Transcript Effects of Regulations on Medication Management for LTC

F 329
Unnecessary Medications:
Geriatric Principles
Meets Regulations
Charles Crecelius MD PhD FACP CMD
F-tag 329
Unnecessary Medications
• Updated, consolidated
• Incorporates newest geriatric principles
• Written by CMS with advise of leading
geriatricians, pharmacists, nurses
• Associated pharmacy tags
– F428 Medication Regiment Review
• Sets guidance for all – physicians,
pharmacists, homes, surveyors
F 329 Unnecessary Meds Intent
•
•
•
•
•
Meds clinically required to treat a condition
Non-pharmacologic measures used
Medication promotes highest well-being
Avoid actual or potential negative outcome
Negative outcome promptly found / treated
Doesn’t empower surveyor to practice
medicine - should investigate the
basis for decisions and interventions
Key Definitions
•
•
•
•
•
•
•
Adverse consequences & ADR
Behavior interventions
Distressed behavior
Gradual dose reduction
Monitoring
Non-pharmacologic intervention
Psychopharmacological medication
Basic Pharmacologic Principles
•
•
•
•
•
•
•
Promote non-pharmacologic interventions
Indication for use
Select based on individual risk / benefit
Appropriate dose / duration
Avoid duplicative therapy
Monitor efficacy & side effects
Prevention, identification, and response to
adverse consequences
• GDR (gradual dose reduction)
Non-pharmacologic Interventions
• Require:
– assessing and understanding causes for need
of medication
– reduction/elimination of impediments, triggers
and causes:
• Examples
– Modification of environment
– Modification/elimination of psychological
stressors
• Accommodation of previous lifelong
activities or roles
• Modification of staff/resident interactions
• Behavioral Interventions
Individual Risk & Benefit
• Distinct / unique review of needs & goals
• Informed choice
– Condition, options, risk / benefit, outcomes
– Effects refusing treatment
– Regular review
• Can’t refuse physician directed treatment
to treat imminent danger
• Advance directives don’t preclude other
treatment (no code is not no care)
Monitoring Criteria
• Identify essential information
– who collects, how recorded
• Determine frequency of monitoring
– Condition, risk ADR
• Define communication and analysis
– Interdisciplinary team, goal
• Re-evaluate & update plan
– Change meds/conditions/diet
When to Evaluate Medication for
Benefit / Adverse Consequences
•
•
•
•
•
•
•
•
Admit / readmit
Clinically significant change in status
New symptom / problem
Worsening existing problem
Unexpected decline function / cognition
Non specific symptom without cause
New med, review of med, med irregularity
MMRR
Special Considerations
• New Admits
– Justify each med, consider ADR
• New med order as an emergency
– Address underlying cause
– Re-evaluate after acute phase over
• Psychiatric disorder or distressed behavior
– Appropriate diagnosis, seek cause
• Multiple prescribers
GDR
• All Medication Potential Candidates
– When condition stable or improved,
causes target symptoms resolved, nonpharmacologic tx success
– Opportunities
• MMR
• Quarterly MDS Review
• Practitioner review
• Psychopharmacologic medication
– Review & document risk/benefit q 3 months
GDR
• Antipsychotics / non-anxiolytic/sedatives
– 1st year – 2 separate quarters, at least 1
month between
– Annually thereafter
– Unless clinically contraindicated
• Sedatives / Hypnotics
– If used more than 3 times a week
– Attempt taper at least quarterly, 3 out of 4
quarters
– Unless clinically contraindicated
Medications of Particular Relevance
to Long-Term Care
• Broad list of medications with potential
concerns in the elderly & long term care
• Replaces revised “Beer’s list”
• Lists medication class, then specific names
• Ask to consider various factors
Indication
Monitoring
Documentation
Dosage / duration
Adverse consequences
• Documentation proportional to degree
risk/benefit
Surveyor Investigative Protocol
Unnecessary Medications
Non-compliance
• Inadequate indication for use
• Inadequate monitoring
• Excessive dose
• Excessive duration
• Adverse consequences
• Antipsychotic
– Absence of specific condition
– Without behavior intervention & GDR
Deficiency Categorization Examples
• Level 4 Immediate Jeopardy
– INR > 9 with failure to assess / act
– Failure to monitor INR without care plan, staff
knowledge potential problems
– Failure to monitor or dose reduce for
antipsychotic in presence of side effect
– Failure to do non-contraindicated GDR with
resulting tardive dyskinesia while on prolonged
antipsychotics
– Failure to recognize, assess or respond to meds
that caused a GI bleed
Deficiency Categorization Examples
• Level 3 Actual Harm that is not Immediate
Jeopardy
– INR 4-9 with failure to act with bleeding
– Failure to evaluate seizure as a result of other
meds, adding potentially unneeded AED
– Failure to perform GDR resulting in continued
antipsychotic use with decline, adverse effect
Deficiency Categorization Examples
• Level 2 No actual harm with potential for
more than minimal harm
– INR 3.5-9 with failure to act and no bleeding
– Failure to monitor INR, prior stable INR, no
bleeding
– Failure to identify med as cause of rash
– Failure to monitor potential med adverse
effect (e.g. no TSH & on thyroid Rx)
Deficiency Categorization Examples
• Level 1 No actual harm with potential for
minimal harm
– Failure to provide appropriate care & services
to avoid unnecessary meds / minimize
adverse outcomes place residents at risk for
more than minimal harm
– No level 1 severity
The Medical Director & F329
Reducing Medication Related Problems
Individualize approach depending on
problematic areas facility
• Education of Staff & Attendings
• Improve systems which impact medication
management
• Monitor performance & provide feedback
Educational Efforts for Staff
•
•
•
•
•
•
Non-pharmacological Interventions
Top offending medications
GDR Requirements
Monitoring tools / requirements
Targeting frail / declining residents
Common ADR (serotonin syndrome, EPS,
TD, NMS anticholinergic side-effect)
Educational Efforts for Staff
Signs, Symptoms & Conditions Possibly
Associated w/ Medications
•
•
•
•
•
•
•
Anorexia, unplanned weight loss or gain
Behavioral changes, unusual behavior patterns
Bleeding / bruising, spontaneous / unexplained
Bowel dysfunction
Dehydration, fluid/electrolyte imbalance
Depression, mood disturbance
Dysphagia, swallowing difficulty
• Falls, dizziness, impaired coordination
Educational Efforts for Staff
Signs, Symptoms & Conditions Possibly
Associated w/ Medications
• Gastrointestinal bleeding
• Headaches, muscle pain, general nonspecific
aching or pain
• Mental status changes, (new, worsening, delirium)
• Rash, pruritus
• Respiratory difficulty or changes
• Sedation (excess), insomnia, disturbed sleep
• Seizure activity
• Urinary retention or incontinence
System Improvements
Utilization Monitoring Tools
• Physiological, cognitive functional
– Vital signs
– Labs, EKGs, blood sugars, Hgb A1C
– RAI, FAST, IADL, PSMS
– MMSE, CAM, AIMS, FAST
• Mood/Affect
(MDS / QI)
– GDS, Cornell DDS, Mania Rating Scale
• Behavior
(MDS / QI)
– Behave AD, CMAI, NPI-NH
System Improvements
Protime / INR Monitoring
• System-wide use coumadin flow sheets
– Pulled when labs drawn
– Sent to physician for fax adjustment or read to
physician if called
– Contains default orders for common situations
• Set standard protime draw days
• CMT “signs off” new order
• Recap orders require check last protime
Auditing Medication Management
Monitor Indication with Consulting
Pharmacist
• Do target symptoms / causes warrant
therapy
• Could non-Rx interventions be relevant
• Is a particular medication pertinent to
managing symptoms or condition
• Is risk worth benefit
• If prn are circumstances for use clearly
delineated
Auditing Medication Management
Review GDR & Psychopharmacologics
• Triggered with new order; tickler system
for old orders
• Special form of MRR using pharmacist &
medical director
• Placed in front of order section
• Lists requirements of F329, offers tapering
suggestions
• Results audited, presented to attendings
Always consider medication
as a possible problem,
and not just as the solution
Any symptom in an elderly patient should
be considered a drug side effect until
proved otherwise (Gurwitz)
A medication is a poison with a desirable
side-effect (Osler)
Appendix
F329 Unnecessary Medications
Medications of Particular Interest
in Long Term care
Medication Issues of Particular
Relevance to Long-Term Care
• Analgesics
– Acetaminophen
– NSAIDs (Traditional, COX-2)
– Opioids (esp. meperidine)
– Pentazocine
– Propoxyphene (and combinations)
• Antibiotics (all)
– Vancomycin / aminoglycosides
– Nitrofuration
– Fluoroquinolones
Medication Issues of Particular
Relevance to Long-Term Care
• Anticoagulants
– Warfarin
• Anticonvulsants
– All
– Seizure or mood stabalizer
• Antidepressants
– All (class listings)
– MAO inhibitors
– Tricyclics
Medication Issues of Particular
Relevance to Long-Term Care
• Anti-diabetic Medication
– Metformin
– Glitazones
– Chlorpropamide & glyburide
• Antifungals
– Imidazoles
• Anti-manic medications
– Lithium
Medication Issues of Particular
Relevance to Long-Term Care
• Anti-Parkinson medication (all)
• Antipsychotics
– Conventionals
– Atypicals
• Anxiolytics
– Short-acting benzodiazepines
– Long-acting benzodiazepines
– Buspirone
– Diphenhydramine / hydroxyzine
– Meprobamate
Medication Issues of Particular
Relevance to Long-Term Care
• Cardiovascular medications
– Antiarrhythmics (amiodarone,
disopyramide)
– Antihypertensives - All
– Methyldopa
– Digoxin
– Diuretics
– Nitrates
Medication Issues of Particular
Relevance to Long-Term Care
• Cholesterol lowering medicines
– Statins
– cholestyramine
• Cognitive enhancers
• Cold, cough and allergy medication
– All
– H1 blockers
– Oral decongestants
Medication Issues of Particular
Relevance to Long-Term Care
• Gastrointestinal medications
– GI antispasmotics
– Phenothiazines, trimethobenzamide
– Metoclopramide
– Proton pump inhibitors
• Glucocorticoids
• Hematinics
– Erythropoiesis stimulants
– Iron
Medication Issues of Particular
Relevance to Long-Term Care
•
•
•
•
Laxatives
Muscle relaxants
Orexigenics (appetite stimulants)
Osteoporosis medications
(biphosphonates)
• Platelet inhibitors
– Salicylates
– Ticlopidine
– Clopidogrel
Medication Issues of Particular
Relevance to Long-Term Care
• Respiratory medication
– Theophylline
– Inhalants
• Sedative / hypnotics
– All
– Barbituates
• Thyroid medication
• OAB medication All
Medications with Significant
Anticholinergic Properties
•
•
•
•
•
•
•
•
•
Antihistamines
Respiratory (ipratropium)
GI drugs
Tricyclic antideressants
Trazedone
Muscle relaxants
Urinary antispasmodics
Antiparkinson
Antipsychotics