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cutting back on medications in nursing homes
David Morris made some waves when he began seeing patients at the Hebrew Home for the Aged in New York City last summer. His faux pas was reviewing drug regimens and cutting back on the number of drugs patients were taking. Most patients applauded but demanded he be taken off their case. Hebrew's administrator backed Morris, while the home's medical chief chastised him for being overzealous.
It's a familiar story for consultant pharmacists, said Tom Clark, director of professional affairs for the American Society of Consultant Pharmacists (ASCP). Between 80% and 90% of consultant pharmacist recommendations are accepted by nursing home physicians, Clark said. But objections can be vocal, bitter, and highly personal.
What makes Hebrew different is that the recommendations to cut back on medication usage didn't come from a consultant pharmacist. Morris is a physician. "We're dealing with medication on top of medication in nursing homes," he said. "If patients are getting long-term meds, the prescription may be for a problem that no longer exists. Treatment must be changed as the patients and their conditions change."
Physicians should evaluate patient drug regimens regularly, agreed gerontologist Jerry Avorn, M.D., but few do. That makes overmedication a significant problem in many nursing homes. Avorn is associate professor of medicine at Harvard Medical School and chief of pharmacoepidemiology and pharmacoeconomics at Brigham & Women's Hospital in Boston.
"The elderly are more susceptible to adverse drug events and much more likely to be on multiple drugs. A regular drug utilization review [DUR] may be the most important intervention you can do for an elderly patient," Avorn said. Reviewing drug regimens is more than simply reducing the number of drugs. Many patients are overmedicated, he said, but there's also a significant population who are undermedicated. Patients with osteoporosis, glaucoma, atherosclerosis, and chronic pain are commonly undertreated. They typically need more drugs, he said, not fewer.
The problem, Morris and Avorn concurred, is pharmacist focus. Consultant R.Ph.s are skilled at screening for clinical interactions and contraindications. But too few evaluate the appropriateness of therapy or the lack of appropriate therapy.
Does that mean consultant pharmacists are not doing their jobs? No, said Stephen Feldman, ASCP v.p. and president/CEO of The ICPS Group in Boston. It means the consultant pharmacist doesn't have solid information. Pharmacy has the complete drug profile, but R.Ph.s don't see patients on a regular basis. If medical files, test results, DURs, and other records indicate no change in the patient's condition, neither the R.Ph. nor the physician is likely to look too closely.
"It is typically the nurse who raises the issue of an inappropriate drug because nurses see patients every day," Feldman said. There is also a communication gap between consultant pharmacists and other caregivers, he added.
Pharmacists are trained to evaluate drug therapy in terms of clinical effects, either therapeutic or adverse. Nurses, physicians, and other professionals are trained to evaluate therapy in terms of how well patients function in daily life.
If a drug leaves a patient confused, or dizzy and apt to fall, Feldman said, nursing home staff is better able to see the decline in functional status and alert the pharmacist. But if the consultant R.Ph. sees only medication records and patient charts, there may be no clue about functional problems. And R.Ph.s aren't schooled to consider functional status along with clinical indicators and endpoints.
"We think in a drug silo, not considering how a drug impacts the patient," Feldman contended. "Other caregivers see the whole patient and evaluate therapy in terms of its impact on patients' functioning. And when you're older, it doesn't take much to affect your level of functioning."
That gap in communication should shrink in coming months. The ASCP Research & Education Foundation has developed a software version of the MDS-MedGuide to help pharmacists evaluate drug therapy in terms of patient physical and psychosocial functionality in addition to more familiar clinical markers.
Called GRAM (Geriatric Risk Assessment MDS-MedGuide), the new software creates a bridge between clinical end points and how well patients function. It lets R.Ph.s correlate drugs with falls, incontinence, depression, and other common problems, said the foundation's executive director Kathleen Cameron.
"We typically talk in drug speak that nobody else can understand," Cameron explained. "With GRAM, pharmacists will be speaking the same language as other geriatric specialists and talking about how well patients function instead of just about interactions and side effects." GRAM will be released in November at the ASCP annual meeting in Chicago.
Fred Gebhart. Are consultant R.Ph.s doing a good job with DURs?.