ul><ul><li>AIMS abnormal involuntary movements associated with antipsychotic drugs. </li></ul><ul><li>NPI neuropsychiatric inventory assessment of psychopathology for dementia and other neuro-psychiatric disorders. </li></ul><ul><li>CAM: instrument screens for overall cognitive impairment. </li></ul>DebbieOhl.com
    51. 51. DebbieOhl.com <ul><li>REASONS FOR MEDICATION USE </li></ul><ul><li>Cure acute illness </li></ul><ul><li>Arrest or slow disease process. </li></ul><ul><li>Decrease or eliminate symptoms. </li></ul><ul><li>Prevent a disease or symptom. </li></ul><ul><li>Therapeutic or enabling for a resident </li></ul><ul><li>with chronic mental or physical problems. </li></ul>The FUNDAMENTAL ISSUES to be addressed in CMS guidelines the lack of clear, solid clinical rational for use of the specific medication identified .