FinalPerniciaro Slides - MemberClicks

8/22/19

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Performing a Patient’s Medication Regimen

Review

Paul G Perniciaro, BS Pharm, R. Ph. BCGP, FASCPPresident /Director of Consultant ServicesPerniciaro and Associates Senior Care Consultants

Disclosure and Conflict of Interest

Paul G Perniciaro has no personal or financial conflicts of interest to disclose.

Pharmacist Objectives

At the conclusion of this program, the pharmacist will be able to:

1. Discuss how to perform a medication regimen review.

2. Identify patients at risk for adverse drug reactions.

3. Outline ways to communicate the care plan with the care team, patient, and caregivers.

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If its’s not broke, don’t fix it

What’s Important to You• Clinical Outcomes

• Error Free Survey

• Improved Patient Quality of Life

• Satisfied Patient

• Satisfied Staff• Satisfied Family Members

• Healthcare Costs

Resources for our Toolkit

• Agencies

• Organizations

• Quality Measures• State and Federal Regulations

Resources for our Toolkit (cont.)

• Patient history with other institutions

Re-hospitalization

Emergency Room Visits

• National Standards

• Clinical Guidelines

• Disease State Management

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Resources for our Toolkit (cont.)

• 2019 Updated Beers Criteria1

• Start and Stopp2

1. By the 2019 American Geriatrics Society Beers Criteria®

Update Expert Panel2. PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.

Know Your patient

What information is needed to perform a medication review for your patient?

Information to Collect

• Gender• Age• Allergies• Diagnoses• Immunization list• Weight and Height• Vitals- BP,P, Resp, Temp• Labs

• Medication List• Patient Testimonials• Care Giver Testimonials, • Assessments: Fall, Gait, Skin, Nutritional, Psych,..

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What is Considered Geriatric?

It’s no surprise that the older people get, the longer they think it takes for a person to reach old age.

• On average, adults between the ages of 30 and 49 think old age begins at 69.

• People who are currently 50-64 believe old age starts at 72.

• Responders who are 65 and older say old age begins at 74.

O'Brien, S. (2019, May 23). How Do You Define "Old Age," Anyway? Retrieved from http://www.liveabout.com/when-does-old-age-begin-2969194

What is Considered Geriatric?

Experts agree individuals 65 or older

What Age Is Considered Geriatric? (n.d.). Retrieved from https://www.reference.com/health/age-considered-geriatric-18c176adc291f168

“Any symptom in an elderly patient should be considered a drug side effect until proven

otherwise.”

-J- Gurwitz et al. Brown UniversityLong Term Care Quality Letter, 1995

“Medications are probably the single most important health care technology in

preventing illness, disability, and death in the geriatric population.”

-J Avorn. “Medication Use and the Elderly; Health Affairs Spring 1995

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An Unnecessary Drug is:

• given in excessive dose• for excessive duration• without adequate monitoring....or..• without adequate indications for use....or..• in the presence of significant adverse side effects

Patient: Male DOB: 8/31/1949 Age: 69 HT: 71 inchesAllergies: Ginseng Siberian

Diagnosis List

VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE PARKINSON'S DISEASEBENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMSMAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURESGENERALIZED ANXIETY DISORDERPERIPHERAL VASCULAR DISEASE, UNSPECIFIEDUNSPECIFIED SEQUELAE OF UNSPECIFIED CEREBROVASCULAR DISEASERESTLESS LEGS SYNDROMEPSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITIONATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORISESSENTIAL (PRIMARY) HYPERTENSIONCEREBRAL INFARCTION, UNSPECIFIED

Namenda Tablet 10 MG (Memantine HCl) --Give 1 tablet by mouth two times a day related to VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCEEscitalopram Oxalate Tablet 20 MG Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURESCoreg Tablet 6.25 MG (Carvedilol) Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION Depakote Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day for Behaviors related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION Famotidine Tablet 20 MG Give 1 tablet by mouth at bedtime for heart burnAspirin Tablet 81 MG Give 1 tablet by mouth in the morning for CADGuaifenesin Liquid Give 10 cc by mouth every 4 hours as needed for congestion Sennosides-Docusate Sodium Tablet 8.6-50 MG Give 2 tablet by mouth at bedtime for ConstipationMirapex Tablet 1.5 MG (Pramipexole Dihydrochloride) Give 1 tablet by mouth three times a day for Parkinson’sFurosemide Tablet 40 MG Give 1 tablet by mouth one time a day for edemaFlomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth in the evening for Urinary retentionFinasteride Tablet 5 MG Give 1 tablet by mouth one time a day for benign prostatic hyperplasiaCarbidopa-Levodopa Tablet 25-250 MG TAKE 1 TABLET BY MOUTH FOUR TIMES A DAY forParkinson's DiseaseAricept Tablet 5 MG (Donepezil HCl) Give 5 mg by mouth at bedtime for DementiaAmLODIPine Besylate Tablet 5 MG Give 5 mg by mouth one time a day for HTN

Medication Regimen Review Should Include:

• Diagnosis• Reason for Use• Duplication of Therapy• Appropriate Use• Allergies• Drug Interactions

• Appropriate Labs• Blood Pressure/Pulse• Efficacy• Side Effects• Medication Toxicity

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Consider…

• What do we look at?• What information do we have or need?• Medication changes?• Labs?• Add on medications?• Discontinue medications ?• Is the patient stable?• Is the medication regimen in need of changes?

Namenda Tablet 10 MG (Memantine HCl) --Give 1 tablet by mouth two times a day related to VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCEEscitalopram Oxalate Tablet 20 MG Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURESCoreg Tablet 6.25 MG (Carvedilol) Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION Depakote Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day for Behaviors related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION Famotidine Tablet 20 MG Give 1 tablet by mouth at bedtime for heart burnAspirin Tablet 81 MG Give 1 tablet by mouth in the morning for CADGuaifenesin Liquid Give 10 cc by mouth every 4 hours as needed for congestion Sennosides-Docusate Sodium Tablet 8.6-50 MG Give 2 tablet by mouth at bedtime for ConstipationMirapex Tablet 1.5 MG (Pramipexole Dihydrochloride) Give 1 tablet by mouth three times a day for Parkinson’sFurosemide Tablet 40 MG Give 1 tablet by mouth one time a day for edemaFlomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth in the evening for Urinary retentionFinasteride Tablet 5 MG Give 1 tablet by mouth one time a day for benign prostatic hyperplasiaCarbidopa-Levodopa Tablet 25-250 MG TAKE 1 TABLET BY MOUTH FOUR TIMES A DAY forParkinson's Disease

Aricept Tablet 5 MG (Donepezil HCl) Give 5 mg by mouth at bedtime for DementiaAmLODIPine Besylate Tablet 5 MG Give 5 mg by mouth one time a day for HTN

Behavior Documentation

Note 5/10/19: Resident at the end of the hallway out of his chair on the floor. He was banging on the glass window with his fist. This nurse approached resident and asked him what was wrong. He stated that someone took his cane that his family had brought him and gave it to someone else. I assured the resident that no one took his cane. He said that they had. No further discussion was made about the

cane. Was able to assist x3 back into his chair and direct him to living area to watch TV.

Note 5/1/19 : Resident put himself in the floor and crawled to his doorway. No injuries present, no c/o pain vocalized. Assisted off the floor x3 assist into his

wheelchair.


Note 4/30/19: Reported by care givers they observed resident slide to the floor leaning on the bathroom door Noted injuries to left hand 2 skin tears 1cm by 0.3 cm, 1 by 0.5 cm Abrasion to left posterior back 5 by 0.5 cm, skin tears cleansed

and dressed. Resident said he was not hurt.

Note 4/29/19: Res in Dining room on Unit and res is by window hitting window with R hand. res approached by staff member asking what is wrong and res stated " I want to go to church" Res upset and staff explained to res it is Monday there is

no church service today. Res did draw fist back at staff but did not swing fist towards them. res redirected and later fell asleep in w/c without further incident.

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Note 4/25/19: continues to be aggressive and non-compliant. getting up out of his w/c all throughout the shift, walking very unsteady. encouraged to sit down, explained that he will get hurt and he says he doesn't care. falls on the floor

continuously and gets himself back up.

Note 4/22/19: Note: resident is physically aggressive towards staff, constantly getting out of his w/c and reinforced that he was going to fall and get hurt, he said he did not care. attempted to redirect several times, with no success. put himself

on the floor several times, and grasping onto the w/c.Note 4/6/19: Resident put himself in the floor twice today. No injury and c/o pain.




Note 4/01/19: resident has been ambulating in halls throughout the day and refusing to sit in his chair. At approximately 1530 he grabbed aide by the throat and yelled at

her because she was trying to get him to sit back down. Instructed aide to allow him to ambulate but walk next to him. He told this nurse that he just wanted to walk, stated

that he couldn't do anything right for us.

Fall Note 3/29/19 : Resident got up out of his chair while eating lunch and fell backwards into the heater. He hit his back and then his head. Assessment was

completed. BP 114/68, P 90, Full ROM, no complaints of pain or discomfort, eyes PERRLA . Reddened area to back shoulder and midback. No abrasions or open areas

noted. Will continue to monitor for any changes relating to this incident.

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BP’s 6051/2019 11:25 141 / 91 mmHg Sitting l/arm (Manual)6/04/2019 21:19 134 / 74 mmHg Sitting r/arm (Manual)6/03/2019 10:41 148 / 66 mmHg Sitting l/arm (Manual)6/02/2019 10:41 140 / 66 mmHg Sitting l/arm (Manual)6/01/2019 19:28 132 / 71 mmHg Sitting l/arm (Manual)5/31/2019 10:55 144 / 78 mmHg Sitting l/arm (Manual)5/30/2019 19:17 137 / 77 mmHg Sitting r/arm (Manual)5/29/2019 10:45 155 / 108 mmHg Sitting l/arm (Manual)5/28/2019 10:45 145 / 99 mmHg Sitting l/arm (Manual)5/27/2019 20:26 122 / 67 mmHg Sitting r/arm (Manual)5/26/2019 11:03 119 / 59 mmHg Sitting l/arm (Manual)5/25/2019 11:02 112 / 59 mmHg Sitting l/arm (Manual)

6/05/2019 11:25 76 bpm Regular (Manual)





5/31/2019 10:55 59 bpm Regular (Manual) •Low of 60.0 exceeded










5/21/2019 10:41 52 bpm Regular (Manual) •Low of 60.0 exceeded



5/13/2019 15:41 229.3 Lbs (Manual)4/11/2019 15:39 233.5 Lbs (Manual)3/14/2019 16:15 235.9 Lbs (Manual)

2/6/2019 07:27 230.1 Lbs Wheelchair/Sitting (Manual) •-3.0% change from last weight[ Comparison Weight 1/14/2019, 238.2 Lbs, -3.4% , -8.1 Lbs ]

•-3.0% change over 30 day(s) [ Comparison Weight 1/14/2019,

238.2 Lbs, -3.4% , -8.1 Lbs ]

1/14/2019 09:35 238.2 Lbs (Manual)

12/24/2018 11:36 236.5 Lbs Standing/Wheelchair (Manual)

12/14/2018 15:33 234.2 Lbs Standing (Manual)

Definition of an Adverse Drug Reaction is any unexpected, unintended, undesired, or excessive

response to a drug:• Requires discontinuing the drug• Requires changing the drug therapy• Modifying the dose• Necessitates admission to hospital• Negatively affects prognosis• Prolongs stay in a health care facility• Necessitates supportive treatment• Significantly complicates diagnosis • Results in temporary or permanent harm, disability, or death

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COMPREHENSIVE METABOLIC PANEL

SODIUM 136 mmol/L 136-145POTASSIUM 4.0 mmol/L 3.5-4.9CHLORIDE 99 mmol/L 98-107CO2 23 mmol/L 22-29 CALCIUM 8.8 mg/dL 8.6-10.2

BUN 23 mg/dL 6-20 H CREATININE 1.10 mg/dL 0.67-1.17 GLUCOSE 104 mg/dL 74-99 H TOTAL PROTEIN 7.6 g/dL 6.0-8.3 ALBUMIN 3.9 g/dL 3.4-4.8 BILIRUBIN TOTAL 0.5 mg/dL 0.2-1.0

ALKALINE PHOSPHATASE 88 U/L 40-129AST 13 U/L 12-38 ALT < 5 U/L <41

GFR > 60 mL/min/1.73 sq meter >=60

eGFR has not been validated for use in the elderly (> 70 years of age), pregnant women, patients with serious co-

morbid conditions, or persons with extremes of body size or muscle mass and should also be interpreted with

caution in patients with acute kidney failure, dialysis dependent patients, patients reporting exceptional

dietary intake (e.g. vegetarian diet, high protein diets, creatine supplementation), and patients with severe

liver disease. Based on National Kidney Disease Education Program ** If patient is African American,

please refer to the GFR African American result.

GFR, AFRICAN AMERICAN > 60 mL/min/1.73 sq meter >=60

CBC WITH DIFFERENTIAL

WBC 5.6 K/uL 4.0-9.8 ANC = 3.89 K/uLRBC 4.72 M/uL 4.50-5.40 HEMOGLOBIN 14.0 g/dL 13.6-16.5 HEMATOCRIT 45.2 % 40.0-48.0 MCV 95.8 fL 82.0-99.0

MCH 29.7 pg 27.2-32.6 MCHC 31.0 g/dL 31.5-35.5 L RDW 13.3 % 11.5-14.5 RDW-STDEV 47.1 fL 37.1-48.7 PLATELETS 143 K/uL 140-350MPV 10.3 fL 9.3-12.4

NEUTROPHILS 69 % LYMPHOCYTES 21 %

MONOCYTES 6 %

EOSINOPHILS 2 % BASOPHILS 1 % IMMATURE GRANULOCYTES 0 % NEUTROPHIL ABSOLUTE 3.89 K/uL 1.90-7.00 LYMPHOCYTE ABSOLUTE 1.16 K/uL 0.70-4.50 MONOCYTE ABSOLUTE 0.36 K/uL 0.10-1.30

EOSINOPHIL ABSOLUTE 0.13 K/uL 0.00-0.70 BASOPHILS ABSOLUTE 0.06 K/uL 0.00-0.20 IMMATURE GRANULOCYTES ABSOLUTE 0.02 K/uL0.00-0.03

ANION GAP 14 mmol/L 8-16

HEMOGLOBIN A1C HEMOGLOBIN A1C 5.4 % 4.0-6.0 HEMOGLOBIN A1C EST. AVERAGE GLUCOSE 108 mg/dL HGB A1C INTERPRETATION NORMAL: <5.7% PRE-DIABETES: 5.7 - 6.4% DIABETES: 6.5% OR GREATER

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Identify the Patient at Risk for Adverse Drug Reactions

• 75 years of age or older• Extremely small stature• Polypharmacy• Co-morbidities • New symptoms or changes in overall condition after

modification of therapy• Kidney dysfunction• High risk medication



What Do we look at…

• What information do we have or need?• Medications changes?• Labs?• Add on Medications?• Discontinue medications ?• Is the patient stable?• Is the medication regimen in need of

changes?

American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication (PIMs)

Use in Older Adults

• Widely used by clinicians, educators, researchers, healthcare administrators, and regulators

• Updates on a 3-year cycle that began in 2012• Explicit list of PIMs that are typically best avoided by older adults

in most circumstances or… • Under specific situations, such as in certain diseases or conditions

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• Know the prescribing doctor • Discuss with patient and/or patient’s care team• Know the pharmacy provider and pharmacist filling Rxs• System of notification• Tracking • Follow up• Re-notification

Reporting Irregularities/ Making Recommendations

Assessment Question #1

What information is needed to perform your duties in a medication regimen review?

A) Age of the patientB) Medication listC) Lab resultsD) Diagnosis list E) Caregiver testimonials F) All of the above G) None of the above

Assessment Question #2When making clinical decisions during a medication regimen review on a 75 year old patient, it is important to consider:

a. Beers criteriab. Guidelinesc. Standards of cared. All of the above


Geriatric patients are at risk for adverse drug reactions if they exhibit which of the following?

A. 75 years of age or olderB. PolypharmacyC. Co-morbiditiesD. New symptoms or changes in overall condition after modification of therapyE. Kidney dysfunctionF. None of the aboveG. All of the above

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When making recommendations and reporting irregularities…

a. Have a system of notifications including tracking, follow-up, and re-notification

b. Know the prescribing doctor and pharmacy/pharmacist

c. Know their caregiversd. Know their 5 cats namese. a, b, and c

Speaker Contact Information

Paul G. Perniciaro, BS Pharm, RPh, BCGP, FASCPPerniciaro Senior Care Consultants, Inc.

President, Director of Consultant Pharmacy ServicesChesterfield, MO. 63017

Business/Fax 636-391-7555Email: [email protected]

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FinalPerniciaro Slides - MemberClicks