IC1 Drug-related Problems in Elderly Flashcards
What do you need to consider for medication appropriateness?
- Indication
- Effectiveness
- ADR
- Drug-disease interaction
- DDI
- Dose
- Dosing regimen / instructions + practical
- Duplications
- Duration
- Cost effectiveness
What is missing from the medication appropriateness index (MAI)?
- Untreated indications
- ADR
- Failure to receive drugs
What are the classification of DRPs?
- Indication-Related
- Untreated Indication
- Improper Selection
- Drug with NO indication
- Dose-Related
- Overdose
- Underdose
- Interactions
- Drug-Drug
- Drug-Food
- Drug-Lab
- Adverse Drug Reactions
- Based on patient-specific outcome
- Failure to receive drugs
- Appropriate drug
- Non-adherence/poor technique/storage
What are some reasons for failure to receive drugs?
- Most common failure to receive drugs is medication non-compliance
- Do not assume that it is ignorance, but it could be some other reasons that lead to non-compliance
- Cognitive impairment (unintentional)
- Too expensive
- Their health belief
Do not like the drs (see the med then remind him of the dr) - Inappropriate administration of drugs e.g. inhaler, bisphosphonates, nasal spray, injections
- Improper storage of drugs
- Affect potency and thus reduce the full benefit of the meds
What is the Pharmaceutical Care Framework?
- What Matters Most / What is important to patient
- Help us to identify untreated indications
- Might need drs help to diagnose patient with the problem e.g. have patient with suspected ADR but might need dr to exclude other stuff first before can say that it is a ADR
- Explicit Criteria/High Alert Medicines
- E.g. Warfarin, anticoagulants, insulin, opioids
- Highly likelihood of patients experiencing more harm than good
- Implicit Criteria
- Need to use clinical judgement, use our priority drugs related problems that we identified in the 1st 2 steps
- But also other drugs not covered in the 1st 2 steps, still need to evaluate them individually
- If see that elderly is taking chlorpheniramine, don’t just tell drs that this is in the beer’s criteria, so need to take away. Beer’s criteria is to help us pick up the drug. Then need to use patient specific info to write our intervention notes to make it more convincing
- Successful delivery of appropriate drugs
What is the difference between inpatient vs ambulatory goals or things that matters to patients?
- IF it’s Inpatient care:
- What’s impt is to stabilize the patient, address the acute and active conditions
- Look at dr notes and look at active issues identified by the team
- Need to address the active issues so that they can survive and get out of the hospital and function maximally as possible to address what matters to them
Once they get out of the hospital then we see them in:
- Ambulatory care:
- There is no active issues for us to focus on
- Thus listen and pick up what are impt to the patient and caregiver
- Communication skills
What are the barriers for appropriate medicines to reach patients?
- Non-adherence
- Lack of support/cost/health belief/poor communication
- Poor technique
- Inappropriate storage
Non-adherence can still happen in the ward!!
Whenever there is a new symptom, what should always be considered as a possible cause?
It is possibly a drug side effect until proven otherwise
What is prescribing cascade?
Using a drug to treat the side effects of another drug with the belief that they arise from a new medical problem
What are some examples of prescribing cascade?
If not careful, this is one of the mechanism by which polypharmacy occurs
But polypharmacy occurs due to many reasons and this is one of it
Always look out for pseudo-indications
Look for drugs with opposing pharmacologies
- use senna/bisacodyl to treat constipation in patient taking morphine (morphine can cause constipation)
- Midodrine (alpha 1 agonist) and alpha blocker
- Spironolactone (diuretic, competes with aldosterone cause excretion of Na and water) vs fludrocortisone (synthetic adrenal steroids with high mineralocorticoid activity, increase reabsorption of Na)
- Anticholinergics (compete with ACh binding) and acetylcholinesterase inhibitors (increase ACh levels, thus increase its activity)
- NSAIDs (increase BP by Na and water retention) and anti-HTN
- Sympathomimetic (mimic response of stimulated sympathetic nerves, thus increase BP is one of them) and anti-HTN
What are the components in the comprehensive geriatric assessment?
- Functional Status
- Medical
- Mental
- Medication/Nutrition
- Socioeconomic Resources
What are we looking at when assessing functional status in CGA?
Domain 1: Functional Status²
- Basic Activities of Daily Living (ADLs)
Dressing, Eating, Ambulating (Transfer), Toileting, and Hygiene (Grooming) [DEATH] - Instrumental Activities of Daily Living (IADLs)
Shopping, Housekeeping, Accounting, Food Preparation, Taking Meds, Using Telephone, and Taking Transport [SHAFTTT] - Develop interventions to maintain or improve functional independence and enhance quality of life.
What is done in medical review in CGA? And what are the 4Ms?
Domain 2: Medical Review²
- Conduct → Conduct a detailed review of systems to identify any medical problems
- Assess and address → Assess and address chronic conditions that impact the patient’s overall health
- Identify → Identify potential geriatric syndromes such as falls, incontinence, and polypharmacy.
- Tailor → Tailor medical interventions to optimize overall well-being and quality of life.
- If there are new medical issues, look at drugs
- First M (matters to them) of the 4M approach must be incorporated in the tailoring stage
The 4Ms are:
Matters
Medication
Mentation
Mobility
What is done for mental assessment in CGA?
Domain 3: Mental (Cognition/Mood)²
- If cognitive impairment is present, need to determine etiology
- Evaluate mood and emotional status to identify signs of depression or anxiety.
- Consider the impact of cognitive and mood status on medication adherence and self-care.
The test that drs do to identify if they have cognitive impairment will not tell us what it is due to
What is pseudo-depression?
Sometimes it can be because of delirium/depression/dementia that affect the mood
Sometimes cognitive impairment associated with depression can be termed as pseudo-depression (drs think that it is due to depression that the patient has cognitive impairment)
The depression may not be a true one as it could be due to the cognitive decline associated with dementia / delirium
