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A Perfect-10 Foundation for Medication Management: Six Choosing Wisely Focus Areas and Four Guiding Principles
Abstract: In an effort to improve health care, the Choosing Wisely campaign has identified common medical practices that should be questioned. Among the more than 500 evidence-based recommendations, more than 110 are medication-related. From these medication-related recommendations, we identified six areas in need of greater provider focus: (1) dementia and behavioral and psychological symptoms of dementia; (2) antimicrobial use; (3) pain management; (4) diabetes management; (5) nutritional management; and (6) screening and polypharmacy. We provide a review of best practices in each of these areas and then provide four guiding principles embodied in four quotations to further guide treatment decision-making in these areas. The following insightful quotations common in the medical field were chosen: (1) “Any symptom in an older adult should be considered a drug side effect until proven otherwise”; (2) “Start low and go slow…but get there”; (3) “A medication only works if the patient takes it”; and (4) “Good geriatrics is a team sport.” By refocusing attention on these six key areas and applying the rationale behind these four quotations, providers can work toward improved medication management and ultimately better outcomes for older adults.
Key words: medication management, adverse drug reaction, polypharmacy
In an effort to improve health care, several national organizations have identified questionable practices in their field and asked health care providers to “choose wisely” before using them.1 Several of the top areas of focus center around medication management, with especially critical implications for post-acute care and long-term care (LTC) providers. This effort, the Choosing Wisely campaign, is an initiative of the American Board of Internal Medicine Foundation in partnership with Consumer Reports that seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures. It has been more than 6 years since its inception in April 2012.1
Among the more than 500 evidence-based recommendations, more than 110 are medication-related.2 For this paper, six Choosing Wisely focus areas have been identified based on their significance and prevalence in the geriatrics and LTC field: (1) dementia and behavioral and psychological symptoms of dementia; (2) antimicrobial use; (3) pain management; (4) diabetes management; (5) nutritional management; and (6) screening and medication management. We offer a review of best practices for managing medications within these areas.
We complete the review by incorporating general guiding principles embodied in the following four medication-related quotations common in the field: (1) “Any symptom in an older adult should be considered a drug side effect until proven otherwise”; (2) “Start low and go slow…but get there”; (3) “A medication only works if the patient takes it”; and (4) “Good geriatrics is a team sport.”
Maintaining focus on these areas with guidance from these principles results in a perfect-10 foundation for post-acute care and LTC providers seeking to improve medication management practices and outcomes for older adults in their care. Providers may consider meeting with a consultant pharmacist to facilitate drug regimen review recommendations and stakeholder education so these best practices and principles can become embedded in the processes of post-acute care and LTC medication management.
Focus Areas for LTC
1. Dementia and Behavioral and Psychological Symptoms of Dementia
Of the 1.3 million people in nursing homes (NHs) and 700,000 in residential care, approximately two-thirds will die with a dementia-related disease.3,4 Behavioral and psychological symptoms occur with all types of dementia and are often among the most prominent symptoms in the clinical course of the disease. Some disturbances, such as agitation and aggression, may be disruptive, distressing, and even life-threatening to patients and the people around them.5 Approximately 30% of the total annual cost of Alzheimer disease (AD) involves the direct management of behavioral and psychological symptoms.4 These symptoms are currently managed by three classes of medications: (1) antipsychotics; (2) benzodiazepines; and (3) acetylcholinesterase inhibitors (AChEIs).
Antipsychotics. Antipsychotic medications and psychosocial interventions are the main methods used to manage behavioral and psychological symptoms of dementia in older adults.6 Atypical antipsychotics showed an efficacy superior to placebo in randomized studies with a better tolerability profile than conventional drugs.7,8 Nonetheless, trials with risperidone and olanzapine in older adults with dementia-related psychosis have suggested an increase in cerebrovascular adverse events.8 Moreover, drug regulatory agencies, such as the Food and Drug Administration (FDA) and the European Medicines Agency, have issued recommendations highlighting the “off-label” nature of using atypical antipsychotics to treat behavioral and psychological symptoms of dementia and have issued warnings to limit such use.9 Conventional antipsychotics, such as haloperidol, have shown the same likelihood as atypical antipsychotics to increase the risk of death in older adults but have still been recommended to replace atypical antipsychotics. Only 10% of antipsychotic medications used for neuropsychiatric symptoms in patients with dementia are fully appropriate.10
For these reasons, the initiation and use of antipsychotics in dementia is an important decision that needs a careful case-by-case assessment. Antipsychotic medications should be reserved for patients with severe symptoms that have failed to respond adequately to nonpharmacologic management strategies.11 Therefore, prescribers must assess possible drug-drug, drug-disease, and drug-food interactions, and evaluate the patient’s baseline corrected QT (QTc) interval, electrolytic imbalances, history of torsade de pointes, concomitant treatments, and use of medications able to lengthen QTc interval.8
If an antipsychotic is warranted, providers should prescribe the minimum effective dose on an as-needed basis. The Medicare and Medicaid Programs; Reform of Requirements for LTC Facilities final or “mega” rule, released in October 2016, suggests reassessment for appropriateness every 14 days.3 Prescribers should receive the patient’s and family’s consents before prescribing when possible and, when appropriate, implement gradual dose reduction. This will eventually count toward the star rating of the facility.
The ultimate goal is to ensure residents with dementia receive appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.3
Benzodiazepines. Although benzodiazepines, alongside antipsychotics and diphenhydramine, are used in the management of behavioral and psychological dementia symptoms, some studies have shown no significant difference in efficacy or tolerability among these active medications. However, one study indicated thioridazine may have better efficacy than diazepam.12 In another study, active medications from all classes of drugs had greater efficacy in treating behavioral and psychological symptoms of dementia compared with placebo.13 Available data, however, do not support the routine use of benzodiazepines for the treatment of behavioral and psychological symptoms of dementia, but only in circumstances in which antipsychotics are unsafe or intolerable. Therefore, prescribers should reassess the appropriateness of their use periodically.13
Acetylcholinesterase Inhibitors (AChEIs). After their relevance was questioned in 2008, AChEIs have demonstrated clear potential to improve or stabilize behavioral and psychological symptoms of dementia in recent studies.14 Treatment response differences have been noted between selective AChEIs (donepezil and galantamine) and dual cholinesterase inhibitors (rivastigmine).15,16 While donepezil has shown efficacy in noninstitutionalized patients with moderate to severe AD, conflicting results have arisen in patients with mild to moderate AD.15,16 In a 5-month study, galantamine delayed the onset of behavioral and psychological symptoms of dementia. But both donepezil and galantamine have yet to demonstrate efficacy in reducing psychotic symptoms or levels of concomitant psychotropic medication use.15 While all agents in this class improve apathy, depression, and anxiety, rivastigmine also improves hallucinations and delusions, possibly as a result of its dual inhibition of acetylcholinesterase and butyrylcholinesterase.17 The presence of hallucinations has been shown to predict response to rivastigmine.17
From a safety prospective, these agents are not totally benign. With cardiovascular and gastrointestinal adverse reactions often in the picture and mounting pressure from family members for providers to prescribe AChEIs for extended periods of time, even up to the time of death, continuous education is paramount.18
2. Antimicrobial Stewardship
Some 4.1 million Americans are admitted to or reside in NHs annually. About 1.6 to 3.8 million infections occur in LTC facilities in the United States every year, with an associated annual cost exceeding $1 billion.19 Over the course of a year, up to 70% of NH residents receive antimicrobials, and as many as 75% of those antimicrobials are prescribed incorrectly in terms of drug choice, dose, duration, and/or indication.20
Clostridioides (Clostridium) difficile infection (CDI) is a serious public health threat in NHs and is associated with increases in mortality and health care costs. Recent estimates cite 240,000 patients with CDI, 46,000 potential deaths, and more than $6 billion in costs.21,22 Although early clinical trials of a C difficile toxoid vaccine show efficacy in preventing CDI mortality, health care utilization and associated costs remain significant following CDI episodes.23 Until a vaccine becomes widely available and affordable, antimicrobial stewardship programs are essential to reduce CDI.24 Successful treatment and containment of CDI can yield significant clinical and economic outcomes.25
Therefore, antimicrobial use is increasingly on surveyors’ radars utilizing F-tag 329 to address unnecessary medications. The mega rule requires facilities to develop an infection prevention and control program focused on preventing, identifying, and observing antimicrobial susceptibility trends in LTC facilities.26 These programs should emphasize investigating and controlling infections and communicable diseases among residents, staff, volunteers, visitors, and other individuals providing services. The program should be reviewed and updated annually.3 Elements of the mandate were implemented in phase 2 on November 28, 2017, and others will be addressed in phase 3 on November 28, 2019.
The Centers for Disease Control and Prevention (CDC) also recommends that NHs adopt and implement its seven core elements of antimicrobial stewardship programs: (1) leadership commitment, (2) accountability, (3) drug expertise, (4) action, (5) tracking, (6) reporting, and (7) education.27
All of the above place clinicians at the forefront.28 Consultant pharmacists, in particular, have a great opportunity to include in their consults not only a comparison of prescribed antimicrobials with available susceptibility reports but also a broader overview of antimicrobial use in the entire facility. A population-based strategy for the development of antibiograms specifically for high-risk patients could better guide appropriate empiric antimicrobial selection in the NH.29 The ultimate goal is to provide a coordinated program that promotes appropriate use of antimicrobial medications, improves patient outcomes, reduces microbial resistance, decreases the spread of infections caused by multidrug-resistant organisms, and reduces adverse drug reactions, drug-drug interactions, and other medication-related problems.30,31 One way to accomplish this goal is through vaccination.
Vaccination. Older adults who live in LTC facilities are at increased risk for infections, eg, NH-acquired pneumonia and community-acquired pneumonia. This could be due to advanced age, decreased immunity, and/or underlying health conditions that lead to increased disease severity and higher mortality rates.32 Older adults admitted to the hospital with NH-acquired pneumonia showed more severe pneumonia at onset, higher rates of potentially drug-resistant pathogens, and worse clinical outcomes compared with older adults with community-acquired pneumonia.32 Living in close quarters and having frequent contact with other residents increases transmission risk. Consequently, vaccination in older adults is an important element of infection control.3
The Choosing Wisely campaign recommends practitioners stress the benefits of vaccination and allay fears and misconceptions. Conversations with patients as well as employees should emphasize that vaccines are safe, pose minimal risk of side effects, and that, in general, their benefits outweigh the risks. Providers should explain that no one can catch a disease from a vaccine. Creative ways to increase staff influenza vaccination rates include using mobile flu carts, accommodating staff on various shifts and weekends, and offering incentives for vaccination.20 The CDC website provides useful vaccination information for both practitioners and patients.
3. Pain Management
A Choosing Wisely recommendation from the American Society of Anesthesiologists states, “Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient.”33 This guidance is based on the belief that patients should be informed of the risks of such treatment, including the potential for addiction. In one study, opioid treatment was discontinued in 48% of cases, mostly because of side effects and a lack of analgesic efficacy.34 Studies like this suggest opioids may be overutilized and unnecessary in some cases.
In the community, physicians and patients should first consider nonpharmacologic interventions for pain. If opioids are deemed appropriate, both parties should review and sign a written agreement that identifies the responsibilities of each (eg, urine drug testing) and the consequences of noncompliance with the agreement. Regardless of the setting, clinicians should be cautious about prescribing opioids with benzodiazepines. They should also proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen.35
4. Diabetes Management
Hemoglobin A1c (HbA1c) goals, sliding-scale insulin, and self-monitoring of blood glucose are common elements of care in older adults with diabetes. Unfortunately, strict control and testing do not necessarily translate to better care or outcomes.
Setting reasonable HbA1c goals consistent with patient goals, health status, and life expectancy is important. Older adults may develop functional limitations and psychological issues, and they may lack social support and access to care—a tetrad often referred to as the four geriatric domains. These factors are of utmost importance when older adults live at home and can negatively affect diabetes self-management and self-efficacy.36 According to Choosing Wisely, reasonable glycemic targets are 7.0% to 7.5% in healthy older adults with long life expectancy, 7.5% to 8.0% in those with moderate comorbidity and a life expectancy of <10 years, and 8.0% to 9.0% in older adults with multiple morbidities and a shorter life expectancy.37
Using the sliding-scale insulin approach only treats hyperglycemia after it has occurred rather than prevents it. This approach requires pre-dose testing of blood glucose leading to potentially 6 or more testings per day. Consequently, patients may be logged more blood glucose readings, which may lead to overtreatment with insulin and eventually risk from prolonged periods of hypoglycemia, precipitating a vicious cycle.16,38 Moreover, risk of hypoglycemia becomes a significant concern because insulin can be administered irrespective of mealtimes. Sliding-scale insulin is neither effective in meeting the body’s insulin needs nor is it efficient in the LTC setting. A better approach may be to use basal insulin, or basal plus rapid-acting insulin, with one or more meals to mimic normal physiologic insulin production and more effectively control blood glucose.39
Contrary to diabetes mellitus type 1, patients with diabetes mellitus type 2 who are not on insulin or medication associated with hypoglycemia obtain no benefit from finger testing to self-monitor blood glucose. In fact, daily glucose testing in these patients comes with a negative economic impact and, potentially, a negative clinical impact. Self-monitoring of blood glucose should be reserved for titration of medication doses or during periods of change in diet and exercise routines in patients with type 2 diabetes not using insulin.40
In summary, providers can assure appropriate diabetes management through establishing a reasonable HbA1c target, advising use of regularly scheduled antidiabetic medications, and by avoiding sliding-scale insulin. Regular self-monitoring of blood glucose is not necessary in stabilized patients with type 2 diabetes not on insulin.
5. Nutritional Management
Food is one of the essentials of life, not only for nourishment of the body but also of the mind and soul. Despite its importance, food is not typically thought of as routine health care and, consequently, is often overlooked by health care providers. All too often, providers fail to recognize the underlying etiology of eating disorders and fall back on medications to stimulate appetite. However, providers should promote oral feeding and rely on appetite stimulants and percutaneous feeding tubes only in rare situations.
Health care providers can also assist older patients in appropriate food intake in light of specific diagnoses. For patients with diabetes, this means limiting carbohydrates, especially sweets. Patients with cardiovascular disease are best served by limiting salt and fluids. Nursing typically takes the lead in educating patients about appropriate food intake and directs the multidisciplinary care team, including environmental services and family.
The bottom line of nutritional intervention is to assist older adults in receiving the beneficial effects of food while avoiding the hidden dangers. This means ongoing education, providing a supportive physical environment, and offering consistent reminders. Through assistance in food choices, older adults can realize the benefits of food, which can result in a higher quality of life and perhaps even less use of medical resources. Appropriate food intake can provide a multitude of benefits.41
6. Screening and Polypharmacy
Choosing Wisely encourages providers to reduce inappropriate screening and testing as well as the use of medications with limited effectiveness and dangerous adverse effects. Clinicians should guard against ordering treatments based on an overestimation of benefits and an undervaluation of risks.
Medication should never be prescribed without first conducting a comprehensive medication review. Older patients disproportionately use more prescription and nonprescription medications than other populations, increasing the risk for side effects and inappropriate prescribing. Polypharmacy can lead to diminished drug adherence, adverse drug reactions, increased risk of cognitive impairment, falls, and functional decline. A medication review can identify high-risk medications, drug interactions, and medications taken beyond their need. A medication review elucidates unnecessary medications as well as underuse of medications, and may reduce medication burden. An annual review of medications is an indicator for quality prescribing in vulnerable older adults.42
Guiding Principles
When tackling medication-related issues in all of the key areas above, providers should strive to keep the following 4 quotations in mind, which succinctly guide providers when faced with challenging situations in medication management in older adults. Below, we examine the implications and ideology behind each quotation and provide examples where applicable.
7. “Any Symptom in an Older Adult Should be Considered a Drug Side Effect Until Proven Otherwise”
Noted geriatrician Jerry Gurwitz, MD, is credited with this quotation, but his wife, pharmacist Leslie Fine, may be the originator of this advice.43 Polypharmacy often results from inappropriate prescribing via a prescribing cascade. When a particular medication regimen is unsuccessful, the health care provider typically prescribes another drug, which is referred to as a prescribing cascade. Polypharmacy and prescribing cascades put patients at increased risk of adverse drug events. Adverse drug events account for 30% of hospital admissions for people aged 65 and older; approximately 106,000 deaths annually are attributed to medication problems including adverse drug reactions. Sadly, 15% to 65% of these events are preventable.44
An example of a prescribing cascade can be seen in the management of one of the most common chronic diseases in the United States, osteoarthritis, which affects 40 million people, the majority of whom are older adults.45 Chronic stiffness and pain from arthritis have an impact on function, prompting the routine use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin products. Long-term use of NSAIDs, however, lowers the prostaglandin level in the gastrointestinal tract, which can cause esophagitis, peptic ulcerations, gastrointestinal hemorrhage, and gastrointestinal perforation.46 In older adults, treatment with histamine-2-receptor blockers or proton pump inhibitors to relieve the adverse effects of aspirin or other NSAIDs may lead to additional side effects, such as confusion and mental status changes, which in turn requires more treatment.47 This illustrates how easily adverse events can snowball into a prescribing cascade in an older patient.
8. “Start Low and Go Slow … But Get There”
The second quotation addresses titration of a medication. It begins with a standard geriatric saying (“start low and go slow”) but add another element (“…but get there”). In other words, prescribers should initiate medications at a low starting dose and titrate slowly, but they should eventually reach the therapeutic dose. This approach prevents adverse events from titrating too quickly at a dose that is too high while also promoting medication use at therapeutic levels.
Unfortunately, electronic prescribing has hampered prescribers by adding steps to order a medication through titration to therapeutic doses. Under a paper system, prescribers could simply write “drug A one tablet q day x 7 days, then one tablet BID x 7 days, then two tablets in the AM and one in the PM x 7 days, then two tablets BID.” But, in an electronic prescribing system, prescribers are forced to write 4 separate orders with the exact start and stop dates for each. As a result, many prescribers simply write the initial dose and delay or even forgo appropriate titration. By adhering to the “start low, go slow…but get there” principle, patients receive the full benefit of their treatment.
9. “A Medication Only Works if the Patient Takes It”
The next quotation comes from C Everett Koop, MD, former Surgeon General of the United States. The phrase, “A medication only works if the patient takes it,” addresses the importance of adherence. After a careful determination of the right medication has been made—and it has been initiated at the right dose for the right duration—assurance of adherence is critical to produce optimal outcomes. A great deal of interventions can assist with adherence.
Adherence can be improved through addressing patient perceptions of cost, concerns, and benefits. Cost-related nonadherence is a common and critical problem for older adults in the outpatient setting who take, on average, 4 to 5 medications each week. Among patients with chronic illness, approximately 50% do not take medications as prescribed.48 Patients who reduce their costs by taking their medications sporadically, splitting pills, or delaying refills do not achieve the full therapeutic benefits of therapy and may be at increased risk of declining health.45
Other behavioral factors that must be addressed include the perceived burden of taking medication, concern about side effects, and failure to understand why the medication is necessary. All can lead to a lack of motivation and commitment. Behavioral factors are just as significant as financial costs and must be addressed. Patients need to fully understand medication benefits and commit to their prescribed therapy. This can be accomplished through providers who are able to educate and motivate patients to comply with their treatment regimen and who consider a patient’s cultural milieu and health care literacy.49
Beyond adherence issues is the problem of forgetting to take medication. Reminders are especially important for patients with cognitive impairment who lack reliable caregivers. Today, a number of reminder aids are available to help patients. Some even enable pharmacists and other providers to monitor and support appropriate adherence.50
10. “Good Geriatrics Is a Team Sport”
The final quotation highlights that a coordinated care team is essential for successful medical care and medication management, such as in the focus areas covered above. “When multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care,” solid teamwork is in play.51 Interprofessional models of care are associated with improved patient outcomes and moving organizational culture and clinician beliefs toward evidence-based practice.52
Medication management does not solely rest in the hands of physicians. Although historically the main prescriber, the physician-prescriber role is increasingly being replaced by nurse practitioners and other prescribers. Beyond prescribers, the nursing staff and certified nurse aides are on the front lines of patient interaction. These critical staff members have opportunities to both educate patients as well as to recognize issues that arise.
Conclusion
These 6 Choosing Wisely focus areas and 4 insightful pharmacologic quotations can help focus and guide post-acute care and LTC providers to improve medication management. These efforts can improve patient outcomes as well as quality measure outcomes of the facilities that serve them.
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