Polypharmacy Best Practices

by Rhonda Lawes, PhD, RN

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    00:00 Hi, I'm Dr. Rhonda Lawes, and I'm going to talk to you in this video series about the best practices for polypharmacy.

    00:08 Now, when it comes to medication treatments, more is not always better.

    00:12 Now, let's start with the definition of polypharmacy.

    00:15 The CDC designs it as the use of five or more prescription medications by any one patient.

    00:22 Now, this isn't a new or even uncommon problem.

    00:25 It is, however, a very dangerous one.

    00:29 Now, this is particularly dangerous in older adults or anyone else who has competing demands on their mental acuities or their physical abilities and has multiple providers that are prescribing for them.

    00:41 But before we talk about how we can address polypharmacy, let's take a brief look at who is most at risk and why.

    00:49 So, I want you to think about three groups.

    00:51 Anyone who has multiple medical conditions, that are managed by multiple subspecialist providers.

    00:58 Second group, anyone who has chronic mental health conditions.

    01:03 And the third group, anyone residing in a long-term care facility.

    01:08 All three of these groups are at an increased risk for polypharmacy.

    01:12 So, don't let this just go by you.

    01:14 You want to pause and make sure you have these specific populations in mind because one of the tips we're going to talk about later is you want to be on high alert whenever you encounter a client that meets one of these three groups.

    01:29 It might seem straightforward why patients with medical problems who have multiple prescribers end up with multiple scripts.

    01:36 But what about those with mental illness? Patients who have a mental health diagnosis are often prescribed psychotropic medications.

    01:45 Now these psychotropic medications can have some significant adverse effects.

    01:50 So in order to address those adverse effects, more medications may be added to mitigate those side effects.

    01:58 Many of the psychotropic medications are also associated with things like metabolic syndrome, which may require additional drugs to address that.

    02:07 That's how this list grows on and on, and so does the risk for drug interactions.

    02:14 Consider the management of osteoarthritis.

    02:16 Simple, right? Well, the initial treatment often starts with an NSAID, such as naproxen or ibuprofen.

    02:22 However, NSAIDs can result in hypertension, which may require antihypertensive therapy, which may include a one or two drug regimen.

    02:31 They can also be hard on a patient's stomach.

    02:34 With gastritis being a frequent issue.

    02:37 For this, a patient may be prescribed a proton pump inhibitor.

    02:41 So, one simple medication turned into potentially three total medications.

    02:47 Here's a more complicated example.

    02:49 Antipsychotic medications can cause extrapyramidal side effects.

    02:53 Now, because of these side effects, a muscarinic receptor antagonist like benztropine may be prescribed.

    03:00 Benztropine can cause dry mouth, which may require prescription for a saliva substitute, as well as constipation for which a laxative may be used.

    03:09 Additionally, antipsychotic medications can result in significant metabolic effects, such as weight gain and hypoglycemia that can lead to diabetes.

    03:18 This would require treatment.

    03:20 And this graphic doesn't even take into account the downstream treatments related to diabetes. Think of things like cardiovascular risk that would indicate the need for a statin therapy or renal protection with an ACE or an SGLT-2.

    03:36 Many patients with diabetes need these additional medications.

    03:40 As you can see, one medication snowballed into multiple medications as a result of managing side effects.

    03:48 Well, primarily because they are likely to be more frail or they wouldn't be in the long term care facility.

    03:54 They likely have multiple medical and cognitive impairment issues, and all of this together are much more likely to warrant complex pharmacological treatment.

    04:05 Now knowing these populations, remember anyone who has Now knowing these populations, remember, anyone who has multiple medical conditions managed by multiple subspecialist providers, has chronic mental health conditions, or is residing in a long term care facility, those are the patient populations i want you to be on high alert for.

    04:23 So you'll hear me repeat this, because I want to study along with you as you're preparing this content.

    About the Lecture

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

    Included Quiz Questions

    1. Use of five or more prescription medications by one patient
    2. Use of three or more prescription medications by one patient
    3. Use of a medication to treat side effects from another medication
    4. Use of seven or more prescription medications by one patient
    5. Use of two or more medications with negative interactions
    1. A patient with high blood pressure managed by their primary care provider
    2. A patient with with multiple medical conditions managed by several different specialists
    3. A patient with multiple chronic mental health conditions managed by a psychiatrist
    4. An older adult with frailty who resides in a long-term care facility
    5. A patient with one chronic mental health condition managed by their primary care provider
    1. The provider prescribes an antipsychotic medication to a patient with schizophrenia. At the patient's 6-month check-up, they have gained 50 lbs, and lab work shows elevated cholesterol and diabetes. The provider prescribes a statin and GLP-1 agonist.
    2. The provider prescribes a diuretic medication to an elderly patient with hypertension. The patient calls the clinic a few weeks later and complains of new-onset urinary incontinence. The provider prescribes oxybutynin. At the patient's annual wellness visit, they report struggles with constipation, and the provider prescribes a laxative.
    3. The provider prescribes a stimulant medication to a patient with attention deficit hyperactivity disorder. At the patient's two-month clinic visit, they report difficulty initiating and maintaining sleep. The provider prescribes doxepin for the insomnia. A few weeks later, the patient calls and states that they are sleeping much better but have developed a dry mouth. The provider prescribes a saliva substitute.
    4. The provider prescribes hydrochlorothiazide to a patient who is taking the maximum dosage of lisinopril for hypertension and is still having elevated blood pressure readings. The provider recommends a combination pill of the two medications to reduce the patient's daily pill burden.
    5. The provider sees an elderly patient in the clinic who has had a recent hip fracture after a fall at home. The patient is taking a daily bisphosphonate. The provider discontinues the bisphosphonate and starts the patient on anabolic therapy.

    Author of lecture Polypharmacy Best Practices

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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