Are you taking too many unnecessary or duplicate medications?
Polypharmacy, or the use of multiple drugs for one or more conditions, has become an increasing problem with elderly patients. A recent study published in the journal Nature showed that the more medications a person took, the worse their health outcomes.
The study included over three million people age 65 or older. Of those, 46.6 percent took five or more medications a day.
Over a five-year follow-up period, an incrementally higher number of daily prescriptions were found to be associated with an increasingly higher risk of hospitalization and death. In other words, the more medications a patient took, the worst their health outcome became.
Ann-Marie Peckham, president and CEO of the Visiting Nurse Association of Cape Cod, and her colleague Susan Donovan, director of Patient Care Transitions, have witnessed this problem firsthand, and their nurses work with patients to ensure this problem doesn’t occur. In fact, medication reconciliation is the first thing a visiting nurse does as part of a patient’s intake care assessment.
“We basically go through the house,” Peckham said. “What’s under the bed? What’s in the closet? What’s in your drawers? Then people start bringing out all of these pills.”
Peckham ran a report on the 1,500 patients under the VNA’s care to see on average how many medications people were actually taking. The average number was 12, but median number was 23.5. She found a lot of patients in the 30 medications a day range and even more in the 20-something range.
“I started to look into those patients in the 30s (medications a day) yesterday and see if I couldn’t pull out some kind of case study, and it turns out that the one common thread is that they have multiple co-morbidities,” Donovan said. “You might have one doctor that you go to for your COPD and he is giving you four inhalers plus three drugs, and you go to your other doctor for your endocrine and he’s prescribing more drugs. Then you go to your PCP and you get even more. You have multiple doctors involved when you have multiple co-morbidities.”
As a high-risk population manager, the highest numbers of drugs are being taken by those with heart failure and COPD, according to Donovan. Those patients have to take multiple cardiac medications as well as multiple pulmonary drugs. Because those illnesses frequently cause depression, it’s not usual for those patients to also be taking anti-depressants, anti-anxiety drugs and sleep aids.
“Between the three prescribing physicians you can easily get into the 20 or 30 range,” she said.
Enlist Your PCP’s Help
One of the things that both women suggest to patients who are worried they are taking too many medications is to put all of their medications in a brown bag and bring it to their primary care physician to review. It’s important to include over-the-counter drugs too, because they might interact with prescriptions in negative ways. For example, you wouldn’t want to take a daily aspirin if you are taking a blood thinner.
In the past, another big problem was that patients who were hospitalized would be sent home with a generic version of a drug when they have the actual version at home. Many people would end up taking both. Their doctor wouldn’t have any way of knowing this was occurring unless the VNA was involved with care. Fortunately, now that Cape Cod Healthcare has the Epic medical records system, PCPs have easy access to their patient’s hospital records, which allows them to avoid duplicate prescribing.
“The primary care providers are going to be able to see what the inpatient notes are, what the inpatient changes were,” Donovan said. “Another wonderful thing about Epic is that if a patient does see a specialist, like their pulmonologist, and he makes a medication change, that is documented in Epic, and their primary care provider is going to be able to see it in Epic.”
But as helpful as the Epic system is, both Peckham and Donovan say there is still plenty of need for the VNA to do medication reconciliation. For one thing, some patients receive care at institutions that don’t use Epic. Also, not all primary care offices on the Cape are part of Cape Cod Healthcare and therefore cannot view the Epic charts.
The other important thing that the VNA nurses pick up on is when patients are prescribed medications like inhalers, but they don’t have the money to pay for them. The nurses will see the medication listed on their medication list, but they won’t find it in the home. Another related problem is patients cutting a pill in half to save money. The nurse will count the pills and realize there are too many of them left in the prescription.
When that happens, or they find other social determinants of health, like patients struggling to pay for food, they call in a social worker.
“The social workers know all of the community resources,” Peckham said. “There are ways we can work with them. There are drug companies that offer coupons and free medication for patients that patients don’t even know about. Social workers are armed with all of the resources that someone might need.”
In addition to medication reconciliation, the VNA does everything it can to simplify the process so the patient understands what they need to take and why. They give patients free pill boxes to keep their medications on track. This makes it convenient for the patient to remember to take their pills, but it also makes it easy for the nurses or home care aids to check and make sure the patient is actually taking their medications.
The VNA also uses zone teaching tools that have been very effective in preventing hospitalizations, said Peckham. The zone tool operates like a stop light. Green is good, yellow is caution, and red is danger. These lists are put on the patient’s refrigerator and the patient is asked to refer to it every day. An example of how this works is that one of the tools for managing heart failure is to weigh yourself every day. If your weight is stable, that is the green zone. If your weight goes up two pounds overnight or five pounds in one week, that is the yellow zone.
When a patient is in the yellow zone, they are encouraged to call their provider or the VNA to make sure that the fluid hasn’t leaked into their lungs. The nurse will also call the cardiologist, so the doctor can change their diuretic medicine right away to address the fluid buildup before it becomes a problem that requires hospitalization. The goal is to never get into the red zone.
“Our most important thing is to make a plan that is livable and manageable for the patient,” Peckham said. “We need to leave knowing they know what to do and they are able to do it. We try to make it as simple as possible.”