Medication Management in Long-Term Care

Abstract

Two-thirds of Americans over the age of 65 have multiple chronic conditions (i.e., multi-morbidities) that affect both quality of life and longevity. The most common chronic diseases and the leading causes of death in this population are heart disease, cancer, stroke, chronic lower respiratory disease, and diabetes mellitus. Census projections estimate that by 2030, 20 % of the US population will be 65 years of age and older. As pharmacotherapy is an essential component of care in older adults, optimization of their drug regimen (where benefit will outweigh risk) is an important public health issue [1]. Multiple chronic diseases, limited physiologic reserves, changes in drug metabolism, and impaired immune and inflammatory mechanisms all result in frail elders being susceptible to serious adverse drug events (ADEs) such as falls, hip fractures, weight loss, cognitive and functional decline.

Appendices

Appendix A. Unnecessary Drugs in the NF/SNF

F-tag #	Regulation	Guidance to surveyors
F329	Unnecessary drugs 1. General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above.	Intent: Unnecessary drugs The intent of this requirement is that each resident’s entire drug/medication regimen be managed and monitored to achieve the following goals: The medication regimen helps promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration with the attending physician and facility staff; Each resident receives only those medications, in doses and for the duration clinically indicated to treat the resident’s assessed condition(s); Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to medication; Clinically significant adverse consequences are minimized; and The potential contribution of the medication regimen to an unanticipated decline or newly emerging or worsening symptom is recognized and evaluated, and the regimen is modified when appropriate. NOTE: This guidance applies to all categories of medications including antipsychotic medications.

Source: Code of Federal Regulations 483.25(l)

Appendix B. Choosing Wisely^® and Medication Management in PA/LTC

Organization	Recommendation
AMDA-Society for PA/LTC Medicine	Do not use sliding scale insulin for long-term diabetes management for individuals residing in the nursing home. Do not routinely prescribe lipid-lowing medication in individuals with limited life expectancy. Do not initiate hypertensive treatment in individuals > 60 years of age for SBP <150 mm Hg or DBP < 90 mm Hg. Do not prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior.
American Geriatrics Society	Do not prescribe a medication without conducting a drug regimen review. Do not prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse GI effects. Avoid using prescription appetite stimulants or high calorie supplements for treatment of anorexia or cachexia in order adults.
AAHPM	Do not use ABH gel (Ativan, Benadryl, Haldol) for nausea.
American Psychiatric Association	Do not routinely prescribe antipsychotic medication as a first-line intervention for insomnia in adults. Do not routinely use antipsychotics as first choice to treat BPSD (see above). Do not routinely prescribe two or more antipsychotic medications concurrently.
American Society of Nephrology	Do not administer erythropoiesis-stimulating agents (ESAs) to chronic renal disease patients with hemoglobin levels ≥ 10 g/dl (without symptoms of anemia). Avoid NSAIDs in individuals with hypertension or heart failure or chronic kidney disease of all causes including diabetes.