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Reviewing medications in elderly inpatients
By Terri D’Arrigo
Multiple medication use is common among the elderly, and carries inherent risks. Consider that more than 60% of American seniors take at least five drugs, and 17% to 19% take at least 10, according to a 2006 report released by Boston University's Slone Epidemiology Center.
Research also indicates that the risk of adverse drug reactions (ADRs) increases with the number of medications a patient takes. Indeed, ADRs are responsible for nearly 11% of hospital admissions in older adults, according to a 2008 study in The Annals of Pharmacotherapy, and seniors are four times more likely than their younger counterparts to be hospitalized because of ADRs, according to a 2002 study in Pharmacy World and Science.
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Other factors can raise the risk of ADRs for an elderly patient, as well, said Melissa Mattison, MD, FACP, associate chief of the section of hospital medicine at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston. For example, age-related changes in physiology affect the body's ability to metabolize and excrete medications.
“Hepatic blood flow changes, first-pass metabolism may not be as efficient, and other age-related changes occur in the liver thereby influencing the way older patients respond to the same dose or medication as younger patients,” she said. “Many older patients have some degree of chronic kidney disease or impairment. There may be pre-existing cognitive impairment that can also predispose an older patient to neuropsychiatric side effects of medications.”
Then there is the prescribing cascade, Dr. Mattison added. “One medication may cause dizziness, so a different medication is prescribed for dizziness, and so on,” she said. “The more medications a person takes, the higher the risk of developing side effects.”
That many seniors see multiple specialists compounds the problem, but hospitalists are in a position to bring the pieces of a patient's medication puzzle together to form a cohesive whole, said Sarah Hilmer, MD, PhD, head of clinical pharmacology, staff specialist in aged care and associate professor at Sydney Medical School at the University of Sydney, Australia.
“When you see patients in a hospital, it's an opportunity to review all of their medications,” Dr. Hilmer said. “Specialists tend to view patients in terms of what they are treating them for, but hospitalists can see the whole patient.”
Where to begin
Experts agree that one of the best ways to ascertain what a patient is taking is “brown-bagging,” or having the patient or caregiver bring all medications, including supplements and over-the-counter drugs, to the hospital. But there are other options.
“If the person lives in a facility, speak to the nurse there and make sure you have the complete list of medications being dispensed. Ask patients who live at home where they fill their prescriptions, and call the pharmacy,” said Dr. Mattison. “Confirm what you have learned with the patient if he or she is reliable, or with the patient's family/caregiver. And of course, contact the primary care [physician].”
Internists should account for every medication the patient is taking, said Michael Steinman, MD, FACP, associate professor of medicine in geriatrics at the University of California-San Francisco and the San Francisco VA Medical Center. “Match each drug with a condition. If you can't figure out why a patient is taking a drug, there is a good chance it can be withdrawn safely.”
Quite a few medications should be used only with caution in seniors, if not passed over entirely. A 2012 update of the American Geriatric Society's Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is available online. It comprises evidence-based recommendations for medications to avoid in older adults, sorted by organ system or therapeutic category, and includes the rationale for avoidance.
Several classes of drugs should be in the forefront of hospitalists' minds when reviewing a senior patient's medications for possible exclusions, said Jeffrey Farber, MD, ACP Member, associate professor of geriatrics and palliative medicine at the Mount Sinai School of Medicine in New York.
“Proton-pump inhibitors are a big one. A lot of older patients get started on them for one reason or another, and they just keep taking them because no one tells them not to,” he said. “Over-the-counter non-steroidal anti-inflammatories are another. They can worsen hypertension, cause gastrointestinal bleeding, and are generally bad for older people with kidney damage, but a lot of older patients take them for osteoarthritis.”
Then there are drugs that can affect a patient's cognitive ability or physical coordination, increasing the risk for falls. “Those would be anti-cholinergics, long-acting benzodiazepines, anti-psychotics, and, because of the risk of hypoglycemia, anti-hyperglycemics,” Dr. Farber said.
Looking at a senior's medication list with a critical eye is good, but don't make assumptions, Dr. Farber said. “Reach out to the primary care physician. There may be a good reason the patient is on the drug. Outpatient physicians follow their patients longitudinally, and they may have information you're not privy to,” he said.
Then again, the primary care physician may jump on the chance to wean a patient off a drug in a controlled environment, he added. “Don't be surprised if they tell you, ‘Yes, I've been trying to get him [or her] off of that for a while.’”
Collaboration with others on the hospital staff, particularly pharmacists and nurses, is also key, Dr. Steinman said.
“In theory, a physician would be able to take a complete medical history, counsel on medication use, and know the side effects and kinetics of the drugs, but that's not always possible or realistic,” he said. “Take advantage of all members of the health care team. Consult with pharmacists, who are experts in medication use. They can take on medication education. Ask the nurses what symptoms the patient has reported, or what they have observed in the patient.”
Dr. Mattison agreed, and stressed multidisciplinary collaboration across the continuum of care. “Physicians need to talk not only to the nurses at the hospital, but those who work with the patient before and after—such as visiting nurses or nurses, doctors or advanced practice clinicians—at long-term care facilities,” she said.
Computerized prescriber order entry (CPOE) can be particularly useful, she added. “Our CPOE was designed and customized by our hospital system and we published a paper in the [August 9-23, 2010] Archives of Internal Medicine showing a related 20% reduction in medication orders for potentially inappropriate medications (as defined by Beers) in older patients,” Dr. Mattison said.
Although patients are less likely to balk at adjusting medications for which there are tests or measurements that quantify need, such as INRs for anticoagulants, there will be times that hospitalists encounter resistance from patients, the experts said. For example, patients who take sleep aids may feel they need the drugs even though physicians may find lifestyle interventions more appropriate. Or, a patient may have been taking a medication habitually for years and be fearful of the consequences when he or she stops.
“It's important to reach concordance, because if [patients] aren't happy with what you say, they'll just get the medications somewhere else,” said Dr. Hilmer. “Explain the risks as they are relevant to the patient, such as increased risk of falling. Then explain the lack of benefits [of taking] the drug, and offer alternative nonpharmacologic or pharmacologic management strategies.”
The buck stops here
Discharge is a particularly important time to ensure patients aren't being burdened with unnecessary drugs. A large study in the September 2005 Journal of the American Geriatrics Society found that 44% of hospitalized older patients were discharged with at least one unnecessary medication. Unfortunately, many of these drugs are first prescribed in the hospital, noted Dr. Steinman.
“If a patient can't sleep after surgery, we give them something to help them sleep. Then it inadvertently gets added to the discharge list. After that, it's inertia. What one provider starts, another continues,” he said.
Clear communication can go a long way toward avoiding ADRs and other mishaps after discharge, Dr. Farber said.
“About half of hospitalized seniors are at risk for some kind of cognitive impairment, so discharge counseling should include another person, such as a family member or caregiver,” he said. “The discharge summary has to be clear for the primary care physician, as well. The primary care physician might not even know the patient was in the hospital.”
Regardless of whether it's a hospitalist, nurse or pharmacist who does the discharge planning, the priorities are a “warm” handoff where there is discussion among in- and outpatient clinicians, and post-discharge follow-up with the patient.
“Identify those [patients] at highest risk, and ensure they are enrolled in follow-up programs like home care nursing or social work. For others, nurses or pharmacists can call a day or two after discharge,” said Dr. Steinman. “Once the patient leaves, that doesn't mean the hospital is absolved of all responsibility.”
Terri D’Arrigo is a freelance writer in Holbrook, N.Y.
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Hajjar ER, Hanlon JT, Sloane RJ, Lindblad CI, Pieper CF, Ruby CM, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc. 2005;53:1518-23. [PMID: 16137281]
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