HPSO 2006 Webflash
The 2006 issue of HPSO Risk Advisor addresses the special challenges of treating elderly individuals. One of these challenges is protecting them from the potential health and liability pitfalls inherent in taking multiple drugs-polypharmacy. Many elders require a variety of drugs to manage multiple health problems. But, the same polypharmacy that keeps so many elderly people functioning well also carries a high degree of risk for adverse drug events (ADEs). These events can result from drug interactions and inappropriate dosing to physiological differences in the way elderly patients process drugs or the stage of the disease. Though protecting the elderly from ADEs is a basic responsibility of pharmacists and primary care providers (PCPs), all healthcare providers have an obligation to be alert for possible adverse reactions, and to report observations and suspicions to the patient's PCP and/or pharmacist.
Scope of the problem
The typical elderly patient is taking two to six prescription
medications a day, plus a variety of OTC products and dietary
supplements.1 Many studies have shown that suboptimal prescribing,
whether related to polypharmacy, underutilization of drugs or taking
inappropriate drugs, is common in elderly patients and is associated
with significant morbidity and mortality. Elderly outpatients in the
U.S. suffer from almost 2 million medication-related injuries per
year, close to 40% of which are serious, life threatening or fatal.
What you can do
All healthcare providers should be aware of what medications an
elderly patient or client is taking. Verify that the patient has had
all of his or her prescriptions filled at the same pharmacy, and if
you have any questions about individual drugs or the safety of
combining them, call the pharmacy and the prescriber. You also should
know what nonprescription agents the patient is taking, and make sure
the pharmacist has this information as well. If you suspect an ADE,
ask the patient to consult his or her PCP-and call the provider
yourself. A counselor, for example, might suspect that one drug's
interaction with a psychotropic medication is causing an ADE, while a
physical therapist might question whether a balance problem could be
drug-related.
To protect yourself from liability, never direct a patient who is
already taking multiple medications to take an OTC product. If you
think the OTC agent would be useful, suggest the patient consult his
or her physician. In addition, advise patients using more than one
pharmacy to consolidate all prescriptions, if possible-and to have
the pharmacist there review the drug regimen. Be sure to document
your conversations.
Preventing ADEs and avoiding liability
The pharmacist or other provider who is advising an elderly patient
should start with a "brown bag" checkup, more formally known as a
drug utilization review: Ask the patient to bring in a brown bag with
all the medications he or she is taking-prescription drugs,
OTC remedies and supplements. Check the contents against the Beers
criteria for potentially inappropriate medications, both for all
elderly patients and for those with a particular condition.
Amitryptline (Elavil), for example, is inappropriate for all elderly
patients because of its strong anticholinergic and sedative
properties, while certain diet aids should not be taken by elderly
patients with hypertension.2
Find out, too, how and when the patient takes each medication: Does
he or she understand and follow the instructions on the label?
Sometimes you'll find that the problem rests with the patient, who
misunderstood instructions or failed to follow them. In that case,
provide-or be sure the patient gets-appropriate counseling from a
pharmacist. If the problem rests with the prescribed medication,
however, follow up with the pharmacist-who has a duty under every
state's Pharmacy Practice Act to review the problem with the
prescribing practitioner. Often the prescriber is unaware that the
patient has one or more prescriptions from another caregiver and is
at risk of a potentially dangerous interaction.
The pharmacist may be able to suggest alternative medications to
achieve the desired result (control of hypertension, for example)
safely. In almost every instance, a collaborative approach will
resolve the difficulty. As a last resort, the pharmacist, using the
standard of a "reasonable person," can refuse to fill the
prescription. However the situation is resolved, the pharmacist
should explain any change in medication or dosage. Naturally, the
pharmacist must document all activities he or she takes on the
patient's behalf.
When it comes to the legal and health risks of polypharmacy, the buck
often stops with the pharmacist and the PCP. Nonetheless, if you are
a healthcare provider who works with elderly patients you should do
your best to avoid these pitfalls by staying current with
polypharmacy education so you are alert to the danger signs. Always
report your concerns and always document your actions. Taking every
precaution can help keep your patient safe, and help keep you for
being named in a lawsuit.
REFERENCES
- Laird RD. Polypharmacy in the elderly. http:/coa.kumc.edu/GEC/password/PowerPointPresentations/Polyphar.ppt.
- Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003;163:2716-2724.
