Staying Out of the Hospital: Polypharmacy
This blog’s topic is about medications. Medications are essential for life. When it comes to older adults, medications are a way of life. Polypharmacy, the idea of taking more than six medications per day per person, has risen in the last few years. Does polypharmacy increase the risk of readmissions in older adults?
First, polypharmacy runs the risk of an adverse drug reaction with a patient. By taking six or more medications, there is a higher risk of two mediations interacting causing an adverse effect. A single drug itself can also cause an adverse reaction because of the person’s genetic makeup or misdiagnosis. Still, how does one accurately diagnosis an adverse drug reaction? Seven questions can help predict if the admission was in fact because of an adverse drug reaction. First, was the drug not considered appropriate for the patient’s diagnosis (Ruiz, GarcÃa, Aguirre, & Aguirre, 2008). Second, was the dosing appropriate to the patient’s age, weight, and disease state (Ruiz et al. 2008). Third, were needed laboratory tests not done while patient was taking this medication, such as Coumadin, insulin, or diabetic tablets (Ruiz et al. 2008). Fourth, was there a history of an allergy to this type of medication or a drug similar to it and fifth was there an interaction involved with taking this medication (Ruiz et al. 2008). Lastly, was there a toxicity level in the patient and was there poor compliance with the patient and the medication (Ruiz et al. 2008). These questions were used as a basis for a research project that dealt with adverse drug reactions and readmissions. Galdakao Hospital conducted research on the cause of readmissions and adverse drug reactions (Ruiz et al. 2008). The study found that out of 1802 readmissions in a 21 month study, 81 of them were because of adverse drug reactions (Ruiz et al. 2008). The study also noted the majority of the medications involved dealt with hypertension and heart rate (Ruiz et al. 2008). The solution to the problem is proper teaching and follow up from the doctor and scheduled laboratory testing (if needed). Patients require specific teaching before they leave the hospital and during their first few weeks at home to ensure proper understanding of the patient’s own medication. Then, by stressing the need to follow up with laboratory tests (if applicable) and doctor visits, the percentage of readmission to hospitals will decrease.
Second, the problem with polypharmacy is lack of knowledge retention about medications. Older adults forget the teaching about the medications they take and even when they took the medication last which leads to hospital readmissions (Russell, 2004). The goal is to teach and monitor those patients that are taking high risk medications (Russell, 2004). Fifty-five percent of drug related fatalities, mostly involving drug administration, were adults 65 or older in 2003 (Russell, 2004). Since this specific population has difficulty in retaining vital information about drug use and dosing, more emphasis on drug teaching and follow up is need to prevent readmissions, especially those that involve medications.
A third concern with polypharmacy and high readmission rates involves the healthcare staff caring for older adults. One example of concern is mismanagement for medication at assisted living facilities. These facilities provide care for adults that need help with medication management, housekeeping, and personal hygiene. Residents receive this care to improve their quality of life. One troubling part of assisted living facilities is the dispensing of medications to older adults as patient’s diagnosis and medications become more complicated (Woods, Guo, Kim, & Phillips, 2010). Another reason is that the personnel dispensing the medication are unlicensed staff (Woods et al. 2010). The unlicensed staff are without proper training or medication knowledge to be giving complex medications to frail adults which may lead to frequent hospitalizations. A study done in Arizona from 2007 to 2008 at 1,335 assisted living facilities reviewed citations received from state surveyors (Woods et al. 2010). The majority of the citations involved (61.3%) medication related errors (Woods et al. 2010). One example stated an assisted living facility was giving the wife’s medication to the husband and the husband’s medication to the wife which ultimately led to the wife’s death (Woods et al. 2010). By licensing and training medication dispensing personnel correctly, the number of errors and readmissions due to medications may be reduced.
Fourth, by creating a cheaper generic world, drug companies and pharmacies are impairing quality assurance for the patient. As the medications become cheaper because of competition, most people are forfeiting giving their insurance information to the pharmacy, which depicts inaccurate numbers of medications dispensed to each individual from the insurance company point of view. This is hazardous because the government is receiving incorrect information from the insurance companies and Medicare about the number of people on prescription medications (Choudhry & Shrank, 2010). This practice places strain on the doctor prescribing because the patient would like to take the cheaper generics on the market and not new drugs that might target their illness or disease more effectively (Choudhry & Shrank, 2010). The need to save money on medications means a higher potential for readmissions.
With the current concern of older adults and medications, is there a solution? By correctly identifying the people at risk for polypharmacy, a solution can start being developed. Characteristics for people with a high risk of pharmaceutical complications are as follows: age over eighty five, low body weight, taking six or more medications, some level of renal insufficiency, taking more than twelve doses of various medications in twenty four hours, and a previous history of adverse drug reactions (Planton & Edlund, 2010). Some providers are not aware of these characteristics and inadvertently do not provide enough care or teaching to their patients which results in more hospital readmissions (Planton & Edlund, 2010). Recognizing these risk factors will provide better care for older adults and decrease hospital readmissions. Polypharmcy leads to more hospital readmission and admissions due to poor medication teaching to patients and poor relationships with their doctors.
In closing, ask questions to your doctor that prescribes the new drug and the pharmacist who fills the prescription. When you receive a new script from your doctor, ask him\her to notify the other doctors that are part of your care you are taking this medication. Most times doctors do not communicate with other doctors caring for you, so be proactive and request this type of communication. Also, if you are prescribed a blood pressure medication, take your blood pressure before you take your medication and keep a daily log to show your doctor how the new medication works when you see him\her next. I had a patient in homecare that told me he felt real tired late morning and had to take a 3-4 hour nap each early afternoon to feel better for the day's activities. We checked his blood pressure and the medication he was taking was causing the sudden drop in blood pressure during the late morning and early afternoon. By checking his blood pressure we realized this was not a symptom of getting old (extreme tired feeling), but the medication was too strong for him. Now if he fell or passed out because his blood pressure got too low, he would have been in the hospital.
Matthew MSN, RN
Hospitals must reduce readmissions as CMS moves to cut reimbursement. (2010). Hospital Case Management, 129-139.
Planton, J., & Edlund, B. (2010). Strategies for reducing polypharmacy in older adults. Journal of Gerontological Nursing, 36(1), 4.
Ruiz, B., GarcÃa, M., Aguirre, U., & Aguirre, C. (2008). Factors Predicting Hospital Readmissions Related to Adverse Drug Reactions. Pharmacoepidemiology and Prescription, 64, 715-722.
Russell, S. (2004). The dangers of polypharmacy. The American Academy of Ambulatory Care Nursing Viewpoint, 3, 8-10.
Wong, F. K., Chow, S., Chung, L., Chang, K., Chan, T., Lee, W. M., & Lee, R. (2008). Can home visits help reduce hospital readmissions? Randomized control trial. Journal of Advance Nursing, 62(5), 585-595.
Woods, D. L., Guo, G., Kim, H., & Phillips, L. R. (2010). We've Got Trouble, Medications in Assisted Living. Journal of Gerontological Nursing, 36(4), 10.