Medication: Best care for older people everywhere - The toolkit - Victorian Government Health Information, Australia

Medication

Five facts everyone should know about medication
Why is medication important for older people in hospital?
What do I need to consider about an older person's medication?
How can I recognise problems with medication?
How can I help with medication management for older people in hospital?
What should I consider when planning discharge to help an older person manage their medication?
What can patients, families or carers do to help an older person manage their medication in hospital and at home?
Case study

Five facts everyone should know about medication

Medication reconciliation should be performed on admission for every inpatient.

High-risk patients should be reconciled as a priority. They include those aged over 75 who have been prescribed medications that require close monitoring, are on five or more medications, have cognitive or sensory impairment, manage their own medications and have been recently discharged from hospital.

Prescribing medications to older people must be carefully planned and monitored because age-related changes, as well as the risks of polypharmacy, predispose older people to adverse drug reactions.

Non-adherence to medication instructions is common among older people and may be related to several factors.

Medications may be implicated in older patients presenting with falls, confusion and incontinence.

Why is medication important for older people in hospital?

Medication errors are implicated in 15-22 per cent of unplanned hospital admissions [17].
Medication errors are a leading factor in injuries sustained by hospitalised patients [18].
Medications may be implicated in older patients presenting with falls, confusion and incontinence [19].
Experience from organisations has shown that poor communication of medical information at transition points (interfaces) is responsible for more than 50 per cent of all medication errors in the hospital [18] and up to 20 per cent of all adverse drug events [20].
Australian studies have reported that an average of five to seven medication changes are made during the hospitalisation of an older person [19].
Medication may impact on, or relate to, other functional domains.

General Practitioners (GPs) frequently fail to receive timely information, and discharge summaries may contain errors in up to 73 per cent of cases [19].

An up-to-date and accurate medication list is essential to facilitate safe prescribing in any setting [26]. This results in a number of organisational challenges including the:

Need for clear ownership of the process.
Need for standardised processes.

To minimise functional decline in hospital, clinical decision-making regarding medication must be communicated to all members of the patient's health care team, including the patient and their family or carers at every transition point (interface) of care [19].

What do I need to consider about an older person's medication?

Prescribing medications to older people must be carefully planned and monitored because age-related changes in pharmacokinetics (the way by which a drug is absorbed, distributed, metabolised and eliminated by the body), as well as the risks of polypharmacy (combining medications), predispose older people to adverse drug reactions.

Important factors that affect medication metabolism in older people.

Factors to consider:

potentially inappropriate medications
polypharmacy
adherence
under-prescribing.

Potentially inappropriate medications

In an attempt to reduce the frequency of adverse drug events, several methods have been developed to assess the appropriateness of medications for older people. The Beers Criteria includes a consensus-based list of medications identified as potentially inappropriate for use in older adults. The list was developed through extensive literature review and evaluated by recognised experts in geriatric medicine, clinical pharmacology and psychopharmacology in the United States (US). In the US, the application of the criteria has become a widely used measure of quality of medication care for older people [21].

Although it is important to prevent harm, the Beers Criteria list is extensive and includes many commonly prescribed medications. Further work has been completed targeting 'high alert' medications. These are medications with the highest risk of causing injury, and it is predicted that targeting these medications could prevent more adverse drug events and emergency department visits. These medications include warfarin, insulin, digoxin, narcotics, opiates and sedatives [21-23].

Further information

Beers Criteria for potentially inappropriate medication use in the elderly.

Prevent harm from high-alert medications: Getting started kit.

Polypharmacy

Given the higher prevalence of disease in older people, it is not uncommon for older people to be taking several medications. As a result, the risk of adverse medication effects and interactions is higher.

Be aware that patients may be taking medications from a number of sources:

Different doctors and hospitals.
Self-prescribed, over the counter medications.
Medications for a previous illness.
Medications prescribed for another person.

Domiciliary medication review may be necessary to confirm exactly what is being taken.

Adherence

Non-adherence to medication instructions is common among older people and may be related to several factors. Estimates of non-adherence in international literature range from 44-95 per cent [19].

Reasons provided by older people for non-adherence [19]:

Intentional non-adherence

Side effects.
No perceived need for medication or dose prescribed.
Taking too many medications.
Concerns about dependence.
The medication is ineffective.
Stopping medication to see if it is still needed.
Going out for the day (especially diuretics).
Cost/affordability.

Unintentional non-adherence

Forgetfulness.
Running out.
Difficulty reading labels, opening containers, halving tablets, or using medication devices.
Confusion about medication regimes.

Communication problems

Lack of information about the medication and side effects from the prescriber.
Failure to discuss non-medication treatment options.
Lack of explanation about the reasons for dosing regimen and special instructions.
Lack of time spent with health professionals.
Failure by health professionals to communicate instructions in a way the patient understands.
Conflicting information from prescriber and pharmacist.
Antagonism between prescriber and pharmacist.

Under-prescribing

Under-use of medications is also common [19]. Under-prescribing can be difficult to identify. For example, one of the most common chronic conditions associated with emergency department visits is chronic obstructive pulmonary disease, however, it has been identified that optimal treatment is prescribed in only 30 per cent of older people [22].

How can I recognise problems with medication?

A Medication Risk Screen (MRS) can assist in the identification of factors that put older people at risk of adverse events relating to medications. As there were no validated screening tools identified, MRS was developed using the best available evidence and pre-existing risk screen tools as guides [23-25].

The MRS is a self-administered medication risk screening tool comprising of ten 'yes/no' questions, with simple and relevant patient information on the back.

The MRS aims to:

Encourage dialogue with health professionals around medications.
Encourage patients and family or carers to be recognised partners in decision making and communication relating to medications.
Not require assistance from health professionals to be completed.

Further information

Medication risk screen.

How can I help with medication management for older people in hospital?

An up-to-date and accurate medication list is essential to facilitate safe prescribing in any setting [26].

Preventing adverse drug events: Toolkit.

Medication history and reconciliation

Medication history and reconciliation is the formal process of obtaining a complete and accurate list of each patient's medications. The Society of Hospital Pharmacists of Australia (SHPA) recommends processes be in place to ensure medication reconciliation is performed on admission for every inpatient [27].

This involves four steps:

Medication history - which includes recording all medications being taken at the time of presentation, GP and pharmacy details, the source of the information, any adherence issues and any other relevant information.
Confirmation - the process of ensuring the accuracy of the information.
Reconciliation - the process of comparing various medication lists to avoid errors in transcription.
Medication liaison - the process of ensuring continuity of care by establishing effective communication lines between care providers and sites.

Safer Systems Saving Lives (SSSL) recommends that participating hospitals utilise the National Inpatient Medication Chart (NIMC) to support this process [26].

Further information

National In-patient Medication Chart (NIMC) [29].

Refer to Medication safety: Improvement toolkit.

The NIMC was developed by the Australian Council for Safety and Quality in Health Care as part of the National Medication Safety Breakthrough Collaborative [28].

Medication changes tool

Enables clinical staff (medical, pharmacy and nursing) to record all medication changes in a single place, co-located with other medication related forms such as the NIMC.

Is a partner document to the Medication History and Reconciliation (MHR) form.

Medication changes tool.

As part of the medication reconciliation process, it is important to establish formal mechanisms that support the sharing of information between health professionals both within the hospital and in the community [26]. When medication liaison occurs it is important for it to be clearly documented. Pharmacists, doctors or nurses can complete this documentation. As pharmacists are usually the most prepared to complete medication reconciliation, it is recommended they also complete the Medication changes tool. This can greatly enhance the clarity of communication, especially for patients with complex medications and where multiple changes have been made.

The National Institute for Health and Clinical Excellence (NICE) [30] recommends that:

All health care organisations put policies in place for medication reconciliation on admission and at transfer points.
Systems for medications reconciliation be standardised.
Pharmacists complete the most accurate history and medication reconciliation.

There is insufficient evidence to make recommendations on specific packages for medication reconciliation or IT-based information transfer initiatives. There are, however, many examples of MHR tools from both Australia and overseas.

Further information

Examples of medication history and reconciliation tools:

Medication reconciliation tool: On admission definitions [31]

Medication safety reconciliation tool kit [32]

Prevention of adverse drug events (Medication reconciliation): Updated how-to guide [20]

Medication history and reconciliation.

For organisations who wish to develop their own document, the Society of Hospital Pharmacists of Australia recommends minimum details to be included on the form [27].

Technical patient safety solutions for medicines reconciliation on admission of adults to hospital.

What should I consider when planning discharge to help an older person manage their medication?

Will the patient be able to manage his or her own medications?
Will there be adherence issues?
Provide the patient, and family or carers, with an accurate list of medications.
Provide education to patients prior to discharge.
Where possible, include the family or carer in education.
Ensure the patient has a sufficient supply of medications until their next GP visit.
Ensure discharge information is accurate and reaches the GP in a timely manner.
Consider home medication review.

Further information

For information on home medication review, refer to Medication Management Review Program.

What can patients, families or carers do to help an older person manage their medication in hospital and at home?

The back of the Medication Risk Screen provides simple messages that assist patients and carers manage medications at home and encourage self-determination and partnership with their health care providers.

The most important messages to convey to patients and carers are:

Always carry an up-to-date list of medications.
Wherever possible, use only one pharmacy and visit only one GP.

These actions encourage continuity of care through partnerships with everyone involved in the care of the older person.

The National Prescribing Service (NPS) is an Australian member-based organisation that provides accurate, balanced, evidence-based information and services to health professionals and the community on quality use of medicines (QUM). The NPS works in partnership with GPs, pharmacists, specialists, other health professionals, government, the pharmaceutical industry, consumer organisations and the community. It is independent, non-profit and funded by the Australian Government Department of Health and Ageing. Free information on QUM is available on-line or in hard copy by contacting the NPS. Information is provided for both health professionals and consumers. A medicines list can be downloaded from the site or sent to consumers.

Further information

The National Prescribing Service.

Case study

Mrs Hayden is an 80-year-old woman presenting with a new onset of falls, unsteadiness, dysarthria, and tremor. Following a recent fall, she sustained a distal radius fracture. She has a past history of long-standing depression, anxiety and panic disorder and chronic lower back pain.

Mrs Hayden was widowed 15 years ago, has no children or close relatives and lives alone. She is a self-funded retiree and uses no services. She attends church every Sunday, but rarely goes out apart from shopping.

On a previous admission Mrs Hayden had been described as 'non-compliant' with medication. She had been visiting several doctors and had not always followed instructions. Medication changes had been made by different doctors without consultation with the original prescribers.

On admission her medications were:

Alprazolam - increased from 1mg three times daily (TDS) to 3mg TDS in the last three months.
Tramadol - increased from 100mg slow release (SR) twice daily (BD) to 200mg BD in the last two months.
Dothiepin - commenced 'years ago' but recently increased to 150mg nocte.
Olanzepine - 7.5 nocte (should have ceased when Dothiepin commenced but patient may still be taking some).
Nitrazepam - 5mg at night (nocte) as necessary (PRN).
Fluoxetine - 20mg BD and 10mg midday.

Scenario 1

Mrs Hayden was admitted to the Orthopaedic Unit for a general anaesthetic manipulation and plaster (GAMP) to repair her fractured radius. Her anticipated length of stay was two to three days.

Mrs Hayden complained of severe pain post operatively. Her analgesics were increased by adding Oxycontin 10 mg BD to the Tramadol. Her pain did not improve and the dose was increased to 20 mg BD. On day two of her admission, she developed acute urinary retention, for which a urinary catheter was inserted. By day four, she had developed abdominal pain. An x-ray confirmed faecal impaction, which was managed with a series of enemas and Lactulose BD. She found the Lactulose unpalatable, so Coloxyl with Senna was added as a PRN order. On day five she complained of dysuria. A urine sample was collected for microscopy and culture, which showed an infection. Her urinary catheter was removed, and she was commenced on Cephalexin 500mg four times a day (QID). During the admission, Mrs Hayden was referred to several units for consultation, resulting in multiple medication changes.

Mrs Hayden was discharged home on day six, with home help and Meals on Wheels arranged to support her. Her discharge medications included changes to some of her admission medications, and the addition of three new medications (Coloxyl with Senna PRN, Oxycontin 20 mg BD, and Cephalexin 500 mg QID).

Mrs Hayden was readmitted two days later with a fractured neck of femur. She had been found, by Meals on Wheels staff, after having spent 24 hours on the floor unable to reach the phone. She had developed serotonin syndrome and had become severely constipated again. She had an extended length of stay and suffered significant functional decline, resulting in decreased mobility and increasing episodes of incontinence. She was eventually discharged to residential care.

Scenario 2

Utilising the following strategies from The toolkit:

Identification and management of risk factors contributing to medication issues.

Use of Medication history and reconciliation process within one working day of admission to ensure that prescribed medications are accurate and identify any potential issues with other key stakeholders.

Use of a clear hospital policy that guides management of medication.

Interdisciplinary assessment and management of medication issues.

Medication changes and reasons for same communicated to the General Practitioner and all other prescribing medical practitioners.

Referral for home medication review.

Use of patient education materials.

Comprehensive discharge education to the patient concerning medications and the reasons for their use, including information concerning medications that have been newly prescribed, dosage changed or ceased.

Mrs Hayden was admitted to the Orthopaedic Unit for a GAMP to repair her fractured radius. The admitting intern assessed possible causes for her fall and suspected they could be related to her medications. The intern referred her to the ward pharmacist as a priority for a Medication history and reconciliation (MHR). Her anticipated length of stay was two to three days.

The MHR was completed and documen29 March, 2010en had the following risk factors:

She was older than 75 years.
Taking multiple medications.
More than one treating doctor.
Multiple medication changes over recent months.
High-risk medications with potential adverse interactions with other prescribed drugs.
Non-adherence with medications.

While Mrs Hayden was in theatre, the ward pharmacist contacted the community pharmacist and the GP. The community pharmacist confirmed that Mrs Hayden had multiple prescribers and specialists who often gave conflicting advice. The GP agreed with the suspected non-adherence with medications, and stated that Mrs Hayden has been become increasingly withdrawn over the past several years since she had been widowed.

The pharmacist alerted the medical team to the medication issues. Following consultation with medical staff, Fluoxetine, Dothiapen and Tramadol were all ceased due to the risk of serotonin syndrome and the perceived lack of efficacy. It was arranged that Mrs Hayden would have a washout period of 14 days and then commence on Mirtazepine 15mg at night, with a view of increasing the dosage to 30 mg if required. The Nitrazepam was ceased and other sleep hygiene measures discussed. Alprazolam was decreased due to a risk of drowsiness contributing to falls. The Olanzapine was also ceased as it was not indicated for Mrs Hayden. Paracetamol was introduced as baseline pain relief with Oxycontin 10mg BD. Endone was prescribed for breakthrough pain and a regular dose of Coloxyl with Senna established. Nursing staff were alerted to asses and manage her bowel function and use Lactulose PRN. Calcium was commenced to manage her risk of osteoporosis.

As she recovered from surgery, Mrs Hayden's pain was monitored closely. The pharmacist and doctor made a time to discuss her medication with Mrs Hayden once she had recovered from the anaesthetic. It was considered extremely important to involve Mrs Hayden in her medication management, especially because there had been so many changes to her regimen.

Mrs Hayden recovered well with careful monitoring and reassurance. She was discharged home on day three with home help and Meals on Wheels arranged to provide support at home. On discharge, the pharmacist counselled Mrs Hayden concerning her medications and decided to refer her for an outreach medication review. Mrs Hayden was provided with an up-to-date list of her medications and arrangements made for her medications to be delivered in a Webster pack. Hospital staff discussed ongoing plans with her GP and local pharmacist, and the medication changes and rationale for these changes were clearly documented on her discharge letter.

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