Medication Management: The Challenge Nurse Practictioners ...



Medication Management: The Challenge Nurse Practitioners Face Caring for SeniorsMonique VeneyCoppin State UniversityMedication Management: The Challenge Nurse Practitioners Face Caring for SeniorsThere is an old adage that says the only constant in life is change. Nothing more true could be said about medicine and health care. There is always constant rapid change and growth in this dynamic field. From advances in modern medicine to newer more specific diagnostic technologies to expanding drug and other therapies, health care is one field that will forever be evolving. It is one of the few basic human needs that every human being will need access to at some point along their lifespan from birth to death. Healthcare and access to its many components has been the topic of heated discussions, debates and political battles for many years, especially in the years since Barack Obama has been in the presidential office. From the very initiation of this current president’s administration, one of the major objectives has been to enact a system of healthcare that will insure all Americans with quality and affordable care. Though this initiative for “universal” healthcare coverage faced many obstacles, a law, The Patient Protection and Affordable Care Act, was officially signed into law on March 23, 2010. Otherwise referred to as “Obamacare,” this law with its many dimensions is gradually being implemented but is expected to add many, many millions of the newly insured to the rolls.For many that were once without healthcare for various reasons, federally supported and mandated affordable healthcare coverage is a blessing. However, there is also great concern about how this plan will impact the nation’s economy and also about who will provide primary care coverage for all of these newly insured individuals. There is a well-known “secret” within the medical community that newly trained physicians are less likely to choose primary care, internal medicine or family practice as their area of practice. They are more apt to choose specialty fields that will garner them more income as their years in the field grow. This leaves a huge gap that family nurse practitioners and other advance practice nurses are currently filling. It is a scary, yet daunting task to serve as primary care provider for so many more individuals, especially those with multiple complex co-morbidities and an aging population that is living longer. Nurse practitioners are fulfilling a much needed role, but there are many pitfalls and challenges that they face as well. For instance, caring for the elderly can be a major challenge all on its own. Statistics from the National Center for Health state that in the year 2000, the number of persons aged 65 or older in the United States was approximately 35,000,000 because of increased life expectancy and advances in healthcare and technology. Although this age group represented only 4% of the general population, they accounted for 30% of the population that take prescription medicines. Further statistics state that 12% of this small percent of the general population took ten or more meds (including vitamins, supplements and “home remedies”) and 23% took five or more drugs. These are alarming statistics in light of the fact that there are dwindling numbers of primary care providers to manage the chronic health conditions of these individuals as they age. Older/elderly patients have significant and noteworthy differences from younger and middle aged clients especially when it involves medication management. Three major challenges that impact nurse practitioner medication management practice in caring for the older/elderly clientele will be explored here. They are: being aware of the age-related physiological changes that affect this population and handling multiple medications of co-morbidities (known as polypharmacy) while making appropriate, cost-effective prescriptive choices.Age-related changesUnderstandably as a person ages chronologically, the bodies’ organs and systems also age. Years of stress, abuse and neglect can take its toll on our physical dwellings and many chronic medical conditions tend to arise as a result. Even the healthiest young adult will experience some form of age related change as they age. These changes can range from the less severe like visual and hearing losses or osteoarthritis that necessitate the use of assistive devices to more chronic or debilitating conditions such as heart disease, hypertension and diabetes that require drug therapy. No matter the medical condition, there are age related changes that nurse practitioners and other clinicians should be aware of when prescribing drugs for older individuals. Among these changes are a decrease in total muscle mass, total body water, lean body mass and an increase in fat. This change alone can lead to drug toxicity as many medications are highly lipophilic, meaning they dissolve or are bound in fat in the body. With this increase of adipose tissue more drugs in the system may accumulate and store in the fat cells (Edmunds & Mayhew, 2013).Similarly, older adults have changes in their renal and hepatic systems, through which drugs are excreted. Typically as we age hepatic blood flow is decreased and the liver is smaller in size. There is also decreased blood flow to the kidneys and decreased renal function. Edmunds and Mayhew write that creatinine clearance (measure to assess renal function) goes down by 10% each decade after the age of 40. These two systemic changes are significant as drugs and other waste products are cleared from the body by the liver and kidneys. Decreased kidney and liver function and clearance equals decreased ability to clear drugs leading to the potential of drug toxicity. Practitioners need to be acutely aware of these factors when prescribing especially potent drugs like digoxin and benzodiazepines. Dosages of these meds when they clinically necessary and indicated are typically adjusted downward to account for the physical changes of the body. Other medications that are notoriously known for causing adverse effects for elderly patients are drugs that act on cardiovascular and central nervous systems like beta blockers, calcium channel blockers and anticholinerigics. Multiple MedicationsAs previously mentioned, as an individual ages, the natural state of health and bodily functions begin to decline. Among some of the myriad of changes experienced by older adults are: vision and hearing often become less acute, various aches and pains become more prominent and the long and short term memory is less reliable. These changes are just a sampling of some of the more common, less serious problems that can happen as a person ages and most of them are often expected. However, the likelihood is that graver, more life-altering health conditions such as cardiovascular disease, hypertension, diabetes, osteoarthritis and depression will arise the older an individual becomes. While vision, hearing, musculoskeletal and memory decline can frequently be treated with aides or therapies and non-pharmacological methods, most ailments of the major organ systems cannot. These disease processes most often require medication maintenance with one or more drugs, and many of these same patients have more than one medical issue (co-existing co-morbidities) further complicating management of their health.Managing the multiple health problems of patients can be a task for any primary care provider, but it especially challenging when caring for older adults. Elderly patients who have multiple co-morbidities and take a number of meds to control them contribute to a phenomenon called “ploypharmacy.” By definition, polypharmacy “refers to the effects of taking multiple medications concurrently to manage coexisting health problems such as diabetes and hypertension” (Woodrup, 2010, para. 1). Aside from the fact that taking multiple medications can cause adverse drug-drug interactions, taking multiple medications can lead to non-compliance issues with patients. For reasons already stated related to physiological changes in the body, drugs can build up in the system causing them to react unfavorably with another medication. Nurse practitioners along with pharmacists must be more aware of the many drugs that potentially may react together. Prescribed medications should frequently and routinely be checked at each medical appointment to verify that they are still clinically indicated. Whenever possible, unnecessary or inappropriate medications should be discontinued. Additionally, nurse practitioners or primary care providers and other providers such as specialists, must continuously communicate with each other to assure that each discipline is aware of medications and treatments prescribed by another. This communication between disciplines will help to assure that duplication of medications is avoided.Resources/organizations that assist the initiativeThe issues that medication management in the elderly present is not a problem uniquely for nurse practitioner prescribers, hence measures developed by various sources and agencies to help improve prescriptive practices among providers. The Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Geriatric Society has devised a list of drugs that are high risk medications when prescribed in the elderly. The CMS High-Risk Medication guide based on the Beers Criteria, is a thorough list of common medications that tend to present high, intermediate and low risk complications in elderly patients taking them. It is an easy to read, well organized (by drug class) resource to have handy for nurse practitioners or anyone treating and prescribing regularly for elderly clients. This list is a free guide that is regularly updated and available to all clinicians to help guide their prescribing practices for this population and keep these patients safe. Many elderly clients receive Medicare services form the government, including prescription coverage; therefore, when these certain risky meds are ordered they initiate a “non-formulary red-flag” at pharmacy counters. This red flag prompts pharmacists to confer with the prescribing provider that the med is not covered by Medicare and that an alternative less risky drug be considered. It is imperative that checks and balances like the list produced by the CMS that initiates a discussion between pharmacist and clinician be in place to avoid major medication problems for older adults ("JAGS," 2012).Similarly, organizations like the ANA, American Nurses Association, have published statements that speak to the issue. The ANA is one of the premiere leaders in addressing issues that pertain to nurses form all practices and the populations they serve. In a position statement approved in 2009, the ANA voices its support of focusing on medication safety in the elderly. The statement briefly highlights 6 key factors that should routinely be followed to promote “safe medication used in the older adult.” These key factors are to: regularly review their medication profiles, clearly communicate information to patients, family and other healthcare providers, review and reconcile meds whenever there is a change in the level of care, always review the age-specific pharmacotherapeutic and pharmocodynamic changes that could affect an older adult with multiple chronic health conditions, and to stay abreast on research surrounding the effects that drugs have on this special population and how it affects our practice (ANA, 2009).Review of literatureMany different reputable medical sources and agencies agree that prescribing medications for an aging population requires careful consideration by providers. Various journal articles have been written over the years addressing this very issue. Of note, The Journal for Nurse Practitioners as recently as 2013 published an article entitled “Prescribing in the elderly: Practical tips and potential pitfalls” to inform nurse practitioner providers. This educational resource speaks to the importance of knowing and understanding pharmacodynamics and pharmacokinetic of the elderly, using resources such as the Beers Criteria to guide appropriate prescribing practices and continually educating clients on their medications and revising as needed to ensure adherence and reduce polypharmacy (Halloran, 2013).Likewise, the Journal of Clinical Pharmacy and Therapeutics discusses risky medications that are often prescribed for elderly patients in the United States and also in Europe and why these should be avoided. The article addresses many of the same principles outlined in this paper (altered physiology, multiple medication use and adverse drug interactions). It also gives the suggestion of the use of “drug utilization review tools” such as the Beers Criteria and other screening tools to reduce prescribing inappropriate medications that can cause more harm than good (Gallagher, Barry, & O’Mahoney, 2007).Conclusive implications for practiceIn conclusion, current evidence and future projections point to evidence that nurse practitioners and other advance practice nurses will play more integral roles in health care. Several factors play into that prediction: the baby boomer generation will age and live longer with multiple health needs, more individuals will become insured via the Affordable Care Act, and the pool of trained primary care physicians is expected to decrease. Consequently, nurse practitioners will have the unique opportunity to care for more diverse and older populations as in the role of primary care giver. It is imperative that as care givers for older adults clinicians are knowledgeable about the unique needs and variances in prescribing medications for this population. Primarily, many older and elderly clients have multiple co-existing co-morbidities that may necessitate multiple medications resulting in a polypharmacy situation or an inability to consistently adhere to a treatment plan. As a result, their ability to afford these various medications may be a challenge. And lastly, they have physiological changes that alter the distribution, absorption and elimination of drugs in their systems. We must recognize these factors when treating these patients and take measures to lessen the burden that medications can cause for patients by only prescribing when absolutely medically necessary, always reviewing and revising medication and treatment plans for the optimal outcomes and by continuing to educate our patients and ourselves as providers to ensure few errors and the best clinical outcomes.ReferencesAmerican Nurses Association. (2011). Advanced practice nursing: A new age in health care [Press release]. Retrieved from PressRoom@American geriatrics society updated Beers criteria for potentially inappropriate medication use in older adults [Special articles]. (2012). Journal of the American Geriatrics Society, 1-16. Retrieved from files/documents/beers/2012BeersCriteria_JAGS.pdfEdmunds, M. W., & Mayhew, M. S. (2013). Special populations: Geriatrics. In Pharmacology for the primary care provider (4th ed., pp. 50-59). St. Louis, MO: Elsevier.Gallagher, P., Barry, P., & O’Mahoney, D. (2007). Inappropriate prescribing in the elderly. Journal of Clinical Pharmacy and Therapeutics, 32, 113-121.Halloran, L. (2013). Prescribing in the elderly: Practical tips and potential pitfalls. Journal for Nurse Practitioners, 9(2), 126-127. Retrieved from , K. (2010). Preventing polypharmacy in older adults. American Nurse Today, 5. Retrieved from ................
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