Addressing Polypharmacy

by Rhonda Lawes, PhD, RN

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    00:00 Now knowing these populations are at specific risk, they should each receive regular evaluation with a medication review tool.

    00:08 with a dMedication Review Tools.

    00:09 Now, this is pretty cool.

    00:10 I wish I had seen this used more in my practice, but medication review tool are setup tools that are steeped in evidence that can help you back off or lower some of the medications that a patient is on.

    00:24 Sometimes a patient gets put on a medication and it doesn't get reevaluated often enough, and so they end up staying on medications that are probably unnecessary or the dosage could be lowered.

    00:36 Examples of medication review tools.

    00:39 The start stop, that's the screening tool to alert to right treatment and the screening tool of older persons prescriptions.

    00:46 Another example is the Medication Appropriateness index.

    00:50 And the third one is specifically for the elderly, the beers criteria.

    00:56 Now as a provider, you need to be aware of these tools, Now, as a provider, you need to be aware of these tools, familiarize yourself with them and make sure you use these and incorporate them into your practice.

    01:05 Here's an example of the the stop start medication review tool.

    01:10 Here's an example of a 70 year old man who presents with type two diabetes.

    01:14 Now, they have an overactive bladder and dyslipidemia.

    01:17 Now, this patient is currently taking the following medications: metformin for the diabetes management, oxybutynin and antimuscarinic medication for the overactive bladder control.

    01:28 Now, for the stop recommendation, oxybutynin would be recommended here because antimuscarinic medications can increase the risk of cognitive impairment, constipation, and urinary retention in older adults.

    01:41 Alternative treatments for overactive bladder should be considered, such as a beta three adrenergic agonist.

    01:49 The Start recommendations.

    01:51 Statin therapy because of the type two diabetes and the dyslipidemia.

    01:55 Since the patient is currently only taking metformin for diabetes management, consideration may be given to adding other anti-diabetic medications to optimize glycemic control.

    02:05 For example, sulfonylureas, DPP-4 inhibitors, GLP-1 receptor agonists, or SGLT-2 inhibitors.

    02:16 Modern electronic health records can do amazing things, but reliably communicating is not always one of them.

    02:24 Think about things like automatically refilling medications that should not have been refilled, but they're in the system that way.

    02:31 What about automated systems that key providers to write prescriptions based on disease specific metrics rather than on individual needs? Now, I'm obviously not against protocols, but you always have to keep in mind the human that's involved in that patient care and evolved in setting up that plan of care that you're going to use as a prescriber.

    02:55 You have to remember who you're treating.

    02:57 Those are guidelines, and there may be something unique about your particular client that you need to adjust or change.

    03:05 So these are just a couple examples that can cause individuals is to end up more medication that they might actually need that comes from the systems that we practice in.

    03:16 Let's take a look at what leaders in the medical community are doing to address polypharmacy.

    03:22 Now this is where I want you to cue in because these are the things you're going to need to incorporate into your practice to be a safe practitioner.

    03:30 Now first up, I'm just going to tell you, it's going to take some extra time and listening, but if you want to be a responsible and safe provider, you need to regularly review the medication lists.

    03:42 Your job is to identify any that are unnecessary or could be safely discontinued.

    03:47 If you're just starting your practice, remember, those tools that we shared are an excellent way for you to get familiar with this process.

    03:55 So first of all, you're going to make sure that you regularly review the medication lists.

    04:00 Second, educating patients and their families is a team sport.

    04:05 We all need to work together on that and prescribers are critical in that role.

    04:10 See, we need to make sure that the patients and the families know the purpose, the benefits and the potential risks of each medication so we can encourage them to make informed decision-making.

    04:21 Now, lastly, consider non-pharmacological alternatives as often as possible.

    04:29 So pause for a minute and think about that.

    04:32 What are three things here that you're willing to do in your practice? Now, what I mean, don't just think about the words.

    04:39 I want you to put an action plan.

    04:41 Like when we say review your medications.

    04:43 I plan to review them before each visit, after each visit.

    04:47 How, when is the timeframe that you're likely to do that? Give yourself a very clear task.

    04:53 What do you plan to do in your practice where you are the one educating the patient and the family? And lastly, how much do you know about non-pharmacological alternatives? Do you often make that part of your thinking process when you're with the patient and working with them? So think of something that you can do to actually make a difference in your practice.

    05:16 Now you might think, why are we going through this? Because there's no point in learning things if you don't see how they're actually gonna fit into your real life practice.

    05:26 Now you might think this sounds kind of textbook.

    05:28 I promise you it's not. It's based in evidence and the ways that you can best address the risks of polypharmacy.

    05:35 Now let's talk about your role as a prescriber with guidelines that are based in evidence.

    05:41 See, when you follow those guidelines, for the most part, patients are gonna get the best care.

    05:47 Remember, it's your job to assess if there's anything unique or particular about this patient that might need to tweak those recommendations.

    05:55 But see, patients end up getting the most appropriate and minimal use of medications for various conditions by following the evidence-based guidelines.

    06:05 Now you're gonna have to be vigilant and observe for and address any adverse effects from these medications, especially when new drugs are added to a regimen.

    06:14 So like we said, teamwork really does make the dream work.

    06:18 By knowing who is working with your patient, you can know what they're prescribing.

    06:23 Working with others ensures a holistic approach in managing and reducing the risk of polypharmacy.

    06:30 Those are all really big ideas, but if I was you, I bet you're thinking, how do I break them down into something I can do right now with one patient at a time? Well, I have some tips for you. Think about when you've been a patient.

    06:45 Have you ever had a provider ask you to physically bring all of your medicine to the appointment? Probably not, but it's really a cool intervention.

    06:55 Now, while that may seem unusual, I wanna give you the rationale on why this is a good idea that you should really consider implementing into your practice.

    07:04 Because first of all, sometimes the patient may struggle to remember everything, particularly if they're not a medical professional. I've had patients tell me, "I take a blue pill and an orange pill and a water pill," and you're like, "Wow, that's gonna be fun to start." So this is something that I have used in my practice and it really is beneficial.

    07:26 So first, patients are not trying to hide something from you all the time, they may just not remember.

    07:33 And a lot of times when they put them into their pill containers, they have no idea what they're taking.

    07:38 You think, well, what about the electronic health record? Well, sometimes the electronic health record doesn't have all the information.

    07:44 Remember, it relies on us inputting the information, all of us that are seeing a patient.

    07:51 The patient could have some prescriptions from one system and some from another and some from another.

    07:56 So there isn't any electronic record that has the full picture.

    08:00 Difference perscriptions may come from different pharmacies.

    08:04 So you thought, I could just call their pharmacy.

    08:06 Many times patients have more than one pharmacy.

    08:10 So, have I won you over yet? Remember, don't forget to ask them to bring in the things they take over the counter.

    08:17 Okay, this can really reveal drug to drug interactions because oftentimes patients don't feel like something that they got from the health food store or something they could buy at Walmart without a prescription should interact with their drugs.

    08:31 and we all know they really, really can.

    About the Lecture

    The lecture Addressing Polypharmacy by Rhonda Lawes, PhD, RN is from the course Role Transitions (APRN).

    Included Quiz Questions

    2. PHQ9
    3. EHR
    4. CHADS2
    5. STOP-BANG
    1. Ask patients to bring all the medications they are taking to the clinic.
    2. Set patients up on automatic refills for the next year at every appointment.
    3. Prescribe medications for chronic health conditions based on general metrics.
    4. Limit focus on non-pharmacologic interventions for the management of chronic disease.
    5. Add additional medications to help manage side effects from existing prescriptions.

    Author of lecture Addressing Polypharmacy

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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