Get more information on why it's important for nurses to monitor medication use in older adults.

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, Part I.

This shows the instrument in its original form. See page 73.

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Clemente Flores, 81 years old, was admitted to the hospital for treatment of acute pneumonia. His history includes hypertension, congestive heart failure, benign prostatic hypertrophy, chronic renal failure, osteoarthritis, falling, depression, chronic constipation, and mild cognitive impairment. (This case is a composite based on my clinical experience.) His medications include digoxin (Lanoxin and others) 0.125 mg by mouth once daily, furosemide (Lasix) 40 mg by mouth once daily, desipramine (Norpramin) 50 mg by mouth twice daily, verapamil (Calan SR) 120 mg by mouth once daily, docusate sodium (Colace and others) 100 mg by mouth twice daily, meclizine (Antivert and others) 25 mg three times daily when necessary, and bisacodyl (Dulcolax and others) one rectal suppository when necessary. Moxifloxacin (Avelox) 400 mg iv every 24 hours was ordered to treat his newly diagnosed pneumonia. His wife, Inez Flores, told his nurse that he had "cut back" on some of his medications at home because he thought they were "too much." As a result of several falls before admission, he complained of low-back pain. After an X-ray ruled out a fracture, an order was written for cyclobenzaprine (Flexeril, a muscle relaxant) 5 mg by mouth three times daily for five days and ibuprofen (Advil and others) 400 mg every six hours when necessary for five days.

Now, two days later, Mr. Flores is confused and agitated. He's found wandering off the unit, disrobing and yelling. Alprazolam (Xanax) 0.25 mg every four to six hours when necessary is ordered for agitation. Mr. Flores falls again, becoming unable to walk without assistance or to urinate. His blood urea nitrogen, serum creatinine, and digoxin levels are elevated, and he is diagnosed with acute urinary retention and acute renal failure. His nurse, recognizing that he is at risk for poor outcomes because of medication overuse, decides to assess him using the Beers criteria.

THE 2002 BEERS CRITERIA

* obtain a list of all medications taken on a regular or as-needed basis, including over-the-counter medications. Ask the patient to bring in all medications (including herbal and nutritional supplements and topical preparations, as well as any "old" or "borrowed" medications).

* assess whether the patient changes the medication dosage or schedule (such as by skipping, raising, or reducing a dose) for any reason.

* highlight any medications that are listed in Beers I or Beers II.

* highlight any medications whose indication for use is unclear.

* consult the patient, caregiver, pharmacist, primary care provider, and other prescribers, if appropriate, to determine whether

[stress outlined white circle] the patient's symptoms could be caused by one of the highlighted medications.

[stress outlined white circle] the indication for using the medication is clear (and still exists).

[stress outlined white circle] the medication is serving its purpose.

[stress outlined white circle] the medication has been titrated appropriately (that is, the dose is high enough to be therapeutic without causing undue adverse effects).

[stress outlined white circle] the dose is correct (this is particularly important for renally excreted drugs, which may need to be given in reduced doses if creatinine clearance is low, as measured or as estimated by the Cockcroft-Gault Formula (at right).

[stress outlined white circle] there are safer alternatives for high-risk medications.

[stress outlined white circle] therapeutic goals should be reevaluated according to stage of illness and prognosis (for example, at the end of life, managing symptoms may be more appropriate than treating the disease).

* make use of nonpharmacologic approaches.

* monitor the effects of changes in the medication regimen made in response to the assessment and educate the patient and family members on medication self-care (including any anticipated effects of changes and when to call the primary care provider).

The nurse says, "That would be very helpful. Please include all medications, including eyedrops, lotions and creams, vitamins, herbs, and other over-the-counter medications that Mr. Flores takes on a regular basis. Any old or borrowed prescriptions that he uses should also be included."

After Ms. Flores agrees, the nurse adds, "In addition to the medications you take every day, I want to ask you about those you use just once in a while. Mr. Flores, do you use medications to treat headaches? Indigestion or heartburn? Cough or cold symptoms? Difficulty sleeping? Arthritis or other aches and pains? Constipation or diarrhea? Allergies? Can you tell me how often you take these?" Mr. Flores mentions that he has been taking Tylenol PM (acetaminophen and diphenhydramine) for difficulty sleeping and Dimetapp Elixir (brompheniramine and pseudoephedrine) for a persistent cough. He also reports occasional use of Alka-Seltzer (aspirin) for indigestion but has not used it recently. The nurse asks, "When did you last use the Alka-Seltzer? How many times per day or per week do you use it?"

The nurse records this information. Asking about specific symptoms may result in a more accurate list of medications taken on an as-needed basis. Maintaining an accurate, up-to-date medication list that includes all medications actually used by the older adult is one of the most important medication risk reduction strategies. When obtaining this list, the nurse can assess the patient's and family's knowledge about each medication, respond to their questions and concerns, and provide education (for example, on old, expired, or borrowed medications). A comprehensive medication list establishes an effective baseline and facilitates comparison between home and hospital therapy (for more, see "Medication Reconciliation," November 2005). This will also help to identify undertreatment, drug interactions, and medication duplication, such as two drugs in the same therapeutic category or the same drug prescribed under two different names (one brand name and one generic). Nonjudgmental questioning may also elicit important information about medication adherence.

When Ms. Flores returns, she shares the written list. The nurse notices that meclizine, which was prescribed in the hospital, isn't on the list. "Oh, yes," Ms. Flores replies, "I forgot to add that. It's new. We got it last week, after we went to the walk-in center when he was dizzy."

The nurse also notices that the list includes tamsulosin (Flomax), which wasn't part of the admission orders. Mr. Flores says, "I stopped taking that a few weeks ago because I read it could cause dizziness and falls." The nurse replies, "Have you made any other changes, such as taking more or less of a medication, or sometimes missing a dose?" Mr. Flores says that he "forgot to fill the water pill prescription for a few days last month" and that he skips the medication when he goes out in public, "maybe two or three times a week."

Using the updated Beers criteria instrument allows the nurse to identify several potential drug-disease interactions and monitoring needs. She assesses Mr. Flores for drug-related problems and reviews recent laboratory values in his chart. After consulting the pharmacist, she contacts the physician to determine whether any medication-related risks might be reduced.

The nurse explains to the physician that she's taken a comprehensive medication history from the Flores family and reviewed the medication record with the pharmacist. She notes that Mr. Flores has been taking several medications with anticholinergic or antihistaminic properties, including desipramine, a tricyclic antidepressant; meclizine, used to treat vertigo; brompheniramine, an over-the-counter cough medication; and diphenhydramine, an over-the-counter sleep aid. Since he has benign prostatic hypertrophy, she's concerned that these medications might increase urinary retention. Also, he recently discontinued his tamsulosin. He has not yet voided since being admitted this morning. The physician agrees and says he's also concerned about the effect these medications might have on Mr. Flores's cognitive function because of his mild cognitive impairment.

The nurse adds that the pharmacist also has questions about the indication for using meclizine and has suggested that Mr. Flores may be using diphenhydramine as a sleep aid to counteract the effects of pseudoephedrine, a central nervous system stimulant in his over-the-counter cough medication; the cough medication may also be elevating his blood pressure, which was 160/84 mmHg on admission.

The physician notes that the information the nurse gathered about Mr. Flores's self-care practices, such as occasionally skipping his Lasix and using over-the-counter medications for indigestion, also suggest that Mr. Flores's heart failure may be exacerbated by fluid retention.

The nurse asks, "How often should we be monitoring his digoxin levels, serum creatinine, and electrolytes?"

The physician replies that the patient's potassium and digoxin levels were normal at his office visit last month, but these should be checked again because the serum creatinine is rising and new medications have been added.

After the physician confers with Mr. and Ms. Flores, as well as with Mr. Flores's cardiologist, urologist, and psychiatrist, a plan is put in place to improve medication safety. To reduce the number of anticholinergic medications, meclizine is discontinued, and over-the-counter medications are avoided. The physician orders inhaled bronchodilators and inhaled steroids to treat Mr. Flores's cough and airway reactivity. Although the desipramine may have anticholinergic adverse effects, the physician and the psychiatrist decide to continue its use because it's been effective in treating Mr. Flores's depression. They will consider having Mr. Flores taper off the desipramine or substituting another antidepressant at some point. Tamsulosin is also reordered and gradually reintroduced, and the nurse carefully monitors Mr. Flores for orthostatic hypotension. A plan to taper the verapamil is instituted. If a calcium channel blocker is still needed to manage hypertension after the tamsulosin has reached therapeutic levels, an alternative long-acting agent that is less constipating will be used.

The nurse recommends a stool softener and a fiber-and-prune-juice mixture to be added to the daily regimen and includes a plan to help Mr. Flores increase his physical activity and maintain adequate fluid intake to prevent constipation. She also includes a plan to monitor him for urinary retention and orthostatic hypotension and to notify the physician immediately if these should occur. She shares this information with all shifts and adds a problem to Mr. Flores's interdisciplinary problem list: "high risk for adverse medication events related to renal and cognitive impairment and potential drug-disease interactions." She posts copies of the Beers criteria near the medication administration area.

OUTCOMES

Optimizing nonpharmacologic care may allow dosage or medication reduction and decrease medication-related risks. Mr. Flores's back pain is treated initially with nonpharmacologic measures, including physical therapy, and acetaminophen. These steps prevent the fecal impaction, acute urinary retention, and delirium that could result from medication use. Benzodiazepines (which may increase the risk of falling) are not prescribed. Mr. and Ms. Flores are looking forward to his discharge.

Just before discharge, the nurse speaks again with Mr. and Ms. Flores. "Here's your updated medication list, with both the generic and the brand names listed, as well as the dose, frequency, and reason for use of each medicine, and special instructions. Do you have any questions?"

Ms. Flores says, "Our daughter bought a new medication box to organize the pills and help us remember what to take when. I just wish he didn't have to take so many!!"

The nurse replies, "I'll ask the physician to speak with you about that. It's important that you discuss any medication changes with your primary care provider or pharmacist, even when you take over-the-counter medicines. Every six to 12 months, the medication plan should be reviewed to make sure the benefits are outweighing the risks and the medication is doing what it should do. And it may be that you can reduce the number of medications then. Would you like more information about what you can do to prevent constipation, reduce pain, and promote sleep without taking a medication?"

CHALLENGES

As illustrated in the Flores case, the Beers criteria and related assessment tools can help guide nursing assessment and intervention and facilitate collaboration with the primary prescriber, clinical pharmacist, and other prescribers. Using these resources properly requires good communication skills and teamwork. Consultation with geriatricians and geriatric pharmacists, if available, is recommended. The plan of care must be continuously updated as the patient's condition changes.

However, there are important medication-related issues that the Beers criteria instrument doesn't address, such as the cost of medications, medication adherence, and undertreatment. The instrument requires the nurse to be familiar with drug classes such as anticholinergics and benzodiazepines and to be aware of ingredients in over-the-counter medications. The pharmacist can assist by providing reference materials with this information. The nurse may want to work with the pharmacy and therapeutics committee and quality improvement team to advocate the adoption of systemwide medication-safety education, easy-to-use reference materials, and electronic medical records that can alert clinicians to high-risk situations or monitoring needs.

CONSIDER THIS

Several factors related to medication use put older adults at high risk for negative health outcomes.

A low creatinine clearance may indicate renal dysfunction, which affects a renally excreted drug's metabolism and appropriate dosage. For men, calculate creatinine clearance using the following formula. For women, use the following formula and multiply the answer by 0.85.

Other Medications Associated with Potentially Preventable Adverse Effects

Their use may be appropriate in older adults; nevertheless, they warrant increased monitoring.

* Angiotensin-converting enzyme inhibitors

* Antiepileptics

* Antiplatelet agents

* Antipsychotics

* Benzodiazepines

* Digoxin

* Hypoglycemic agents

* Loop diuretics

* Opioids

* Theophylline

* Warfarin