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Slide 2 Polypharmacy JENNIFER SCHIERMEYER, KATHIE ODELL, AND TINA KAHN CONCORDIA UNIVERSITY NURSING 430 Slide 3 Polypharmacy defined Polypharmacy is defined as the prescription, administration, or use of more medications than are clinically indicated in a given patient (Tabloski, p. 170). Examples: Medication use without indication Continuing medication after condition is resolved Medication used to treat side effects of other medications Inappropriate dose usage Duplicate medication prescribed by more than one prescriber Generic and brand name medications used concurrently Use of OTC or herbal medications (Tabloski, p. 170) Slide 4 Symptoms of polypharmacy TIREDNESS, SLEEPINESS, DECREASED ALERTNESS CONSTIPATION, DIARRHEA, INCONTINENCE LOSS OF APPETITE CONFUSION FALLS DEPRESSION WEAKNESS TREMORS HALLUCINATIONS ANXIETY DIZZINESS DECREASED SEXUAL BEHAVIOR (PETERSON, 2014) Slide 5 Research Findings Use of one or more inappropriate medications was documented in 128 patients (65%), including 73 (37%) taking a medication in violation of the Beers drugs-to-avoid criteria and 112 (57%) taking a medication that was ineffective, not indicated, or duplicative (Steinman, Landefeld, Rosenthal, Berthenthal, Sen, & Kaboli, (2006). The US General Accounting Office reports significant morbidity and mortality associated with inappropriate polypharmacy. In addition, polypharmacy is recognized as an expensive practice: the US Center for Medicare and Medicaid Services estimates that polypharmacy costs its nations health plans more than $50 billion annually (Berenbeim 2002). Slide 6 Polypharmacy and Cultures o Blacks were found to use complementary and alternative medicines more that whites. o Hispanics were found to be more likely to choose herbal medications to self-treat colds and insomnia than whites or blacks. o More Hispanics chose herbal treatments for insomnia rather then over-the- counter or prescription medications. Tabloski, P., (2013). p. 130. Slide 7 Ethnic Beliefs and Polypharmacy o ASIAN PATIENTS TEND TO EXPECT QUICK RELIEF FROM SYMPTOMS YET ARE CAUTIOUS ABOUT USING AMERICAN MEDICINE; THEY MAY DECREASE DOSAGES TO AVOID EVEN MINIMAL SIDE EFFECTS (GRISSINGER, 2007). o SOME AFRICAN AMERICANS STILL DO NOT HAVE TRUST IN THE HEALTHCARE SYSTEM DUE TO RESEARCH STUDIES WHERE THEIR CULTURE WAS USED. o WOMEN FROM ISLAMIC AND AFRICAN CULTURES WHO HAVE VAGINAL YEAST INFECTIONS MAY PREFER ORAL DRUGS RATHER THAN VAGINALLY INSERTED MEDICATIONS DUE TO CULTURAL TABOOS RESTRICTING INSERTION OF FOREIGN BODIES INTO THE VAGINA (TABLOSKI, P., 2013, P. 130). Slide 8 Nursing Interventions Review all home medications with the patient and/or patients family. Ideally have them bring in all medications for review, a brown bag approach. Review should include medication names, dosages, and reason/indication used. Review patients medical conditions and allergies. Is the medication prescribed by a doctor, or is it an OTC or herbal medication. Ask if the patient is taking the medication as prescribed. Find out if the medication is providing the intended therapeutic effect. Note if the medications are outdated. Are they being stored properly? Does the patient understand the medication use and side effects to report? Is the patient able to afford the prescribed medications? If not, are generic versions less expensive? Note if the patient has physical or cognitive conditions affecting the ability to safely administer medication. Note if there are medications that can stopped and discuss findings with the doctor (Tabloski, p.188). Slide 9 Additional Nursing Interventions 1. Create a list of patient medications with both the generic and trade name, along with medication dosages, times and reason for use. 2. Simplify medication times (e.g. at meals or before brushing teeth at night). 3. Audiotape medication instructions for the visually impaired (Tabloski, 2010, p.183,184). Slide 10 Spiritual Considerations and Polypharmacy A large amount of those working within the healthcare industry use alternative healthcare. According to a study published in Health Services Research, three out of every four health care worker use some form of complementary and alternative medicine including massage, yoga, acupuncture, herbal medicine and prayer. Thats right. Prayer a form of treatment utilized by no less than 49% of the general population and 29% of all medical students (CAM, 2012). Slide 11 Case Study Mrs. Hayden is an 80- year-old woman presenting to the emergency department with a new onset of falls, unsteadiness, dysarthria, and tremor Slide 12 Medication stated by the patient taken daily Her daughter brought in her medication box Alprazolam - increased from 1mg three times daily to 3mg TID in the last three months. Tramadol - increased from 100mg slow release (SR) twice daily (BID) to 200mg BID in the last two months. Dothiepin - commenced 'years ago' but recently increased to 150mg. Olanzepine - 7.5 (should have ceased when Dothiepin commenced but patient may still be taking some). Nitrazepam - 5mg at night as necessary (PRN). Fluoxetine - 20mg BID and 10mg midday. Slide 13 Patient and Family Teaching Assessment Older adults who self-manage their medication regimen (and family members who provide assistance) benefit from knowledge of: Adverse medication reactions. Agings effects on medication action. Alcoholmedication interactions. Possible effects of OTC medications and herbs (Curry, Walker, Hogstel, & Burns, 2005). Prior to teaching self medication we are going to assess if the patient is responsible for administering her own medications, an older adult needs to: have the motivation, knowledge, and skills to follow the recommended medication instructions. recognize the need for regular re- evaluation of their routine. ask nurses and other health care providers questions about their medications. seek assistance when there are adverse or side effects. knowledge to make minor adjustments in their medication routine. Slide 14 Patient and Family teaching We are going to teach our patient and her daughter about the following items for home administration: Storage of medications. Recordkeeping system. Whether they have medications no longer prescribed. Use of daily and weekly medication dispensers. Ask the patient in a teach back method what medications they are taking, what they are for and how they take them. Slide 15 A row of bottles on my shelf Caused me to analyze myself. One yellow pill I have to pop Goes to my heart so it wont stop. A little white one that I take Goes to my hands so they wont shake. The blue ones that I use a lot Tell me Im happy when Im not. The purple pill goes to my brain And tells me that I have no pain. The capsules tell me not to wheeze Or cough or choke or even sneeze. The red ones, smallest of them all Go to my blood so I wont fall. The orange ones, very big and bright Prevent my leg cramps in the nights. Such an array of brilliant pills Helping to cure all kinds of ills. But what Id really like to know.. Is what tells each one where to go! From Bioethics Discussion Board Slide 16 References: Berenbeim, D.M. (2002). Polypharmacy: Overdosing on good intentions. Manag Care Q; 10(3):1-5. Bioethics Discussion Board. Polypharmacy : Is it truly beneficent? Retrieved from: http://bioethicsdiscussion.blogspot.com/2007/03/polypharmacy-is-it-truly-beneficen_11.html http://bioethicsdiscussion.blogspot.com/2007/03/polypharmacy-is-it-truly-beneficen_11.html Curry, L., Walker, C., Hogstel, M., & Burns, P. (2005). Teaching older adults to self-manage medications: preventing adverse drug reactions. Journal Of Gerontological Nursing, 31(4), 32-42 Grissinger, M., (2007). Cultural diversity and medications safety. Pharmacotherapy and Therapeutics. Retrieved from http://www.nipcweg.com/Meication_Errors.pdf http://www.nipcweg.com/Meication_Errors.pdf Mario, V., Hartmann, C., Poston, S., Liu-Chen, X., Diamond, J., & Arenson, C. (2006, May-June). Potentially inappropriate prescribing for elderly patients in two outpatient settings. American Journal of Medical Quality, 21(3), 162-168. Nelson, E., Complementary and alternative medicine (CAM). (2012). Retrieved from: http://www.norcalcs.org/2012/06/alternative-to-polypharmacy.html http://www.norcalcs.org/2012/06/alternative-to-polypharmacy.html Peterson, E. (2014). Aging gracefully: reducing the risks of polypharmacy. Northwest surgicare an affiliate of SCA. Retrieved from http://www.northwestsurgicare.com/apps/HealthGate/Article.aspx?chunkiid=45329http://www.northwestsurgicare.com/apps/HealthGate/Article.aspx?chunkiid=45329 Steinman, M.A, Seth Landefeld, C., Rosenthal, G.E., Berthenthal, D., Sen, S., and Kaboli, P. J. (2006). Polypharmacy and prescribing quality in older people. Journal of the American Geriatrics Society, 54: 1516-1523. doi: 10.1111/j.1532- 5415.2006.00889.x Tabloski, P. (2010). Gerontological nursing. (2 nd ed). Upper Saddle River, NJ. Pearson Tabloski, P. (2013). Gerontological Nursing. Upper Saddle River, New Jersey. Pearson Education Inc.