DebbieOhl.com

Meeting Professional Standards of Practice

Debbie Ohl RN, NHA, M.Msc.Ohl & Associates

Consultant and Educator

MDSCAREPLANBUILDER.comTHINKTHETHOUGHTS.com

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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.

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Question

In your own words, what do you

consider to be unnecessary drugs?

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UNNECESSARY MEDS ARE

D2UM

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Regulatory Interrelationships

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

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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?

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Key TermsLinked 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

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Failure to protect from undue adverse medication consequences and/or failure

to provide medications 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.

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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

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Adverse Drug Events

• Pharmacodynamics: drugs with similar or opposing effects

• Pharmacokinetics: what the body does to a drug

AD ME• Absorption • Distribution • Metabolism • Elimination

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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

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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

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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 Events6. Weight history of note.7. Hydration / intake records of note.

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Regulator’s Looking For:

• Comprehensive Assessment• Quality of Care• ADL decline• Urinary Incontinence’• Mental and Psychosocial function• Physician Services and Visits• Medical Director• Pharmacy Services

– Medical Regimen Review

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Predictability

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 certain body systems: liver, kidneys, and nervous system.

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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

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Minimizing Occurrence

• Understand pharmacokinetic and pharmacodynamics.

• Monitor drugs with narrow therapeutic range.

• Avoid polypharmacy.

• Know, convey, and document baseline status.

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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 duration5. Lack of assessment 6. Lack of monitoring 7. Lack of recognition of ADR’s 8. Lack of adherence to drug therapy

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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.

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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.

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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.

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Possible Impacts of Polypharmacy

• Adverse drug reactions

• Drug-drug interactions

• Medication errors made up of non-compliance

• Link to 5% of hospital admission

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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.

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Resident Medication Profile

Medications(brand and

generic)

Drug Class

Clinical indication

Common Side

Effects

Expected Response

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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.

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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.

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Pharmaceutical Process Where Drug Errors are Most Likely to Occur

• Prescribing

• Transcribing

• Dispensing

• Administering

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ProcessCausative Problems

& Reasons For Potential Solutions

Prescribing

Transcribing

Dispensing

Administering

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Citations for violations of drug-misuse rules have

increased by nearly 40% since 2004, according to

CMS.

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beers

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Psychoactive MedicationsTHINK

• Why are you using them?

• Consider:– Interpretive guidelines criteria for use– Potential benefits– Potential adverse effects– Impact on other health conditions

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Causes of Behavior Disturbances

• Altered cognition

• Altered emotions

• Mood disturbances

• Physical illness

• Drug toxicity

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Behavioral Disturbance Prompting PA Med Use

Aggression

• Is it offensive or defensive?

• Stimulus internal or external?

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Cognitive Compromise

• Amnesia

• Aphasia

• Apraxia

• Agnosia

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ALTERED MENTAL STATUS

Delirium• Acute confusion that

is reversible.

Dementia

Decline in multiple cognitive functions:

OrientationAttentionmemory language

occurring in clear consciousness.

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Mood Disturbances

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

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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

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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?

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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?

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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?

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Antipsychotic MedsCan 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

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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?

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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

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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

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Beers Criteria Antianxiety/ Sedative Agents

Principle• •Select short-acting

agents, without activemetabolites

• Lowest possible dose• Shortest possible time• Evaluate need for therapy

frequently

Preferred• Lorazepam, Triazolam,

Zolpidem, Zopiclone

Avoid• Diazepam, • Chlordiazepoxide

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Beers Criteria Antipsychotics

Principle• Use least sedating agents• Minimal anticholinergic

effectsPreferred

• Atypical antipsychotics– Risperidone,- Olanzapine- Ziprasidone- Quetiapine,- Aripiprazole

Avoid• Chlorpromazine• Perphenazine

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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

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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.

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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

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Assessment Tools for Benchmarking Behavior Cont’

• Mini-Mental State Examination (MMSE), used to evaluate cognition.

• AIMS abnormal involuntary movements associated with antipsychotic drugs.

• NPI neuropsychiatric inventory assessment of psychopathology for dementia and other neuro-psychiatric disorders.

• CAM: instrument screens for overall cognitive impairment.

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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

CMS guidelines the lack of clear,

solid clinical rational for use of the specific medication identified.