Medication management in nursing homes is complicated and time consuming. It can also be fraught with risks.
Most nursing home residents take more than five medications daily, which makes them particularly vulnerable to the many consequences of polypharmacy.
Risks include contraindications, problems with medication adherence, errors in dispensing, functional declines and increased falls — all of which can result in emergency department visits, hospitalization and increased mortality.
Once a patient is on five or more medications, he or she is at increased risk for drug interactions or other side effects, which, in turn, can trigger a prescribing cascade of other medicines and supplements.
For example, if you have a patient with high blood pressure and you prescribe amlodipine, she might get swelling in her legs, so you add furosemide. But then her potassium and magnesium levels become low, so you add those supplements. Now the patient is taking four medications when you could have just used a different blood pressure medication that doesn’t cause swelling.
Exacerbating the problem is the fact that more than 50% of nursing home residents have some cognitive impairment, which makes it difficult to determine if the medication is effective and whether or not the patient is experiencing side effects.
The medical community has long looked toward “deprescribing” as the solution to polypharmacy. Unfortunately, while there’s a lot of training on how to prescribe medicines, there’s not a lot of training on how to deprescribe.
Here are five steps that can help reduce polypharmacy in your community:
1. Change your philosophy. Look for reasons to stop medications rather than continue or start them. One way to advance this philosophical change is to emphasize the benefits of reducing medication to reduce side effects.
2. Consider non-pharmacological alternatives. Seek other treatment options, such as physical, occupational and restorative therapy, stretching, exercise, ice, heat, and behavioral and diet changes.
For some conditions, behavioral interventions work best. For insomnia, implement a consistent bedtime routine, reduce noise levels, and avoid bright lights. With heartburn or high cholesterol, consider diet modifications. For dementia patients with behavioral expressions, plan meaningful activities and schedule toileting.
3. Focus on the patient’s goals. When determining if treatment is appropriate, look at each medication to see if it’s effective, if there are side effects and whether it’s still appropriate in terms of the patient’s care objectives.
This, of course, requires ongoing conversations with the patient about their goals, and whether they are most concerned about longevity, function or comfort.
4. Consolidate medications — less is more. My response to concerns about polypharmacy is usually to stop as many medications as possible and focus on the ones that are the most important, meaning medications that are going to help them feel better and improve their quality of life.
5. Prioritize dosage management. Find medications that can be given just once or twice a day when possible. There are many options for even the most common medications, including blood pressure treatments and antibiotics.
Medication management is a continual process, and one that takes a group effort between providers, the resident, their family, the resident’s multiple doctors and community staff.
It’s important to remain on the constant lookout for unnecessary medicines or high-risk combinations. Always review the resident’s medications after a hospital stay or any time he or she has a decline in function or a change in goals.
Ongoing conversations are key, because prescribing for a patient whose goals are comfort should be different than for one whose goal is longevity. For example, a patient with a limited life expectancy who values comfort doesn’t need to take a statin for cholesterol management or a bisphosphonate for osteoporosis.
Having a successful deprescribing conversation is like having a successful advanced-care planning conversation. And when done successfully, everyone can benefit.
Monica Ott, MD, is medical director for Optum Senior Community Care in Indiana, Missouri and Kansas.
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